From the Duke University School of Medicine, Durham, North Carolina.
Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina.
Anesth Analg. 2023 Aug 1;137(2):256-266. doi: 10.1213/ANE.0000000000006428. Epub 2023 Mar 22.
Optimizing analgesia after cesarean delivery is essential to quality of patient recovery. The American Society of Anesthesiologists and the Society for Obstetric Anesthesia and Perinatology recommend multimodal analgesia (MMA). However, little is known about clinical implementation of these guidelines after cesarean delivery under general anesthesia (GA). We performed this study to describe the use of MMA after cesarean delivery under GA in the United States and determine factors associated with use of MMA, variation in analgesia practice across hospitals, and trends in MMA use over time.
A retrospective cohort study of women over 18 years who had a cesarean delivery under GA between 2008 and 2018 was conducted using the Premier Healthcare database (Premier Inc). The primary outcome was utilization of opioid-sparing MMA (osMMA), defined as receipt of nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen with or without opioids and without the use of an opioid-combination drug. Any use of either agent within a combination preparation was not considered osMMA. The secondary outcome was use of optimal opioid-sparing MMA (OosMMA), defined as use of a local anesthetic technique such as truncal block or local anesthetic infiltration in addition to osMMA. Mixed-effects logistic regression models were used to examine factors associated with use of osMMA, as well as variation across hospitals.
A total of 130,946 patients were included in analysis. osMMA regimens were used in 11,133 patients (8.5%). Use of osMMA increased from 2.0% in 2008 to 18.8% in 2018. Black race (7.9% vs 9.3%; odds ratio [OR] [95% confidence interval {CI}] 0.87 [0.81-0.94]) and Hispanic ethnicity (8.6% vs 10.0%; OR, 0.86 [0.79-0.950]) were associated with less receipt of osMMA compared to White and non-Hispanic counterparts. Medical comorbidities were generally not associated with receipt of osMMA, although patients with preeclampsia were less likely to receive osMMA (9.0%; OR, 0.91 [0.85-0.98]), while those with a history of drug abuse (12.5%; OR, 1.42 [1.27-1.58]) were more likely to receive osMMA. There was moderate interhospital variability in the use of osMMA (intraclass correlation coefficient = 38%). OosMMA was used in 2122 (1.6%) patients, and utilization increased from 0.8% in 2008 to 4.1% in 2018.
Variation in osMMA utilization was observed after cesarean delivery under GA in this cohort of US hospitals. While increasing trends in utilization of osMMA and OosMMA are encouraging, there is need for increased attention to postoperative analgesia practices after GA for cesarean delivery given low percentage of patients receiving osMMA and OosMMA.
优化剖宫产术后的镇痛对于患者康复质量至关重要。美国麻醉医师学会和产科麻醉与围产医学学会推荐多模式镇痛（MMA）。然而，关于全身麻醉（GA）下剖宫产术后这些指南的临床实施情况知之甚少。我们进行了这项研究，以描述美国 GA 下剖宫产术后 MMA 的使用情况，并确定与 MMA 使用相关的因素、医院间镇痛实践的差异，以及 MMA 使用随时间的变化趋势。
使用 Premier Healthcare 数据库（Premier Inc）对 2008 年至 2018 年期间接受 GA 剖宫产的 18 岁以上女性进行回顾性队列研究。主要结局是使用阿片类药物节省 MMA（osMMA），定义为使用非甾体抗炎药（NSAIDs）和对乙酰氨基酚，无论是否使用阿片类药物，而不使用阿片类药物联合药物。在联合制剂中使用任何一种药物均不视为 osMMA。次要结局是使用最佳阿片类药物节省 MMA（OosMMA），定义为使用局部麻醉技术，如躯干阻滞或局部麻醉浸润，外加 osMMA。使用混合效应逻辑回归模型来检查与 osMMA 使用相关的因素以及医院间的差异。
共纳入 130946 名患者进行分析。11133 名患者（8.5%）使用了 osMMA 方案。osMMA 的使用从 2008 年的 2.0%增加到 2018 年的 18.8%。与白人及非西班牙裔患者相比，黑种人（7.9%比 9.3%；比值比[OR] [95%置信区间{CI}] 0.87 [0.81-0.94]）和西班牙裔（8.6%比 10.0%；OR，0.86 [0.79-0.950]）接受 osMMA 的可能性较小。一般来说，合并症与接受 osMMA 无关，但患有子痫前期的患者接受 osMMA 的可能性较低（9.0%；OR，0.91 [0.85-0.98]），而有药物滥用史的患者（12.5%；OR，1.42 [1.27-1.58]）更有可能接受 osMMA。osMMA 的使用存在中度医院间差异（组内相关系数=38%）。2122 名（1.6%）患者使用了 OosMMA，其使用率从 2008 年的 0.8%增加到 2018 年的 4.1%。
在本研究的美国医院队列中，GA 下剖宫产术后 osMMA 的使用存在差异。尽管 osMMA 和 OosMMA 使用率的上升趋势令人鼓舞，但鉴于接受 osMMA 和 OosMMA 的患者比例较低，仍需要更多关注 GA 下剖宫产术后的术后镇痛实践。
