404 ERAS protocol to improve racial and ethnic disparities in pain management following cesarean delivery

Abstract

To assess efficacy of an enhanced recovery after surgery (ERAS) protocol on racial/ ethnic disparities in pain management after cesarean. We performed a retrospective cohort study of all scheduled cesarean deliveries 6 months before and after ERAS implementation at our institution. Pre-ERAS, only sodium citrate was given preoperatively, and all postoperative medications were given as needed. The ERAS protocol included preoperative acetaminophen, celecoxib, ondansetron, and sodium citrate. Postoperatively, patients received scheduled nonsteroidal anti-inflammatory drugs and acetaminophen. Oral oxycodone was used as needed. The primary outcome was total opioid use in the first 48 hours post-cesarean before and after ERAS, reported in equivalents of 5mg Oxycodone tablets. Data were also analyzed by racial/ethnic groups; non-Hispanic Black (NHB), non-Hispanic White (NHW), Asian (A), and Hispanic (H). Analysis was by chi squared, independent t-tests, ANOVA, Mann Whitney U, and Kruskal-Wallis tests depending on variable and data normality. Pre-ERAS and post-ERAS groups included 50 and 99 women. There were more women and a higher percentage of Hispanic women in the post-ERAS group due to closure of another city hospital. Post-ERAS, total opioid use in 48 hours was less (13.6 vs 3.0 5mg Oxycodone tablets, p<0.001) and pain scores were lower on postoperative day 1 (POD1) and 2 (POD2) (POD1 max rest- 6.7 vs 5.3, p= 0.001; POD2 max rest 6.9 vs 6.0, p = 0.041). Pre-ERAS pain scores differed by race with NHB and Hispanic patients reporting the highest mean and max VAS pain scores POD1 and POD2 (POD1, max VAS rest: NHB-7.5, NHW-6.3, A-3.8 H-8.0, p=0.007). Pre-ERAS there were also differences in acetaminophen use and number of pain assessments by group on POD1. Post-ERAS, analgesic use, number of pain assessments and max VAS pain scores on POD1 were similar in all racial/ ethnic groups. A standardized ERAS protocol for post-cesarean pain management may improve disparities in post-cesarean pain control. More research is needed to continue addressing this important topic.