Patient-controlled oral analgesia versus nurse-controlled parenteral analgesia after caesarean section: a randomised controlled trial

Abstract

SummaryWe assessed the effectiveness of early patient-controlled oral analgesia compared with parenteral analgesia in a randomised controlled non-inferiority trial of women undergoing elective caesarean section under regional anaesthesia. Seventy-seven women received multimodal paracetamol, ketoprofen and morphine analgesia. The woman having patient-controlled oral analgesia were administered four pillboxes on the postnatal ward containing tablets and instructions for self-medication, the first at 7 h after the spinal injection and then three more at 12-hourly intervals. Pain at rest and on movement was evaluated using an 11-point verbal rating scale at 2 h and then at 6-hourly intervals for 48 h. The pre-defined non-inferiority limit for the difference in mean pain scores (patient-controlled oral analgesia minus parenteral) was one. The one-sided 95% CI of the difference in mean pain scores was significantly lower than one at all time-points at rest and on movement, demonstrating non-inferiority of patient-controlled oral analgesia. More women used morphine in the patient-controlled oral analgesia group (22 (58%)) than in the parenteral group (9 (23%); p = 0.002). The median (IQR [range]) number of morphine doses in the patient-controlled oral analgesia group was 2 (1-3 [1-7]) compared with 1 (1-1 [1-2]); p = 0.006) in the parenteral group. Minor drug errors or omissions were identified in five (13%) women receiving patient-controlled oral analgesia. Pruritus was more frequent in the patient-controlled oral analgesia group (14 (37%) vs 6 (15%) respectively; p = 0.03), but no differences were noted for other adverse events and maternal satisfaction. After elective caesarean section, early patientcontrolled oral analgesia is non-inferior to standard parenteral analgesia for pain management, and can be one of the steps of an enhanced recovery process.

Patient-controlled oral analgesia for acute abdominal pain: A before-and-after intervention study on pain intensity and use of analgesics

“…One study of postpartum pain management showed similar findings, where patients in the PCOA group used fewer analgesics than patients receiving standard care (East et al, 2007). Other studies of IV-PCA (McNicol et al, 2015) and PCOA (Bonnal et al, 2016) have shown an increase in the use of opioids postoperatively, which is the opposite finding to our study. The difference might be explained by the fact that fewer patients in the PCOA group underwent surgery than in the control group in our study.…”

“…The pattern with a lower pain score in our study is equivalent to studies of IV-PCA (Birnbaum et al, 2012, McNicol et al, 2015; however, neither our study nor other studies on PCOA (Bonnal et al, 2016;East et al, 2007;Kastanias et al, 2010) have shown a significant decrease in pain scores as in the studies with IV-PCA (Birnbaum et al;2012, McNicol et al, 2015. An explanation of the differences could be the lack of instructions to the patients on how to use the PRN analgesics in PCOA.…”

“…In the PCOA group, the patients used either no medication or paracetamol only after vaginal delivery and after caesarean the use of opioids was unchanged when compared with standard care (East, Dube, & Perreault, 2007). One study in women undergoing elective caesarean section showed that the PCOA group had unchanged pain scores, and an increased patient satisfaction and use of opioids when compared with women receiving parenteral analgesia (Bonnal et al, 2016). Studies of pain management in cases of knee arthroplasty have shown no difference in pain score, patient satisfaction, opioid consumption or side effects when PCOA was compared with usual care (Kastanias, Gowans, Tumber, Snaith, & Robinson, 2010), but showed less pain interference with general activity, mood, physical therapy, sleep, and appetite,…”

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“…In accordance with the former study, we found that the multidrug therapy was more effective than the single drug therapy in postoperative pain relief. Bonnal A et al, compared multimodal analgesia and patient controlled oral analgesia in elective caesarean section and found that multimodal analgesia is advantageous than patient controlled analgesia in relieving pain but no differences were noted for other adverse events and maternal satisfaction 16 . Roman Schumann et al, in their study proposed that the multimodal therapy is more effective than the single modal therapy in postoperative pain management 17 .…”

Factors associated with success and failure of patient-controlled oral analgesia after total hip and knee arthroplasty: a historical comparative cohort study

“…14 There is evidence that oral opioid alternatives to IV-PCA have equivalent analgesic effects in the postoperative period with a lower incidence of adverse effects. [15][16][17] Patient-controlled oral analgesia (PCOA) is a novel method of oral opioid administration practiced at our institution whereby breakthrough pain is managed with a set dose of a short-acting oral opioid that is available at the patient's bedside and is replaced if exhausted following regular lockout intervals (every two hours) while patients record pain levels and opioid use. 18 Patient-controlled oral analgesia may offer benefits such as a better analgesic profile, increased mobility, and less constipation, 19 and allows patients to vary their analgesia more easily according to pain and activity levels, 20 while minimizing costs.…”