Evaluation of the impact of enhanced recovery after surgery protocol implementation on maternal outcomes following elective cesarean delivery

Effect of Enhanced Recovery after Surgery (ERAS) protocol on maternal outcomes following emergency caesarean delivery: A randomized controlled trial

Background

With ever increasing rates of emergency caesarean deliveries (CD),incorporating the ERAS protocol might provide a perfect window of opportunity to increase maternal comfort during the postsurgical period, but also improve outcomes and facilitate optimal return of physiological function.

Objective

To determine whether an ERAS pathway at emergency caesarean birth would permit a reduction in postoperative length of stay and improve postoperative patient satisfaction.

Material & methods

Patients undergoing emergent caesarean delivery at ≥ 34 weeks of gestation were randomized to ERAS or conventional care. The primary outcome was to compare postoperative length of hospital stay. Secondary outcome variables included first oral intake, passage of flatus/defecation, first ambulation, first urination after catheter removal and postoperative pain scores in both groups.

Results

We randomized 142 women (71 each in ERAS versus Conventional arm) undergoing emergency cesarean delivery. Incorporation of ERAS protocol resulted in shorter length of hospital stay (73.92 ± 8.96 in conventional arm vs 53.87 ± 15.02 in ERAS arm; p value <.0001). Significant difference was seen in visual analogue scoring during initial ambulation and rest on day 0 and day 1 between ERAS and conventional arms with mean scores being lower in ERAS arm compared to Conventional arm (p value <.05). In terms of quality of life, ERAS arm had better quality of life compared to conventional arm.

Conclusion

Incorporation of ERAS protocol in emergency caesarean definitely improves patient outcome in terms of early resumption of activities with better quality of life.

Intra- and post-operative outcomes of the Enhanced Recovery after Surgery (ERAS) Program in laparoscopic hysterectomy

PURPOSE

To investigate the effect of the Enhanced Recovery After Surgery (ERAS) protocol on perioperative and post-operative outcomes in laparoscopic hysterectomies (LHs) performed for benign gynecological diseases.

METHODS

This prospective study was conducted with randomized 100 participants who underwent LH between 1 January and 31 December, 2022. A standard care protocol was applied to 50 participants (Group 1, control) and the ERAS protocol to the other 50 (Group 2, study). Length of hospitalization was compared between the groups as the primary outcome, and the duration of the operation, the amount of bleeding, post-operative nausea-vomiting, gas discharge time, visual analog scale (VAS) pain scores, and complications as the secondary outcomes.

RESULTS

No statistically significant difference was seen between the groups in terms of sociodemographic characteristics, medical history, operation indications, surgical procedures applied in addition to hysterectomy, operative time, pre-operative and post-operative hemoglobin levels, amount of bleeding, or drain use (p > 0.05). However, a statistically significant difference was observed in terms of nausea (60% vs. 26%, p = 0.001), vomiting (28% vs. 10%, p = 0.040), duration of gassing (17.74 ± 6.77 vs. 14.20 ± 7.05 h, p = 0.012), length of hospitalization (41.78 ± 12.17 vs. 34.12 ± 10.90 h, p = 0.001), analgesic requirements (4.62 ± 1.36 vs. 3.34 ± 1.27 h, p < 0.001), or VAS scores at the 1st (5.86 ± 1.21 vs. 4.58 ± 1.31, p < 0.001), 6th (5.16 ± 1.12 vs. 4.04 ± 1.08, p < 0.001), 12th (4.72 ± 1.12 vs. 3.48 ± 1.12, p < 0.001), 18th (4.48 ± 1.21 vs. 3.24 ± 1.34, p < 0.001), and 24th (4.08 ± 1.29 vs. 3.01 ± 1.30, p < 0.001) hours.

CONCLUSION

The findings of this study show that the ERAS protocol has a positive effect on peri- and post-operative outcomes in LH. Further prospective studies are now needed to confirm the validity of the results.

Impact of enhanced recovery after surgery (ERAS) guidelines implementation in cesarean delivery: A systematic review and meta-analysis

BACKGROUND

Cesarean delivery rate is increasing, with no prediction of this rate to drop. Implementation of Early Recovery After Surgery (ERAS) program adapted to this high prevalent obstetrical surgical procedure proposes better peri-operative care achievement with improved maternal medical care, namely reduced morbidity, faster return to normal daily activities and improved impact on quality of life. Our aim was to analyze the outcomes of ERAS guidelines implementation in cesarean sections (CS).

MATERIAL AND METHODS

A systematic review was performed across 3 databases (MEDLINE (Pubmed), Scopus and Web of Science), with no time or language filters, for articles comparing outcomes on pregnant women who delivered via CS with ERAS guidelines implementation versus the traditional approach without ERAS implementation. Outcomes established: primary - hospital length of stay; secondary - opioid consumption, readmission rates and maternal complications (overall, surgical site infection and emetic morbidity). Statistical analyses were conducted using Review Manager 5.4 and its results were expressed as mean difference, standardized mean difference and odds ratio, with 95% of confidence intervals. This systematic review was reported according to the PRISMA statement.

RESULTS

This systematic review included 16 studies (3 randomized controlled trials (RCT), 4 prospective cohorts and 9 retrospective cohorts), with a pool analysis of 19,001 women (9752 with the traditional approach and 9249 following ERAS guidelines). Our results showed a significative decrease in length of hospital stay (MD: -13.78 h; CI 95 % -19.28 to -8.28; p < 0.00001) and opioid consumption (SMD: -0.91; CI 95 % -1.51 to -0.32; p = 0.003), with similar readmission rates (OR: 0.85; CI 95 % 0.50 to 1.44; p = 0.53) and maternal complications, namely: overall (OR: 0.87; CI 95 % 0.56 to 1.35; p = 0.53); surgical site infection (OR: 1.13; CI 95 % 0.72 to 1.77; p = 0.60) and emetic morbidity (OR: 0.78; CI 95 % 0.31 to 1.96; p = 0.60).

