Impact of patient choice for different postcesarean delivery analgesic protocols on opioid consumption: a randomized prospective clinical trial

Abstract

BackgroundChoice of postcesarean delivery analgesic protocol may improve pain experience and reduce analgesic requirements.MethodsCesarean delivery patients were randomly assigned either to choose their postcesarean delivery analgesia protocol or to have no choice and receive routine care. Choices were low (50 μg intrathecal morphine), medium (identical to routine care: 150 μg intrathecal morphine), or high (300 μg intrathecal morphine with 600 mg oral gabapentin). All groups received scheduled acetaminophen and ibuprofen. The primary outcome was oxycodone requirements 0–48 hours postdelivery in those offered versus not offered a choice.ResultsOf 160 women enrolled, 120 were offered a choice and 40 were not offered a choice. There was no difference in oxycodone requirements or pain associated with choice, but those who had a choice expressed more satisfaction than those who did not have a choice (mean (95% CI) difference 5% (0% to 10 %), p=0.005). In the choice group, the high dose group required more oxycodone (5 (0 to 15) mg 0–24 hours after delivery and 15 (10 to 25) mg at 24–48 hours; p=0.05 and p=0.001) versus the low and medium groups. The low dose group had less pruritus (p=0.001), while the high dose group had more vomiting (p=0.01) requiring antiemetic treatment (p=0.04).ConclusionHaving a choice compared with no choice routine care did not reduce oxycodone requirements or pain scores. However, women have insight into their analgesic needs; women offered a choice and who chose the higher dose analgesic protocol required more oxycodone, and women who chose the lower dose protocol required less oxycodone. Despite providing additional analgesic (six times more intrathecal morphine plus gabapentin in high dose vs low dose protocols), we still did not equalize postcesarean oxycodone requirement differences between groups.Trial registration number NCT02605187.

PROSPECT guideline for elective caesarean section: updated systematic review and procedure‐specific postoperative pain management recommendations

“…A total of 145 studies were included, of which 126 were randomised controlled trials and 19 were systematic reviews and meta‐analyses (Fig. 1) [9–153]. The methodological quality assessments of the 126 randomised controlled trials included in the final qualitative analysis are summarised in online Supporting Information Table S1.…”

“…In a comparative study, intrathecal morphine provided better analgesia compared with epidural morphine and patient-controlled epidural analgesia of ropivacaine with sufentanil [44]. In two studies, women were offered to choose the analgesic strategy and select either no intrathecal morphine or a low or high dose of intrathecal morphine [45,46]. Having a choice did not impact on rescue opioid consumption, but women were very good in predicting their actual opioid needs.…”

“…Having a choice did not impact on rescue opioid consumption, but women were very good in predicting their actual opioid needs. Choosing high-dose intrathecal morphine was associated with increased rescue analgesia and more vomiting [45,46]. Apart from one study [44], all studies used basic analgesia with NSAIDs [42,43,46] or a combination of NSAIDs and paracetamol [45].…”

“…Choosing high-dose intrathecal morphine was associated with increased rescue analgesia and more vomiting [45,46]. Apart from one study [44], all studies used basic analgesia with NSAIDs [42,43,46] or a combination of NSAIDs and paracetamol [45]. Intrathecal morphine was similar to intrathecal hydromorphone in a recent trial by Sharpe et al [47].…”

Tailoring postoperative pain management with a procedure‐specific approach: how to best apply this concept to caesarean deliveries

“…breastfeeding, caring for their newborn) that differ immensely from the general population. It has been shown that patient choice is an important factor to take into account when tailoring post‐caesarean analgesic approaches [15]. In addition, assessments should continue beyond the immediate surgical period, as adverse outcomes related to poorly controlled pain may arise beyond the usual 72 postoperative hours.…”