Multimodal Pain Management for Cesarean Delivery: A Double-Blinded, Placebo-Controlled, Randomized Clinical Trial

Abstract

Objective Our objective was to evaluate the efficacy of perioperative multimodal pain management in reducing opioid use after elective cesarean delivery (CD). Study Design A single-center, double-blinded, placebo-controlled randomized trial of women undergoing elective CD. Participants were allocated 1:1 to receive the multimodal protocol or matching placebos. The multimodal protocol consisted of a preoperative dose of intravenous acetaminophen, preincision injection of subcutaneous bupivacaine, and intraoperative injection of intramuscular ketorolac. Primary outcome was total opioid intake at 48 hours postoperatively. Secondary outcomes were pain scores, time to first opioid intake, neonatal outcomes, and total outpatient opioid intake on postoperative day (POD) 7. Data were analyzed using parametric and nonparametric tests and quantile regression as appropriate. Results A total of 242 women were screened with 120 randomized, 60 to the multimodal group and 60 to control group. There was no significant difference in the primary outcome of opioid use nor in the secondary outcomes. Smokers and patients with a history of drug use had higher median postoperative opiate use and earlier administration. On POD 7, only 40% of prescribed opioids had been used, and there was no difference between the groups. Conclusion This perioperative multimodal pain regimen did not reduce opioid use in 48 hours after CD. Patients who smoke or with a history of drug use required more opioids in the postoperative period. Providers significantly overprescribed opioids after CD.

Enhanced Recovery after Surgery Protocol to Improve Racial and Ethnic Disparities in Postcesarean Pain Management

“…This finding is similar to other studies that have evaluated the efficacy of ERAS after CD for postoperative pain control. 4 5 15…”

“…This finding is similar to other studies that have evaluated the efficacy of ERAS after CD for postoperative pain control. 4,5,15 Clinical Implications ERAS implementation was associated with significantly decreased racial and ethnic differences in POD1 and POD2 VAS pain scores with movement but not at rest after CD. Notably, our data show a trend toward higher total opioid use in NHB women compared with all other groups in both the pre-and post-ERAS timeframes although this difference did not meet statistical significance.…”

<p>The Advantage of Implementation of Enhanced Recovery After Surgery (ERAS) in Acute Pain Management During Elective Cesarean Delivery: A Prospective Randomized Controlled Trial</p>

“…Some investigators have shown that acetaminophen or NSAIDs could decrease the requirement of postoperative opioids, 17 while others were of the opposite view. 18,19 Transversus abdominis plane (TAP) blocks helped provide improved postoperative analgesia and reduce morphine consumption in patients who underwent CD under general anesthesia, 20 but not in those who received intrathecal morphine. 21 Compared to the standard analgesic regimen, TAP blocks do not have any effect in reducing the incidence or severity of chronic postsurgical pain after CD.…”

A comparison of acute pain management strategies after cesarean delivery

“…The use of a multimodal postoperative pain management regimen alone, without other ERAS measures, can provide a meaningful change to current practice even in facilities with limited resources. Other studies such as the randomized control trial by Hadley et al 15 did not demonstrate a difference in opioid consumption. However, nonnarcotic pain medications such as acetaminophen and ibuprofen were not scheduled after surgery and were only administered as needed, which was a limitation recognized by the authors.…”

“…12 whereas others showing no difference. 11,15 While we plan to implement other portions of the ERAS for cesarean delivery guidelines in the future, we were able to demonstrate that a dramatic decrease in postoperative opioid use was possible with a change to a simple medication regimen alone.…”