CONCLUSIONS

ERAS guidelines applied at CS management are associated with decreased length of stay and opioid consumption, without negatively impact on readmission rates and overall maternal complications, including surgical site infection and emetic morbidity. The reduced number of RCT studies and the heterogeneity of the studies (heterogeneous inter-study protocols) constitutes the major limitation of the evidence found. Still, these findings may be a foremost help to confirm the beneficial impact of an ERAS approach during peri-cesarean management.

The efficacy of preoperative low-residue diet on postoperative ileus following cesarean section

OBJECTIVE

To evaluate the efficacy of preoperative low-residue diet on postoperative ileus in women undergoing elective cesarean section (CS).

METHODS

This is a surgeon-blind, randomized controlled trial enrolling pregnant women at ≥39 weeks of gestation undergoing elective CS. Patients were preoperatively randomized to receive either low-residue diet (arm A) or free diet (arm B) starting from three days before surgery. The primary outcome was the postoperative ileus. The secondary outcomes were the postoperative pain (assessed through VAS scale), the quality of the surgical field (scored using a 5-point scale, from poor to excellent), postoperative complications, and the length of hospital stay. Perioperative data were collected and compared between groups.

RESULTS

A total of 166 patients were enrolled and randomized in arm A (n = 83) and arm B (n = 83). Postoperative ileus over 24 h was significantly shorter in arm A, compared to arm B (19.3% vs 36.2%). The surgical evaluation of small intestine was scored ≥3 in 96.4% of arm A patients versus 80.7% in arm B, while evaluation of large intestine, respectively, in 97.7% and 81.9%. Postoperative pain after 12 h from CS was significantly lower in arm A (VAS, 3.4 ± 1.7) compared to arm B (VAS, 4.1 ± 1.8). There were no significant differences as regards postoperative pain at 24 and 48 h, nausea/vomit, surgical complications, and hospital stay.

CONCLUSIONS

Implementation of a preoperative low-residue diet for women scheduled for elective CS would reduce postoperative ileus and pain. Further large-scale studies are required before translating these research findings into routine obstetrical practice.

Evolution of postoperative care: marked reduction of opioid consumption when ERAC pathway added to wound soaker therapy for cesarean delivery

OBJECTIVE

Achieving functional recovery after cesarean delivery is critical to a parturient's ability to care for herself and her newborn. Adequate pain control is vital, and without it, many other aspects of the recovery process may be delayed. Reducing opioid consumption without compromising analgesia is of paramount importance, and enhanced recovery pathways have generated considerable interest given their ability to facilitate this. Our group's process for reducing opioid consumption for cesarean delivery patients evolved over time. We first demonstrated that providing additional incisional pain control with continuous bupivacaine infusions through wound catheters, with the concurrent use of neuraxial morphine, reduced postoperative opioid use. Iterations of an enhanced recovery after cesarean (ERAC) delivery pathway were then implemented after the Society for Obstetric Anesthesia and Perinatology's consensus statement for ERAC was issued to eliminate variability in both hospital course and in the treatment of postoperative pain. In this retrospective cohort analysis, we sought to identify whether adding ERAC protocols to our existing combination of neuraxial morphine and wound soaker catheters further reduced opioid consumption after cesarean delivery.

METHODS

A retrospective cohort analysis of cesarean deliveries from 2015 through 2020 was performed. Deliveries were divided by analgesic pathway into four time-periods - time-point 1 [January 2015-April 2016, previous standard of care (control, N = 61)]: neuraxial morphine in addition to as needed opioid and non-opioid analgesics; time-point 2 [May 2016-May 2019, introduction of wound soaker (wound-soaker, N = 40)]: continuous wound catheter infusions of local anesthetic, neuraxial morphine in addition to as needed opioid and non-opioid analgesics; time-point 3 [May 2019-December 2019, wound soaker + early ERAC pathway (early ERAC, N = 78)]: continuous wound catheter infusion of local anesthetic, neuraxial morphine, in addition to scheduled non-opioid analgesics (acetaminophen and ibuprofen) every 6 h, alternating in relation to one another so that one is given every 3 h; time-point 4 [January 2020-July 2020, wound soaker + late ERAC pathway (late ERAC, N = 57)]: continuous wound catheter infusion of local anesthetic, neuraxial morphine in addition to non-opioid analgesics scheduled together every 6 h (to facilitate periods of uninterrupted rest). Cumulative and average daily opioid use for postoperative days (POD) 1-4 were analyzed using ANOVA and a mixed effect model, respectively.

RESULTS

Average daily opioid consumption and total cumulative opioid consumption POD 1-4 (morphine milligram equivalents) for both early and late ERAC groups (23.9 ± 31.1 and 29.4 ± 35.1) were significantly reduced compared to control and wound soaker groups (185.1 ± 93.7 and 134.8 ± 77.1) (p < .001).

CONCLUSION

The addition of ERAC protocols to our standardized multimodal analgesic regimen (local anesthetic wound infusion catheters and neuraxial morphine) for cesarean delivery significantly reduced postoperative opioid consumption.

Naturalistic Evaluation of ERAS Bundle Implementation Feasibility in Elective Cesarean Deliveries of Tertiary Care Hospital in a Low-Middle-Income Country

The present study assessed whether applying enhanced recovery after surgery (ERAS) guidelines for cesarean delivery is feasible in the tertiary care setting with an add-on objective to identify barriers to successful implementation. The cross-sectional study included women undergoing elective CS and willing to participate. The study attempted to understand barriers to ERAS implementation through timely interviewing study participants. Sixty-two patients participated in the study. Antenatal and fetal complications were observed in 39(63%) and 32(51%) participants. The study observed that at least 80% of the proposed components could be applied to 71% of the study population. All 15 components could be applied to 7(11.2%) patients, and at least 50% could be applied to 58(94%) patients. The least applied component was minimizing starvation by taking clear liquids until 2 hrs before surgery in 26(42%) patients due to waiting hours outside the operation-theater (OT). When fitness-for-discharge was assessed against the percent components of ERAS implemented, the area under the curve (AUC) value was 0.75, with a specificity value of 95.65% and a positive predictive value of 94.12%. In the postoperative ERAS bundle, fitness-for-discharge on day-two was statistically associated with early and frequent breastfeeding (p = 0.000) and prevention of intra-op hypotension (p = 0.03). In conclusion, the primary barriers to implementing ERAS were resource limitations in the form of single functional OT and limited doctors.

