843 A comparison of acute pain management strategies after cesarean delivery

Abstract

To determine if a multimodal pain management regimen after cesarean delivery reduces the number of morphine milligram equivalents (MME) compared to traditional patient controlled opioid analgesia (PCA) while adequately controlling postoperative pain. This was a prospective inception cohort analysis of postoperative pain management for women undergoing cesarean delivery at a large county hospital during a transition from a traditional morphine PCA to a multimodal regimen that included scheduled NSAIDs and acetaminophen, with opioids as needed. Data was collected for a 6 week period before and after the transition. The primary outcome was postoperative opioid use defined as MME in the first 48 hours. Secondary outcomes included serial pain scores, time to discharge, and exclusive breastfeeding rates. Women who required general anesthesia, had a history of substance abuse disorder or who delivered in the first 4 weeks after the transition were excluded. Statistical analysis included Student’s t test, Wilcoxon rank sum and Hodges-Lehman shift. During the study period 878 women underwent cesarean delivery and 775 met inclusion criteria: 376 received the traditional PCA and 399 received the multimodal regimen. Implementation of a multimodal regimen resulted in a significant reduction in MME use in the first 48 hours (30 [16,45] MME vs 135 [88,177] MME, p<0.001, Figure). Compared to the traditional group, more women in the multimodal group reported a pain score ≤ 4 by 48 hours (88% vs 77%, p<0.001). There was no difference in time to discharge. Of women who planned to exclusively breastfeed, fewer used formula prior to discharge in the multimodal group as compared to the traditional group (9% vs 12%, p<0.001). Transition to a multimodal pain management regimen for women undergoing cesarean delivery resulted in decreased opioid use while adequately controlling postoperative pain. A multimodal regimen was associated with early successful exclusive breastfeeding.