Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Biology, the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, and the Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
Obstet Gynecol. 2019 Jan;133(1):91-97. doi: 10.1097/AOG.0000000000003010.
To evaluate the effects of eliminating the routine use of oral opioids for postcesarean delivery analgesia on postcesarean opioid consumption.
At a tertiary care center, we implemented a quality improvement intervention among faculty practice patients undergoing cesarean delivery, which consisted of 1) eliminating routine ordering of oral opioids after cesarean delivery, 2) implementing guidelines for ordering a short course of opioids when deemed necessary, and 3) coupling opioid prescribing at discharge to patterns of opioid use in-hospital combined with shared decision-making. All patients, both before and after the intervention, were administered neuraxial opioids and scheduled acetaminophen and nonsteroidal antiinflammatory medications in the absence of contraindications. The primary outcome was the percentage of women who used any opioids postoperatively in-hospital. Secondary outcomes included the percentage of women discharged with a prescription for opioids, the quantity of opioids used in-hospital, pain scores, satisfaction, opioid-related side effects, and opioid prescriptions ordered in the 6 weeks after delivery. The effects of this intervention were assessed based on a chart review of patient data and a survey of patients in the 12 weeks before and 12 weeks after the intervention.
We evaluated the records of 191 postcesarean delivery patients before and 181 after the intervention. Less than half of women used oral opioids in-hospital after the intervention, 82 (45%) compared with 130 (68%) before (P<.001). However, there was no change in pain scores or overall satisfaction with pain relief. Postintervention, only 40% of patients were discharged with prescriptions for opioids compared with 91% of patients before the intervention (P<.001).
Eliminating routine ordering of oral opioids after cesarean delivery is associated with a significant decrease in opioid consumption while maintaining the same levels of pain control and patient satisfaction. Oral opioids are not needed by a large proportion of women after cesarean delivery.
评估取消剖宫产术后常规口服阿片类药物镇痛对剖宫产术后阿片类药物使用量的影响。
在一家三级保健中心，我们对行剖宫产术的教职员工患者实施了一项质量改进干预措施，该措施包括：1）取消剖宫产术后常规口服阿片类药物的医嘱；2）在需要时制定短期使用阿片类药物的指南；3）将出院时的阿片类药物处方与住院期间的阿片类药物使用模式相结合，并结合共同决策。所有患者均在无禁忌证的情况下接受了椎管内阿片类药物，并给予了预定的扑热息痛和非甾体类抗炎药。主要结局是术后住院期间使用任何阿片类药物的女性比例。次要结局包括出院时开具阿片类药物处方的女性比例、住院期间使用的阿片类药物数量、疼痛评分、满意度、阿片类药物相关副作用以及分娩后 6 周内开具的阿片类药物处方。通过对患者数据的病历回顾和干预前后 12 周的患者调查评估了该干预措施的效果。
我们评估了干预前 191 例和干预后 181 例剖宫产术后患者的记录。干预后，不到一半的女性在住院期间使用口服阿片类药物，82 例（45%）比 130 例（68%）（P<.001）。然而，疼痛评分或整体疼痛缓解满意度没有变化。干预后，只有 40%的患者出院时开具了阿片类药物处方，而干预前这一比例为 91%（P<.001）。
取消剖宫产术后常规口服阿片类药物与阿片类药物消耗显著减少相关，同时保持相同水平的疼痛控制和患者满意度。很大一部分女性在剖宫产术后不需要口服阿片类药物。
