Ubom Ememobong O, Wang Carrie, Klocksieben Farina, Flicker Amanda B, Diven Liany, Rochon Meredith, Quiñones Joanne N
Department of Obstetrics and Gynecology, Lehigh Valley Health Network, Allentown, PA (Drs Ubom, Flicker, and Diven).
University of South Florida Morsani College of Medicine, University of South Florida, Tampa, FL (Mses Wang and Klocksieben).
AJOG Glob Rep. 2023 May 6;3(3):100220. doi: 10.1016/j.xagr.2023.100220. eCollection 2023 Aug.
Opioids are routinely prescribed to patients postoperatively after cesarean delivery. With rates of cesarean deliveries increasing globally and the opioid epidemic continuing to have deleterious effects, finding methods to achieve effective pain control without opioids is of increasing importance. The ERAS (Enhanced Recovery After Surgery) protocol applied following cesarean delivery engages multimodal perioperative management techniques to encourage early recovery. In the obstetrical surgery setting, these interventions include increasing scheduled nonsteroidal anti-inflammatory drug administration and laxative use to improve postoperative gastrointestinal motility and pain scores. Postcesarean patients are also encouraged to use abdominal binders, incentive spirometry, and early movement as pain modulators.
This quality improvement study aimed to measure whether the introduction of an ERAS protocol following cesarean delivery at a United States-based health network would improve outcomes such as the use of opioid medications for pain and pain control.
This single-center retrospective cohort study compared patients who gave birth via cesarean delivery before (n=1425) and after (n=3478) the implementation of the postsurgical recovery protocol. Outcomes of interest included total postoperative opioid medications used, discharge opioid prescription, average pain score, pain scores by postoperative day, and highest pain score. Patients with a history of opioid use disorder, those who underwent a cesarean hysterectomy, and those who experienced a major surgical complication at delivery were excluded. Data were collected from the electronic medical record.
Patients in the postimplementation period used significantly fewer opioid medications than those who gave birth before the protocol was introduced at the institution. The total median opioid use before implementation was 75 morphine milligram equivalents (interquartile range, 45-112.5) vs 30 (interquartile range, 15-52.5) after implementation (<.001). The median discharge prescription was 225 (interquartile range, 150-225) before implementation vs 112.5 (interquartile range, 75-150) after implementation (<.001). Pain scores were also significantly lower after implementation. The median highest pain score was 8 (interquartile range, 6-8) on a 10-point pain scale before implementation vs 7 (interquartile range, 6-8) after implementation (<.001). The average pain score before implementation was 3.4 (interquartile range, 2.4-4.5) vs 2.9 (interquartile range, 1.9-3.9) after implementation (<.001). Results of paired-sample analyses of 177 patients who gave birth by cesarean delivery in both time periods showed statistically significant outcomes similar to those of the larger cohort groups.
Implementation of multimodal pain regimens following cesarean delivery, such as the ERAS protocol, which incorporate both pharmacologic (nonsteroidal anti-inflammatory drugs, laxatives) and nonpharmacologic methods (abdominal binders, deep breathing, movement) can be effective for pain control and may decrease postoperative opioid prescribing needs, thus mitigating the potential for opioid misuse and dependence.
剖宫产术后通常会给患者开具阿片类药物。随着全球剖宫产率的上升以及阿片类药物流行持续产生有害影响，寻找无需使用阿片类药物实现有效疼痛控制的方法变得越来越重要。剖宫产术后应用的加速康复外科（ERAS）方案采用多模式围手术期管理技术以促进早期康复。在产科手术环境中，这些干预措施包括增加非甾体类抗炎药的定期给药以及使用泻药以改善术后胃肠蠕动和疼痛评分。剖宫产术后患者还被鼓励使用腹带、激励肺活量测定法以及早期活动作为疼痛调节手段。
这项质量改进研究旨在衡量在美国一家医疗网络机构实施剖宫产术后的ERAS方案是否会改善诸如用于止痛的阿片类药物使用情况和疼痛控制等结果。
这项单中心回顾性队列研究比较了在实施术后恢复方案之前（n = 1425）和之后（n = 3478）剖宫产分娩的患者。感兴趣的结果包括术后使用的阿片类药物总量、出院时的阿片类药物处方、平均疼痛评分、术后每日疼痛评分以及最高疼痛评分。排除有阿片类药物使用障碍病史的患者、接受剖宫产子宫切除术的患者以及分娩时发生重大手术并发症的患者。数据从电子病历中收集。
实施该方案后的患者使用的阿片类药物明显少于该机构引入该方案之前剖宫产分娩的患者。实施前阿片类药物使用总量的中位数为75吗啡毫克当量（四分位间距，45 - 112.5），而实施后为30（四分位间距，15 - 52.5）（P <.001）。实施前出院时阿片类药物处方的中位数为225（四分位间距，150 - 225），实施后为112.5（四分位间距，75 - 150）（P <.001）。实施后疼痛评分也显著更低。在10分制疼痛量表上，实施前最高疼痛评分的中位数为8（四分位间距，6 - 8），实施后为7（四分位间距，6 - 8）（P <.001）。实施前平均疼痛评分为3.4（四分位间距，2.4 - 4.5），实施后为2.9（四分位间距，1.9 - 3.9）（P <.001）。对在两个时期均剖宫产分娩的177例患者进行的配对样本分析结果显示，与较大队列组的结果具有统计学意义上的相似性。
剖宫产术后实施多模式疼痛治疗方案，如ERAS方案，其结合了药理学方法（非甾体类抗炎药、泻药）和非药理学方法（腹带、深呼吸、活动），对于疼痛控制可能是有效的，并且可能减少术后阿片类药物的处方需求，从而降低阿片类药物滥用和依赖的可能性。
