A standardized post-cesarean analgesia regimen reduces postpartum opioid use

Optimal post-cesarean pain control is important. With the rising opioid epidemic it is imperative to maximize non-opioid based primary approaches to post-cesarean pain control. In 2018, we implemented a standardized post-cesarean analgesia regimen. To determine if implementation of a standardized postoperative analgesic regimen decreases opioid use following cesarean birth. A standardized postoperative analgesia protocol was implemented in June 2018, which included scheduled oral acetaminophen (975 mg every 6 h) and nonsteroidal anti-inflammatory drugs (NSAIDs) (ketorolac 15 mg IV every 6 h for 5 doses followed by ibuprofen 600 mg oral every 6 h) with opioids available for breakthrough pain. There was no prior standardized protocol. A before-and-after study design was used to compare oral morphine milligram equivalents (MME) for nine months prior to and nine months after this protocol was implemented, excluding the two month period of protocol rollout. Women with opioid use disorder or postoperative intubation were excluded. The primary outcome was the cumulative MME used in the first 72 h postoperatively. Total dose at 12, 24, and 48 h were also compared. Of 2340 women who underwent cesarean birth during the study period (1 July 2017 − 30 April 2019), 2001 women met inclusion criteria (914 before 10 April 2018 (pre-protocol) and 1087 after 17 June 2018 (post-protocol)). Baseline characteristics of the two groups were similar, including gestational age at delivery, maternal body mass index (BMI), planned versus unplanned cesarean birth, and type of intraoperative anesthesia used. The cumulative opioid dose in the first 72 h postoperatively was 216.3 ± 84.3 MME prior to implementation compared to 171.5 ± 91.5 MME following implementation (<i>p</i> &lt; .001). The average cumulative MME use was higher in the pre-protocol period compared to post-protocol at all time periods: 12 h (57.3 ± 23.8 vs 48.6 ± 26.2 MME, <i>p</i> &lt; .001), 24 h (98.1 ± 34.1 vs 82.1 ± 38.8 MME, <i>p</i> &lt; .001), and 48 h (165.8 ± 58.3 vs 134.9 ± 66.2 MME, <i>p</i> &lt; .001). The average pain scores were lower in the pre-protocol group (3 vs 3.3, <i>p</i> &lt; .001). Scheduled administration of acetaminophen and NSAIDs following cesarean birth significantly decreased the cumulative dose of opioids used in the first 72 h postoperatively.剖宫产术后最优镇痛管理至关重要。随着阿片类药物流行态势加剧，最大化采用非阿片类核心方案用于剖宫产术后疼痛管理已成为当务之急。2018年，我们推行了标准化的剖宫产术后镇痛方案。本研究旨在明确标准化术后镇痛方案的实施是否可降低剖宫产术后的阿片类药物使用量。2018年6月，我们正式实施标准化术后镇痛方案，该方案包含定时口服对乙酰氨基酚（acetaminophen，975mg，每6小时1次）与非甾体抗炎药（nonsteroidal anti-inflammatory drugs, NSAIDs）：先予酮咯酸15mg静脉注射，每6小时1次，共5剂，后续予布洛芬600mg口服，每6小时1次；同时预留阿片类药物用于爆发痛处理。此前并无标准化镇痛方案。本研究采用前后对照研究设计，比较方案实施前9个月与实施后9个月的口服吗啡毫克当量（morphine milligram equivalents, MME），并排除方案推广的2个月窗口期。研究排除合并阿片类物质使用障碍或术后需气管插管的产妇。主要结局指标为术后前72小时的累计阿片类药物MME用量，同时对比术后12、24及48小时的阿片类药物总剂量。研究周期为2017年7月1日至2019年4月30日，期间共2340名产妇接受剖宫产手术，其中2001名符合纳入标准：2018年4月10日前的方案实施前组共914例，2018年6月17日后的方案实施后组共1087例。两组产妇的基线特征均衡可比，包括分娩时孕周、产妇体质量指数（body mass index, BMI）、计划性与非计划性剖宫产术式，以及术中麻醉方式。方案实施前，产妇术后前72小时累计阿片类药物用量为216.3±84.3 MME，实施后降至171.5±91.5 MME（p<0.001）。在所有时间节点，方案实施前组的累计MME用量均高于实施后组：术后12小时（57.3±23.8 vs 48.6±26.2 MME，p<0.001）、术后24小时（98.1±34.1 vs 82.1±38.8 MME，p<0.001）及术后48小时（165.8±58.3 vs 134.9±66.2 MME，p<0.001）。方案实施前组的平均疼痛评分更低（3分 vs 3.3分，p<0.001）。剖宫产术后定时给予对乙酰氨基酚与NSAIDs，可显著降低术后前72小时的阿片类药物累计用量。