Standardized Order Sets Do Not Eliminate Racial or Ethnic Inequities in Postpartum Pain Management

Objective

To quantify the extent to which a standardized pain management order set reduced racial and ethnic inequities in post-cesarean pain evaluation and management.

Methods

We conducted a retrospective cohort study to quantify racial and ethnic differences in pain evaluation and management before (July 2014-June 2016) and after implementation of a standardized post-cesarean order set (March 2017-February 2018). Electronic medical records were queried for pain scores >7/10, number of pain assessments, and opioid, nonsteroidal anti-inflammatory drug (NSAID), and acetaminophen doses. Outcomes were grouped into 0 to <24 and 24-48 h postpartum, and stratified by race/ethnicity (Hispanic, non-Hispanic Black [NHB], non-Hispanic White [NHW], Asian, and other), as documented in the electronic health record. Analyses included logistic regression for the categorical outcome of pain score >7 (severe pain), and linear regression, with propensity score adjustment. Main effect and interaction terms were used to calculate the difference-in-difference in pain process and outcome measures between the baseline and follow-up periods.

Results

After order set implementation (N=888), severe pain remained more common among NHB patients (% pain scores >7 NHW vs. NHB 0 to <24 h: 22% vs. 33%, p=0.003; 24-48 h: 26% vs. 40%, p<0.001). Among all patients, pain management processes changed after implementation of the order set, with overall fewer assessments, less Opioids, and more nonopioid analgesics. However, racial and ethnic inequities in a number of assessments and in treatment were unchanged (all p for interaction >0.05), with the exception of a modest increase in NSAID doses 24-48 h postpartum for Hispanic patients.

Conclusion

A standardized pain management order set reduced overall postpartum opioid use, but did not reduce racial and ethnic disparities in pain evaluation and management. Future work should investigate racial equity-focused education and interventions designed to eliminate disparities in pain management.

Effect of early oral carbohydrate intake after elective Cesarean delivery on maternal body temperature and satisfaction: a randomized controlled trial

PURPOSE

Although the Enhanced Recovery After Cesarean Delivery (ERAC) consensus statement provides recommendations for early postoperative drinking and eating, evidence from high-quality clinical research directly addressing parturients is sparse. Our objective was to assess if early oral carbohydrate intake after elective Cesarean delivery improves maternal recovery.

METHODS

In this randomized controlled trial, we enrolled parturients undergoing elective Cesarean delivery under spinal anesthesia with tympanic membrane temperatures ≤ 36.5 °C immediately upon arrival at the postanesthesia care unit. Parturients were randomized to either 100 mL of oral complex carbohydrate intake (group CC) or 10 mL of water (group C). The primary outcome was maternal tympanic membrane temperature. Other outcomes included maternal thermal comfort score, degree of shivering, satisfaction, degree of thirst and hunger, and gastric emptying assessed by ultrasonography.

RESULTS

We included 90 participants in the final analysis. The mean (standard deviation [SD]) maternal body temperature at 120 min after ingestion was 36.7 (0.3) °C in group CC and 36.6 (0.3) °C in group C (difference in means, 0.14 °C; 95% confidence interval, 0.02 to 0.26; P = 0.02). Furthermore, using repeated measure models, the linear trends of temperature changes over time between groups CC and C were significantly different (P = 0.04). The thermal comfort scores at 120 min after ingestion were higher in group CC than in group C (P = 0.02), and the linear trends of shivering score changes over time between groups CC and C also were different (P = 0.003). The mean (SD) visual analogue scale scores for maternal satisfaction were 84 (13) mm in group CC and 47 (20) mm in group C (P < 0.001). Nevertheless, at 90 and 120 min after ingestion, there were no differences between the two groups in the number of participants with a gastric antrum cross-sectional area > 10.3 cm2.

CONCLUSIONS

Early oral carbohydrate intake after Cesarean delivery helped to restore maternal body temperature postoperatively and improve maternal satisfaction. Nevertheless, the clinical importance of these finding is unclear, given that most of the differences were small. In addition, there was no delay in maternal gastric emptying after consumption of a complex carbohydrate beverage in the early post-Cesarean period.

STUDY REGISTRATION

www.chictr.org.cn (ChiCTR2000031085); first submitted 13 November 2022.

Clinical Outcome in Patient Undergoing LSCS via ERAS Pathway versus Traditional Pathway: A Prospective Observational Study

Introduction

ERAS is an evidence-based management protocol for perioperative care, to accelerate patient recovery. The field of obstetrics has been a late adapter of ERAS pathway for CS, and the literature is limited from Indian population.

Material and Methods

This prospective non-randomized comparative clinical study was conducted on 190 pregnant patients, out of which 95 were subjected to ERAS protocol (Group 1) and remaining 95 cases were enrolled in existing traditional protocol (Group 2). The primary objective was to compare quality of recovery based on obstetric-specific QoR 11 questionnaire between patients undergoing ERAC and traditional protocol for elective LSCS. Secondary objective was to compare perioperative bleeding, breast feeding initiation and difficulties, first oral intake, ambulation attempts, decatheterization, surgical site infection and length of hospital stay.

Results

At 24 h postoperatively, mean QoR score was significantly higher for patients in the ERAC group (85.5 ± 7.46 vs 57.1 ± 11.33, p value < 0.01). In the ERAC group, 50.5% of the mothers started breastfeeding within first hour. The mean duration to start oral intake postoperatively was significantly lower in ERAC group. In the ERAC group, ambulation and decatheterization were attempted within 6 h postoperatively in 86.3%. The mean length of hospital stay was significantly lower for patients in the ERAC group (68.8 ± 1.9 vs 105.4 ± 25.7 h, p value < 0.001).

