Introduction of enhanced recovery for elective caesarean section enabling next day discharge: a tertiary centre experience

Wrench, I.; Allison, Andrew; Galimberti, Andrea; Radley, Stephen; Wilson, Matthew

doi:10.1016/j.ijoa.2015.01.003

Cited by 90 publications

(79 citation statements)

References 10 publications

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“…[2] These goals must be met without compromising the quality of care, which includes patient satisfaction. [3] In light of this, a clear definition of the period of the greatest postoperative analgesic requirement should be a priority.…”

Section: Introductionmentioning

confidence: 99%

Analgesic efficacy of intrathecal fentanyl during the period of highest analgesic demand after cesarean section

et al. 2016

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Cesarean section (CS) is one of the most common surgical procedures in female patients. We aimed to evaluate the postoperative analgesic efficacy of intrathecal fentanyl during the period of greatest postoperative analgesic demand after CS. This period was defined by detailed analysis of patient-controlled analgesia (PCA) usage.This double-blind, placebo-controlled, parallel-group randomized trial included 60 parturients who were scheduled for elective CS. Participants received spinal anesthesia with bupivacaine supplemented with normal saline (control group) or with fentanyl 25 μg (fentanyl group). To evaluate primary endpoints, we measured total pethidine consumption over the period of greatest PCA pethidine requirement. For verification of secondary endpoints, we recorded intravenous PCA requirement in other time windows, duration of effective analgesia, pain scores assessed by visual analog scale, opioid side effects, hemodynamic changes, neonatal Apgar scores, and intraoperative pain.Detailed analysis of hour-by-hour PCA opioid requirements showed that the greatest demand for analgesics among patients in the control group occurred during the first 12 hours after surgery. Patients in the fentanyl group had significantly reduced opioid consumption compared with the controls during this period and had a prolonged duration of effective analgesia. The groups were similar in visual analog scale, incidence of analgesia-related side effects (nausea/vomiting, pruritus, oversedation, and respiratory depression), and neonatal Apgar scores. Mild respiratory depression occurred in 1 patient in each group. Fewer patients experienced intraoperative pain in the fentanyl group (3% vs 23%; relative risk 6.8, 95% confidence interval 0.9–51.6).The requirement for postoperative analgesics is greatest during the first 12 hours after induction of anesthesia in patients undergoing CS. The addition of intrathecal fentanyl to spinal anesthesia is effective for intraoperative analgesia and decreases opioid consumption during the period of the highest analgesic demand after CS, without an increase in maternal or neonatal side effects. We recommend using intrathecal fentanyl for CS in medical centers not using morphine or other opioids intrathecally at present.

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Section: Introductionmentioning

confidence: 99%

Analgesic efficacy of intrathecal fentanyl during the period of highest analgesic demand after cesarean section

et al. 2016

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“…After removing duplicates, 35 unique papers remained, eight of which were deemed ‘eligible at title/abstract’. Of these eight papers, three [30–32] met the inclusion criteria at full text. Of the remaining five, four were conference abstracts [33–36] covering two studies, which were not retrievable at full text but were included in the study as relevant qualitative data (reported enhanced recovery components in elective caesarean) were extracted from the abstract.…”

Section: Resultsmentioning

confidence: 99%

“…Two of the five eligible studies proposing ERAS packages for elective caesarean were rated moderate quality guidelines (Wrench [32] and Halder [31]) scoring 61% and 62% across the AGREE II domains respectively. The other eligible studies (Lucas [30], Damluji [33] and Abell / Long [34–36]) were rated low quality evidence as they only scored 39%, 28% and 30% respectively across the domains.…”

Section: Resultsmentioning

confidence: 99%

Enhanced recovery after elective caesarean: a rapid review of clinical protocols, and an umbrella review of systematic reviews

Corso

Hind

Beever

et al. 2017

BMC Pregnancy Childbirth

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BackgroundThe rate of elective Caesarean Section (CS) is rising in many countries. Many obstetric units in the UK have either introduced or are planning to introduce enhanced recovery (ER) as a means of reducing length of stay for planned CS. However, to date there has been very little evidence produced regarding the necessary components of ER for the obstetric population. We conducted a rapid review of the composition of published ER pathways for elective CS and undertook an umbrella review of systematic reviews evaluating ER components and pathways in any surgical setting.MethodsPathways were identified using MEDLINE, EMBASE and the National Guideline Clearing House, appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool and their components tabulated. Systematic reviews were identified using the Cochrane Library and Database of Abstracts of Reviews of Effects (DARE) and appraised using The Grading of Recommendations Assessment, Development and Evaluation (GRADE). Two reviewers aggregated summaries of findings for Length of Stay (LoS).ResultsFive clinical protocols were identified, involving a total of 25 clinical components; 3/25 components were common to all five pathways (early oral intake, mobilization and removal of urinary catheter). AGREE II scores were generally low. Systematic reviews of single components found that minimally invasive Joel-Cohen surgical technique, early catheter removal and post-operative antibiotic prophylaxis reduced LoS after CS most significantly by around half to 1 and a half days. Ten meta-analyses of multi-component Enhanced Recovery after Surgery (ERAS) packages demonstrated reductions in LoS of between 1 and 4 days. The quality of evidence was mostly low or moderate.ConclusionsFurther research is needed to develop, using formal methods, and evaluate pathways for enhanced recovery in elective CS. Appropriate quality improvement packages are needed to optimise their implementation.Electronic supplementary materialThe online version of this article (doi:10.1186/s12884-017-1265-0) contains supplementary material, which is available to authorized users.

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“…Compared with spontaneous birth, CS is associated with prolonged hospital stay, despite recommendations by the UK National Institute for Health and Care Excellence that, if recovering well, women can go home 24 hours after surgery 2 . Women have expressed a strong desire for earlier discharge after elective CS, provided their care needs are met 3 . The proportion of women leaving hospital the day after elective CS continues to rise in the UK 1 , suggesting that 'enhanced recovery' (ER) principles are being practised, albeit inconsistently 4 , 5 .…”

Section: Working Title: Enhanced Recovery Pathway For Elective Caesarmentioning

confidence: 99%

Enhanced recovery pathway for elective caesarean section

Coates

Fuller

Hind

et al. 2016

International Journal of Obstetric Anesthesia

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Introduction of enhanced recovery for elective caesarean section enabling next day discharge: a tertiary centre experience

Cited by 90 publications

References 10 publications

Analgesic efficacy of intrathecal fentanyl during the period of highest analgesic demand after cesarean section

Analgesic efficacy of intrathecal fentanyl during the period of highest analgesic demand after cesarean section

Enhanced recovery after elective caesarean: a rapid review of clinical protocols, and an umbrella review of systematic reviews

Enhanced recovery pathway for elective caesarean section

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