Department of Obstetrics and Gynecology, Naval Medical Center Portsmouth, Portsmouth, Virginia.
Obstet Gynecol. 2019 Apr;133(4):700-706. doi: 10.1097/AOG.0000000000003156.
To evaluate the association of a standardized, structured approach to in-hospital postcesarean delivery pain management with maternal opioid use after cesarean delivery.
We conducted a retrospective cohort study of women who underwent cesarean delivery before and after a quality improvement intervention at a single tertiary care center. A multidisciplinary task force revised electronic order sets for all patients who underwent cesarean delivery with neuraxial anesthesia. The revised order set separated acetaminophen from opioids, scheduled acetaminophen and nonsteroidal antiinflammatory drug administration, and limited opioid use to breakthrough pain. Data were collected by electronic chart review. The primary outcome was median morphine milligram equivalents per hospital stay. Secondary outcomes included median morphine milligram equivalents per day, median pain scores, time to discharge, and opioid-nonopioid pain medication use. Descriptive and bivariable analyses were performed.
There were no significant differences in baseline characteristics in the preintervention (n=283) and postintervention (n=286) groups. There was a 75% reduction in median morphine milligram equivalents per stay from 120 (90-176 interquartile range) preintervention to 30 (5-68) postintervention (P<.001) and a 77% reduction in median morphine milligram equivalents per day (51 [41-60] vs 12 [2-25], P<.001). There was no difference between groups in time to discharge or median pain scores. There was no difference in ketorolac use (80% preintervention vs 75% postintervention, P=.14) or in median ibuprofen mg per day (1,391 preintervention vs 1,347 postintervention, P=.22). There was an increase in median acetaminophen mg per day (753 preintervention vs 2,340 postintervention, P<.001). There was a significant increase in patients who used no opioids during their hospital stay (6% preintervention vs 19% postintervention, P<.001).
A multimodal stepwise approach to postcesarean delivery pain control was associated with markedly reduced opioid consumption without increasing hospital stay or median pain scores. By separating acetaminophen from opioids and limiting opioids to breakthrough pain, we were able to operationalize a tier-based approach to pain management.
评估一种标准化、结构化的院内剖宫产术后疼痛管理方法与剖宫产术后阿片类药物使用的相关性。
我们对一家三级保健中心进行了一项回顾性队列研究，纳入了在质量改进干预措施实施前后接受剖宫产术的女性。一个多学科工作组修订了所有接受椎管内麻醉的剖宫产患者的电子医嘱集。修订后的医嘱集将对乙酰氨基酚与阿片类药物分开，安排对乙酰氨基酚和非甾体抗炎药的给药时间，并将阿片类药物的使用限制在爆发性疼痛。通过电子病历回顾收集数据。主要结局为住院期间吗啡毫克当量中位数。次要结局包括每日吗啡毫克当量中位数、疼痛评分中位数、出院时间和阿片类药物与非阿片类药物疼痛药物的使用情况。进行描述性和双变量分析。
在干预前（n=283）和干预后（n=286）组之间，基线特征无显著差异。与干预前相比，住院期间吗啡毫克当量中位数从 120（90-176 四分位距）降低至 30（5-68）（P<.001），每日吗啡毫克当量中位数从 51（41-60）降低至 12（2-25）（P<.001）。两组间出院时间或疼痛评分中位数无差异。酮咯酸的使用率（干预前 80%，干预后 75%，P=.14）或布洛芬每日毫克数（干预前 1391 毫克，干预后 1347 毫克，P=.22）无差异。每日对乙酰氨基酚毫克数中位数增加（干预前 753 毫克，干预后 2340 毫克，P<.001）。住院期间不使用阿片类药物的患者比例显著增加（干预前 6%，干预后 19%，P<.001）。
采用多模式阶梯式方法控制剖宫产术后疼痛与阿片类药物消耗明显减少相关，而不会延长住院时间或疼痛评分中位数。通过将对乙酰氨基酚与阿片类药物分开，并将阿片类药物的使用限制在爆发性疼痛，我们能够实施一种基于级别的疼痛管理方法。