Conclusion

The use of ERAC protocol at cesarean delivery significantly improves quality of recovery and length of hospital stay.

Variation in Opioid Prescribing After Vaginal and Cesarean Birth: A Statewide Analysis

INTRODUCTION

Our aim was to evaluate variation in opioid prescribing rates and prescription size following childbirth across providers and hospitals.

METHODS

This retrospective cohort study analyzed claims data from a single-payer Preferred Provider Organization from June 2014 to May 2019 in 84 hospitals in a statewide quality collaborative. All patients aged 12-55 years, undergoing childbirth, with continuous enrollment in pregnancy were included. The primary outcome was the predicted rate of postpartum opioid fills from 7 days before birth to 3 days after discharge. Secondary outcomes included postpartum opioid prescription size in oral morphine equivalents, a standardized measure that includes the number of pills prescribed times the strength of the medication. Multilevel regression models accounted for clustering. We calculated attributable variation in opioid fills using the intraclass correlation coefficient.

RESULTS

Of 41,427 births, 15,459 patients (37.2%) filled a postpartum opioid prescription (vaginal, 4,624/27,536 [16.8%]; cesarean, 10,835/13,891 [78.0%]). The median postpartum prescription size was 150 oral morphine equivalents (interquartile range [IQR], 30) (vaginal, 135; [IQR, 45]; cesarean, 150 [IQR, 75]). In adjusted models, the rates of opioid prescribing after vaginal birth differed from cesarean birth (vaginal median, 12.1% [range, 1.1%-60.0%]; cesarean median, 80.4% [range, 43.6%-90.2%]). More variation in postpartum opioid fills was attributable to providers and hospitals for vaginal (provider, 29%; hospital, 24%) than cesarean birth (provider, 8%; hospital, 6%). Variation in prescription size was driven by providers for vaginal birth (provider, 27%; hospital, 6%) and providers and hospitals for cesarean birth (provider, 29%; hospital, 21%).

CONCLUSIONS

Across a statewide quality collaborative, variation in postpartum opioid prescribing is attributable to providers and hospitals. Future efforts at the provider and hospital levels are needed to implement best practices for postpartum opioid prescribing.

Colloid Preload versus Crystalloid Co-Load in the Setting of Norepinephrine Infusion during Cesarean Section: Time and Type of Administered Fluids Do Not Matter

Background and Goal of Study: Spinal anesthesia for cesarean section is frequently associated with a high incidence of hypotension, which may bring about untoward effects for both the mother and fetus. Recently, norepinephrine has emerged as a promising alternative in maintaining blood pressure in the obstetric setting. Fluid administration is another technique still widely used to prevent maternal hypotension. The optimal fluid strategy to prevent maternal hypotension has not been elucidated yet. It has been recently suggested that the main strategy in the prevention and management of hypotension should be the combination of vasoconstrictive medications and fluid administration. The aim of this randomized study was to compare the incidence of maternal hypotension in parturients receiving either colloid preload or crystalloid co-load in the setting of prophylactic norepinephrine infusion during elective cesarean section under combined spinal-epidural anesthesia. Materials and Methods: After ethics committee approval, 102 parturients with full-term singleton pregnancies were randomly allocated to either 6% hydroxyethyl starch 130/0.4 5 mL/kg before the onset of spinal anesthesia (colloid preload group) or Ringer's lactate solution 10 mL/kg concurrent with the subarachnoid injection (crystalloid co-load group). In both groups, norepinephrine 4 μg/min starting simultaneously with the administration of the subarachnoid solution was also administered. The primary outcome of the study was the incidence of maternal hypotension, defined as systolic arterial pressure (SAP) <80% of baseline. The incidence of severe hypotension (SAP < 80 mmHg), total dose of vasoconstrictive agents administered, as well as the acid-base status and Apgar score of the neonate and any incidence of maternal side effects were also recorded. Results: Data analysis was performed on 100 parturients: 51 in the colloid preload group and 49 in the crystalloid co-load group. No significant differences were demonstrated between the colloid preload group and the crystalloid co-load group in the incidence of hypotension (13.7% vs. 16.3%, p = 0.933) or the incidence of severe hypotension (0% vs. 4%, p = 0.238). The median (range) ephedrine dose was 0 (0-15) mg in the colloid preload group and 0 (0-10) mg in the crystalloid co-load group (p = 0.807). The incidence of bradycardia, reactive hypertension, requirement for modification of vasopressor infusion, time to the first occurrence of hypotension, and maternal hemodynamics did not differ between the two groups. There were no significant differences in other maternal side effects or neonatal outcomes between groups. Conclusions: The incidence of hypotension with a norepinephrine preventive infusion is low and comparable with both colloid preload and crystalloid co-load. Both fluid-loading techniques are appropriate in women undergoing cesarean delivery. It appears that the optimal regimen for prevention of maternal hypotension is a combined strategy of a prophylactic vasopressor such as norepinephrine and fluids.

