Abstract
Introduction
Caesarean delivery is the most common major surgical procedure performed worldwide and pain management after caesarean delivery remains challenging. Finding a balance between sufficient postoperative pain relief and excess sedation secondary to opioids is often difficult in this patient population. This quality improvement project aimed to manage the amount of opioid consumption after caesarean delivery using a new postoperative analgesic regimen.
Methods
The current practice was analysed in 52 patients before introducing the new regimen. Oxycodone consumption, pain scores and quality of recovery were recorded. Following this pre-implementation audit, a new postoperative analgesic protocol was introduced. All patients received standard doses of intrathecal morphine, paracetamol and diclofenac. Regular oxycodone sustained-release (SR) was replaced with oxycodone immediate-release (IR) as needed. These changes also coincided with education to improve midwifery assessment of pain and the delivery of analgesia.
Results
The outcome measures were re-audited in 178 patients which showed that oxycodone consumption had reduced median (IQR) 30 mg (20–40) vs 10 mg (5–15) (p < 0.001). There was no significant difference in the pain scores between the before and after groups at rest median (IQR) 2.0 (0–4.8) vs 2.0 (0.8–4.0) or at movement 5.0 (3.0–6.0) vs 5.0 (3.0–6.3) (p = 0.292, p = 0.482 respectively). The quality of recovery scores were also equivalent mean (SD) 78.6 (20.6) vs 77.8 (19.0) (p = 0.792).
Conclusion
The results of this study suggest that postoperative opioid consumption can be reduced with specific analgesic protocols and allow us to improve patient’s quality of recovery.
References
Gerbershagen HJ, Aduckathil S, van Wijck AJ, Peelen LM, Kalkman CJ, Meissner W (2013) Pain intensity on the first day after surgery: a prospective cohort study comparing 179 surgical procedures. Anesthesiology 118:934–944
Wong CA, Girard T (2018) Undertreated or overtreated? Opioids for postdelivery analgesia. Br J Anaesth 121:339–342
Neil MJ, Bannister J (2015) When acute pain becomes chronic. Anaesthesia 70:779–783
Ciechanowicz S, Setty T, Robson E et al (2018) Development and evaluation of an obstetric quality-of-recovery score (ObsQoR-11) after elective caesarean delivery. Br J Anaesth 122:69–78
Levy N, Mills P (2018) Controlled-release opioids cause harm and should be avoided in management of postoperative pain in opioid naïve patients. Br J Anaesth S0007-0912:30711–30716
Eisenach JC, Pan PH, Smiley R, Lavand’homme P, Landau R, Houle TT (2008) Severity of acute pain after childbirth, but not type of delivery, predicts persistent pain and postpartum depression. Pain 140:87–94
Jin J, Peng L, Chen Q et al (2016) Prevalence and risk factors for chronic pain following cesarean section: a prospective study. BMC Anesthesiol 16:99
Wright JD, Huang Y, Melamed A et al (2019) Use and misuse of opioids after gynecologic surgical procedures. Obstet Gynecol 134:250–260
Centers for Disease Control and Prevention (2017) Opioid overdose. Available from: https://www.cdc.gov/drugoverdose/index.html. [Accessed 16 October 2019]
Lee B, Schug SA, Joshi GP, Kehlet H, PROSPECT Working Group (2018) Procedure-specific pain management (PROSPECT) – an update. Best Pract Res Clin Anaesthesiol 32:101–111
Australia and New Zealand College of Anaesthesia (2018) Position statement on the use of slow-release opioid preparations in the treatment of acute pain. Available from: http://www.anzca.edu.au/resources/endorsed-guidelines/positionstatement-on-the-use-of-slow-release-opio. [Accessed 25 January 2020]
Acknowledgements
We would like to thank all the women who helped make this quality improvement initiative a success. We also thank the midwives, post-anaesthetic care unit nurses, anaesthetic clinic, anaesthetists and obstetricians for their diligence and patience.
Author statement
All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Ruairi Irwin and Glenn Paul Abela. The first draft of the manuscript was written by Ruairi Irwin, with other authors reading and approving the final version.
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This study was a quality improvement initiative not requiring local ethical committee approval.
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Irwin, R., Abela, G.P., Stanescu, S. et al. Managing opioid consumption after caesarean delivery: a quality improvement initiative. Ir J Med Sci 189, 1069–1072 (2020). https://doi.org/10.1007/s11845-020-02201-x
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DOI: https://doi.org/10.1007/s11845-020-02201-x