163 Impact of a standardized post-cesarean analgesia regimen on postpartum opioid use

Abstract

To determine if implementation of a standardized postoperative analgesic regimen decreases opioid use following cesarean birth. A standardized postoperative analgesia protocol was implemented in June 2018. It included scheduled acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) with opioids for breakthrough pain. There was no prior standardized protocol. A before-and-after study design was used to compare oral morphine milligram equivalents (MME) for nine months prior to and after this protocol was implemented, excluding the two month period of protocol rollout. Women with opioid use disorder or postoperative intubation were excluded. The primary outcome was the cumulative MME used in the first 72 hours postoperatively. Total MME dose at 12, 24, and 48 hours were also compared. Of 2340 women who underwent cesarean birth during the study period (7/1/17 – 4/30/19), 2001 women met inclusion criteria (914 before 4/10/18 (pre-protocol) and 1087 after 6/17/18 (post-protocol)). Baseline characteristics of the two groups were similar, including maternal body mass index (BMI), planned versus unplanned cesarean birth, and type of intraoperative anesthesia used. The cumulative opioid dose in the first 72 hours postoperatively was 216.3+/-84.3 MME prior to implementation compared to 171.5+/-91.5 MME following implementation (p<0.001). The average cumulative MME use was higher in the pre-protocol group compared to post-protocol at all time periods: 12 hours (57.3+/-23.8 vs 48.6+/-26.2 MME, p<0.001), 24 hours (98.1+/-34.1 vs 82.1+/-38.8 MME, p<0.001), and 48 hours (165.8+/-58.3 vs 134.9+/-66.2 MME, p<0.001). The average pain scores were lower in the pre-protocol group (3 vs 3.3, p<0.001). Scheduled administration of acetaminophen and NSAIDs following cesarean birth significantly decreased the cumulative dose of opioids used in the first 72 hours postoperatively by 20.7%. While the impact of this change is less than a full enhanced recovery after surgery protocol, this simple change resulted in an MME decrease that equates to 5-6 less doses of oral opioids.