Measuring enhanced recovery in obstetrics: a narrative review

Enhanced recovery after cesarean delivery is a protocolized approach to perioperative care, with the aim to optimize maternal recovery after surgery. It is associated with improved maternal and neonatal outcomes, including decreased length of hospital stay, opioid consumption, pain scores, complications, increased maternal satisfaction, and increased breastfeeding success. However, the pace and enthusiasm of adoption of enhanced recovery after cesarean delivery internationally has not yet been matched with high-quality evidence demonstrating its benefit, and current studies provide low- to very low-quality evidence in support of enhanced recovery after cesarean delivery. This article provides a summary of current measures of enhanced recovery after cesarean delivery success, and optimal measures of inpatient and outpatient postpartum recovery. We summarize outcomes from 22 published enhanced recovery after cesarean delivery implementation studies and 2 meta-analyses. A variety of disparate metrics have been used to measure enhanced recovery after cesarean delivery success, including process measures (length of hospital stay, bundle compliance, preoperative fasting time, time to first mobilization, time to urinary catheter removal), maternal outcomes (patient-reported outcome measures, complications, opioid consumption, satisfaction), neonatal outcomes (breastfeeding success, Apgar scores, maternal-neonatal bonding), cost savings, and complication rates (maternal readmission rate, urinary recatheterization rate, neonatal readmission rate). A core outcome set for use in enhanced recovery after cesarean delivery studies has been developed through Delphi consensus, involving stakeholders including obstetricians, anesthesiologists, patients, and a midwife. Fifteen measures covering key aspects of enhanced recovery after cesarean delivery adoption are recommended for use in future enhanced recovery after cesarean delivery implementation studies. The use of these outcome measures could improve the quality of evidence surrounding enhanced recovery after cesarean delivery. Using evidence-based evaluation guidelines developed by the COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) group, the Obstetric Quality of Recovery score (ObsQoR) was identified as the best patient-reported outcome measure for inpatient postpartum recovery. Advances in our understanding of postpartum recovery as a multidimensional and dynamic construct have opened new avenues for the identification of optimum patient-reported outcome measures in this context. The use of standardized measures such as these will facilitate pooling of data in future studies and improve overall levels of evidence surrounding enhanced recovery after cesarean delivery. Larger studies with optimal study designs, using recommended outcomes including patient-reported outcome measures, will reduce variation and improve data quality to help guide future recommendations.

Impact of Enhanced Recovery After Surgery pathway for cesarean delivery on postoperative pain

BACKGROUND

Enhanced Recovery After Surgery pathways provide evidence-based recommendations to optimize perioperative care.

OBJECTIVE

This study aimed to holistically investigate the effect of implementing an Enhanced Recovery After Surgery pathway for all cesarean deliveries on postoperative pain experience.

STUDY DESIGN

This was a prepost study comparing subjective and objective measures of postoperative pain before and after the implementation of an Enhanced Recovery After Surgery pathway for cesarean delivery. The Enhanced Recovery After Surgery pathway was developed by a multidisciplinary team and included preoperative, intraoperative, and postoperative components, with emphasis on preoperative preparation, hemodynamic optimization, early mobilization, and multimodal analgesia. All individuals undergoing cesarean delivery, whether scheduled, urgent, or emergent, were included. Demographic, delivery, and inpatient pain management data were obtained through medical record review. Of note, 2 weeks after discharge, patients were surveyed about their delivery experience, analgesic usage, and complications. The primary outcome was inpatient opioid use.

RESULTS

The study included 128 individuals, 56 in the preimplementation cohort and 72 in the Enhanced Recovery After Surgery cohort. Baseline characteristics between the 2 groups were similar. The survey response rate was 73% (94/128). Opioid use in the first 48 hours postoperatively was significantly lower in the Enhanced Recovery After Surgery group than the preimplementation group (9.4 vs 21.4 morphine milligram equivalents 0-24 hours after delivery [P<.001]; 14.1 vs 25.4 morphine milligram equivalents 24-48 hours after delivery [P<.001]) with no increase in either average or maximum postoperative pain scores. Individuals in the Enhanced Recovery After Surgery group used fewer opioid pills after discharge (10 vs 20; P<.001). Patient satisfaction and complication rates did not change after the implementation of an Enhanced Recovery After Surgery pathway.

CONCLUSION

The implementation of an Enhanced Recovery After Surgery pathway for all cesarean deliveries decreased both inpatient and outpatient postpartum opioid use without increasing pain scores or decreasing patient satisfaction.

What Is New in Obstetric Anesthesia: The 2021 Gerard W. Ostheimer Lecture

The Gerard W. Ostheimer lecture is given annually to members of the Society for Obstetric Anesthesia and Perinatology. This lecture summarizes new and emerging literature that informs the clinical practice of obstetric anesthesiologists. In this review, some of the most influential articles discussed in the 2021 virtual lecture are highlighted. Themes include maternal mortality; disparities and social determinants of health; cognitive function, mental health, and recovery; quality and safety; operations, value, and economics; clinical controversies and dogmas; epidemics and pandemics; fetal-neonatal and child health; general clinical care; basic and translational science; and the future of peripartum anesthetic care. Practice-changing evidence is presented and evaluated. A priority list for clinical updates, systems, and quality improvement initiatives is presented.

Cesarean delivery using an ERAS-CD process for nonopioid anesthesia and analgesia drug/medication management

Cesarean delivery (CD) is a surgical delivery of a neonate with surgical access through the maternal abdominal and uterine structures. The Enhanced Recovery After Surgery (ERAS) protocol is a standardized perioperative care program and surgery quality improvement process that has had global spread across numerous surgical disciplines. The medical and surgical use of opioids for pain management and the nonmedical opioid use, over the last three decades, have significantly increased the prevalence of abuse and addiction to opioids. This review summarizes pain, pregnancy substance use, and ERAS-directed analgesia and anesthesia for opioid use reduction or elimination in the operative and postoperative periods. Enhanced recovery (quality and safety) in the surgical CD context requires collaboration, consensus, and appropriate clinical prioritization to allow for the identification of 'the right patient, in the right clinical situation, with the right informed consent, and the right clinical care team and health system'.

Enhanced recovery for cesarean delivery leads to no difference in length of stay, decreased opioid use and lower infection rates

OBJECTIVE

The primary objective of this study was to report surgical outcomes for cesarean delivery (CD) patients following the implementation of an Enhanced Recovery after Surgery (ERAS) pathway based on the ERAS Society recommendations. The primary outcome for which the study was powered was the length of stay (LOS).

METHODS

This IRB-approved cohort study was conducted at a single tertiary-care labor and delivery unit and utilized a pre-post intervention design. Our ERAS for CD protocol was designed using the ERAS Society recommendations and implemented globally for every patient admitted to the labor and delivery unit including both scheduled and unscheduled cases. The study was designed to have at least 85% power to detect a 6-h difference in length of stay (LOS) between the pre-intervention and post-intervention cohorts, assuming a standard deviation of 18 h. A total of 339 records were included for data analysis, 170 in the pre-intervention cohort and 169 in the post-intervention cohort. To assess the difference between groups with respect to the primary outcome of LOS, linear regression was used with and without adjusting for covariates. Differences in dichotomous secondary outcomes were assessed using binary logistic regression. Differences in continuous secondary outcomes were assessed via a two-sample t-test or Wilcoxon rank sum test. Individual components of protocol adherence were compared using chi-square tests.

RESULTS

Mean LOS was 80.5 ± 22.9 h and 82.3 ± 28.0 h, pre- and post-intervention respectively. There was no difference in LOS between the 2 cohorts (difference of means = 1.8 h; 95% confidence interval (CI): (-3.7, 7.3); p = .51). Cesarean procedure infection decreased from 11.8% pre-intervention to 5.3% post-intervention, corresponding to a 58% decrease in odds of cesarean procedure infection (odds ratio (OR)=0.42; 95% CI: (0.19, 0.96); p = .04). Inpatient opioid use also significantly decreased in the post-intervention cohort with a median MME per 12 h-period of 5.1 (25^th percentile = 2.2, 75^th percentile = 7.8) pre-intervention and 3.3 (25^th percentile = 1.0, 75^th percentile = 7.6) post-intervention (p = .04).

CONCLUSION

The results of this study support the implementation of an ERAS for CD protocol based on ERAS Society recommendations as evidenced by the statistically significant decrease observed in both procedure-related infection rates and inpatient opioid use. We did not find a significant difference in LOS, which leaves room for further investigation into factors that impact LOS after CD.

Effect of enhanced recovery after surgery for elective cesarean deliveries on neonatal outcomes

OBJECTIVE

To evaluate the impact of initiation of an enhanced recovery after cesarean delivery (ERAC) protocol for elective cesarean delivery (CD) on neonatal outcomes.

STUDY DESIGN

We performed a retrospective analysis of elective CD at ≥39 weeks gestational age between September 2014 and August 2018 at a single institution before and after ERAC protocol implementation. Our primary outcome was composite neonatal complication rate and secondary outcome was rate of breastfeeding. We performed univariate analyses to detect differences in outcomes between the pre-ERAC and post-ERAC groups.

RESULTS

We included 362 neonates born via elective CD before (n = 135) and after (n = 227) ERAC implementation. The post-ERAC group experienced fewer composite neonatal complications (33.0% vs. 47.4%, p = 0.009) and greater breastfeeding rates (80.2% vs. 67.4%, p = 0.009) compared to the pre-ERAC group.

CONCLUSION

ERAC protocol implementation does not negatively impact neonates and may benefit both mother and baby.

Impact of timing of multimodal analgesia in enhanced recovery after cesarean delivery protocols on postoperative opioids: A single center before-and-after study

STUDY OBJECTIVE

Enhanced recovery after cesarean delivery (ERAC) programs aim to decrease maternal morbidity and aid in maternal recovery and return to baseline. Multimodal analgesia is an important element of ERAC protocols, but no consensus exists on the timing of medication administration. We compared maternal pain outcomes following scheduled cesarean delivery with modification of the timing of administration of multimodal analgesia with non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen.

DESIGN

Before-and-after study.

SETTING

Labor and delivery unit at a single academic institution.

INTERVENTION

NSAIDs and acetaminophen were administered as a fixed-interval alternating regimen every 3 h for the initial ERAC group (ERAC 1) and fixed-interval combined regimen every 6 h for the modified ERAC group (ERAC 2). ERAC 1 and ERAC 2 groups were compared to historical controls (Pre-ERAC).

PATIENTS

520 women undergoing scheduled cesarean delivery (Pre-ERAC n = 179, ERAC 1 n = 179, and ERAC 2 n = 162).

MEASUREMENTS

The primary outcomes were postoperative total and daily opioid utilization as measured in morphine milligram equivalents (MME). Secondary outcomes included postoperative length of stay, maximum pain scores, and racial disparities in care.

MAIN RESULTS

The modified schedule of non-opioid analgesics involving combined administration (ERAC 2) versus alternating administration (ERAC 1) of multimodal analgesia resulted in decreased total postoperative opioid utilization (median = 26.3 vs 52.5 MME, Bonferroni corrected P = 0.002). Total postoperative opioid utilization among the ERAC 2 group was also significantly reduced compared to the Pre-ERAC group (median = 26.3 vs 105.0 MME, Bonferroni corrected P < 0.0001).

CONCLUSIONS

Multidisciplinary teams developing or modifying ERAC protocols for scheduled cesarean delivery should consider a combined administration at fixed intervals of NSAIDs and acetaminophen throughout the hospital stay to optimize postoperative pain management.

The effect of preoperative oral carbohydrate on the time to colostrum and amount of vaginal bleeding after elective cesarean section

OBJECTIVE

To investigate the effect of oral carbohydrate at 2 h before elective cesarean section on postoperative recovery indicators such as the time to colostrum and vaginal bleeding.

METHODS

Women undergoing elective cesarean section under spinal-epidural anesthesia, aged 20-40 years, with a body mass index (BMI) of 19-30 kg/m² and an American Society of Anesthesiology (ASA) score of II were randomized to the oral carbohydrate group (the OC group), the oral placebo group (the OP group), or the control group (the C group). The OC group underwent oral carbohydrate preloading (300 mL/bottle), the OP group orally consumed 300 mL of distilled water, and the C group was forbidden from drinking or eating on the day of the operation. The time to colostrum, vaginal bleeding, time to exhaust, and complications were recorded.

RESULTS

A total of 38 participants in the OC group, 37 in the OP group, and 37 in the C group completed the study. Compared with the OP group and the C group, the OC group produced colostrum significantly earlier, had a lower amount of 24-h vaginal bleeding, and had a higher 24-h consumption of analgesics. Compared with OP and OC groups, the C group took longer to exhaust. No significant intergroup difference was observed for any other indicator.

CONCLUSION

Oral carbohydrates loading 2 h before elective cesarean section significantly reduces the time to produce colostrum and the amount of vaginal bleeding, which contributes to postoperative recovery.

How Can We Get to Equitable and Effective Postpartum Pain Control?

Postpartum pain is common, yet patient experiences and clinical management varies greatly. In the United States, pain-related expectations and principles of adequate pain management have been framed within established norms of Western clinical medicine and a biomedical understanding of disease processes. Unfortunately, this positioning of postpartum pain and the corresponding coping strategies and pain treatments is situated within cultural biases and systemic racism. This paper summarizes the history and existing literature that examines racial inequities in pain management to propose guiding themes and suggestions for innovation. This work is critical for advancing ethical practice and establishing more effective care for all patients.

Maternal perceptions of cesarean birth care: A qualitative study to inform ERAS guideline development

BACKGROUND

Cesarean birth (CB) is the most common inpatient surgical procedure, and until recently, there were no internationally accepted, standardized clinical guidelines available. The Enhanced Recovery After Surgery (ERAS^® ) program aims to improve outcomes through the development of international guidelines (IGs). As an ERAS IG for CB was being developed, this qualitative study was conducted to explore and consolidate women's experiences with CB.

METHODS

Qualitative methods were used to assess the patient experience with current evidence-based CB protocols across operative phases. Twelve women who experienced CB at a single center in Canada were interviewed using an open-ended, semi-structured interview guide at six weeks postpartum. Two researchers coded the emerging themes separately and compared findings.

RESULTS

Women described feeling informed, but felt they did not have a choice. Presurgery, women wanted more information about the risks of CB. Preoperatively, women expressed confusion with the procedures, but felt informed about local anesthesia and thermoregulation. Post-CB, women felt informed about pain and nausea control; however, urinary catheter removal was delayed when compared to the ERAS recommendations. Information about postpartum infant care was not well communicated, as many women were uninformed about delayed cord clamping and infant thermoregulation.

CONCLUSIONS

This qualitative study provides opportunities to improve communication, the patient-practitioner relationship, and the overall satisfaction throughout the CB process. The findings support the implementation of patient decision aids and training with the shared decision model. The improved procedures recommended in the ERAS IG for CB have the potential to deliver significant improvements to patient care and patient satisfaction.

Impact of enhanced recovery after cesarean delivery on maternal outcomes: A systematic review and meta-analysis

BACKGROUND

This meta-analysis explores the impact of enhanced recovery after cesarean delivery (ERAC) on maternal outcomes.

METHODS

We searched 4 databases (Web of Science, Embase, PubMed and CINAHL) in October 2020 without date limiters, for studies quantitatively comparing ERAC implementation to a control group. The primary outcome was length of hospital stay and secondary outcomes included time to mobilization and time to urinary catheter removal, opioid consumption, readmission rates and cost savings. Mean differences and odds ratios (MD and OR with 95% confidence intervals) were calculated. Levels of evidence were assessed using GRADE.

RESULTS

Twelve studies involving 17,607 patients (9693 without ERAC and 7914 with ERAC) were included. ERAC was associated with reduced: length of hospital stay (MD -0.51 days [-0.94, -0.09]; p = 0.018; I2 = 99%), time to first mobilization (MD -11.05 h [-18.64, -3.46]; p = 0.004; I2 = 98%), time to urinary catheter removal (MD -13.19 h [-17.59, -8.79]; p < 0.001; I2 = 97%) and opioid consumption (MD -21.85 mg morphine equivalents [-33.19, -10.50]; p = < 0.001; I2 = 91%), with no difference in maternal readmission rate (OR 1.23 [0.96, 1.57]; p = 0.10; I2 = 0%). Three studies reported cost savings associated with ERAC. The GRADE levels of evidence were rated as low or very low quality for all study outcomes.

CONCLUSION

ERAC is associated with reduction in length of stay, times to first mobilization and urinary catheter removal and opioid consumption. ERAC does not significantly affect maternal hospital readmission rates following discharge. Further studies are required to determine which ERAC interventions to implement and which outcomes best determine ERAC efficacy.

The successful implementation of the Enhanced Recovery After Surgery (ERAS) program among caesarean deliveries in Bhutan to reduce the postoperative length of hospital stay

BACKGROUND

Enhanced Recovery After Surgery (ERAS) is a multidisciplinary perioperative care program to optimize and enhance postoperative recovery. It has a beneficial role in decreasing the length of hospital stay and improving the quality of care. This study aims to observe the successful implementation of ERAS in reducing the length of hospital stay (LOS) among caesarean deliveries.

METHODS

A pre-and post-implementation study of ERAS protocol was conducted, among cohort of women who underwent caesarean deliveries from January to December 2020 in the Department of Obstetrics and Gynaecology, Mongar Regional Referral hospital. Data collected retrospectively and analyzed in SPSS (IBM SPSS trial version); and comparison of length of hospital stay between the two groups were tested by t-test.

RESULTS

One hundred seventy-one patients were included in the study: 87 in the pre-ERAS and 84 in the post-ERAS cohort. Post implementation, LOS decreased by an average of 21.0 (CI 16.11-24.64; p-value < 0.001) hours in the postoperative period. A greater proportion of patients were discharged on day-2 (2.3% in pre-ERAS and 81% in ERAS; p-value < 0.001).

CONCLUSION

Implementation of ERAS protocol can significantly decrease the postoperative length of hospital stay without increasing the complications and readmission rates.

Pharmacologic Stepwise Multimodal Approach for Postpartum Pain Management: ACOG Clinical Consensus No. 1

SUMMARY

Pain in the postpartum period is common and considered by many individuals to be both problematic and persistent (1). Pain can interfere with individuals' ability to care for themselves and their infants, and untreated pain is associated with risk of greater opioid use, postpartum depression, and development of persistent pain (2). Clinicians should therefore be skilled in individualized management of postpartum pain. Though no formal time-based definition of postpartum pain exists, the recommendations presented here provide a framework for management of acute perineal, uterine, and incisional pain. This Clinical Consensus document was developed using an a priori protocol in conjunction with the authors listed. This document has been revised to incorporate more recent evidence regarding postpartum pain.

A standardized post-cesarean analgesia regimen reduces postpartum opioid use

BACKGROUND

Optimal post-cesarean pain control is important. With the rising opioid epidemic it is imperative to maximize non-opioid based primary approaches to post-cesarean pain control. In 2018, we implemented a standardized post-cesarean analgesia regimen.

OBJECTIVE

To determine if implementation of a standardized postoperative analgesic regimen decreases opioid use following cesarean birth.

STUDY DESIGN

A standardized postoperative analgesia protocol was implemented in June 2018, which included scheduled oral acetaminophen (975 mg every 6 h) and nonsteroidal anti-inflammatory drugs (NSAIDs) (ketorolac 15 mg IV every 6 h for 5 doses followed by ibuprofen 600 mg oral every 6 h) with opioids available 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 nine months 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 h postoperatively. Total dose at 12, 24, and 48 h were also compared.

RESULTS

Of 2340 women who underwent cesarean birth during the study period (1 July 2017 - 30 April 2019), 2001 women met inclusion criteria (914 before 10 April 2018 (pre-protocol) and 1087 after 17 June 2018 (post-protocol)). Baseline characteristics of the two groups were similar, including gestational age at delivery, maternal body mass index (BMI), planned versus unplanned cesarean birth, and type of intraoperative anesthesia used. The cumulative opioid dose in the first 72 h postoperatively was 216.3 ± 84.3 MME prior to implementation compared to 171.5 ± 91.5 MME following implementation (p < .001). The average cumulative MME use was higher in the pre-protocol period compared to post-protocol at all time periods: 12 h (57.3 ± 23.8 vs 48.6 ± 26.2 MME, p < .001), 24 h (98.1 ± 34.1 vs 82.1 ± 38.8 MME, p < .001), and 48 h (165.8 ± 58.3 vs 134.9 ± 66.2 MME, p < .001). The average pain scores were lower in the pre-protocol group (3 vs 3.3, p < .001).

CONCLUSION

Scheduled administration of acetaminophen and NSAIDs following cesarean birth significantly decreased the cumulative dose of opioids used in the first 72 h postoperatively.

The Clinical Efficacy and Safety of Enhanced Recovery After Surgery for Cesarean Section: A Systematic Review and Meta-Analysis of Randomized Controlled Trials and Observational Studies

Background: Enhanced recovery after surgery (ERAS) has been adopted in some maternity units and studied extensively in cesarean section (CS) in the last years, showing encouraging results in clinic practice. However, the present evidence assessing the effectiveness of ERAS for CS remains weak, and there is a paucity in the published literature, especially in improving maternal outcomes. Our study aimed to systematically evaluate the clinical efficacy and safety of ERAS protocols for CS.

Methods: A systematic literature search using Embase, PubMed, and the Cochrane Library was carried out up to October 2020. The appropriate randomized controlled trials (RCTs) and observational studies applying ERAS for patients undergoing CS were included in this study, comparing the effect of ERAS protocols with conventional care on length of hospital stay (LOS), readmission rate, incidence of postoperative complications, postoperative pain score, postoperative opioid use, and cost of hospitalization. All statistical analyses were conducted with the RevMan 5.3 software.

Results: Ten studies (four RCTs and six observational studies) involving 16,391 patients were included. ERAS was associated with a decreased LOS (WMD −7.47 h, 95% CI: −8.36 to −6.59 h, p < 0.00001) and lower incidence of postoperative complications (RR: 0.50, 95% CI: 0.37 to 0.68, p < 0.00001). Moreover, pooled analysis showed that postoperative pain score (WMD: −1.23, 95% CI: −1.32 to −1.15, p < 0.00001), opioid use (SMD: −0.46, 95% CI: −0.58 to −0.34, p < 0.00001), and hospital cost (SMD:−0.54, 95% CI: −0.63 to −0.45, p < 0.00001) were significantly lower in the ERAS group than in the conventional care group. No significant difference was observed with regard to readmission rate (RR: 0.86, 95% CI: 0.48 to 1.54, p = 0.62).

Conclusions: The available evidence suggested that ERAS applying to CS significantly reduced postoperative complications, lowered the postoperative pain score and opioid use, shortened the hospital stay, and potentially reduced hospital cost without compromising readmission rates. Therefore, protocols implementing ERAS in CS appear to be effective and safe. However, the results should be interpreted with caution owing to the limited number and methodological quality of included studies; hence, future large, well-designed, and better methodological quality studies are needed to enhance the body of evidence.

Post-Cesarean Opioid Use after Implementation of Enhanced Recovery after Surgery Protocol

OBJECTIVE

This study aimed to evaluate whether implementation of an enhanced recovery after surgery (ERAS) protocol is associated with lower maternal opioid use after cesarean delivery (CD).

STUDY DESIGN

We performed a pre- and postimplementation (PRE and POST, respectively) study of an ERAS protocol for cesarean deliveries. ERAS is a multimodal, multidisciplinary perioperative approach. The four pillars of our protocol include education, pain management, nutrition, and early ambulation. Patients were counseled by their outpatient providers and given an educational booklet. Pain management included gabapentin and acetaminophen immediately prior to spinal anesthesia. Postoperatively patients received scheduled acetaminophen and ibuprofen. Oxycodone was initiated as needed 24 hours after spinal analgesia. Preoperative diet consisted of clear carbohydrate drink consumed 2 hours prior to scheduled operative time with advancement as tolerated immediately postoperation. Women with a body mass index (BMI) <40 kg/m² and scheduled CD were eligible for ERAS. PRE patients were randomly selected from repeat cesarean deliveries (RCDs) at a single site from October 2017 to September 2018, BMI <40 kg/m², without trial of labor. The POST cohort included women who participated in ERAS from October 2018 to June 2019. PRE and POST demographic and clinical characteristics were compared. Primary outcome was total postoperative morphine milligram equivalents (MMEs). Secondary outcomes included length of stay (LOS) and maximum postoperative day 2 (POD2) pain score.

RESULTS

All women in PRE (n = 70) had RCD compared with 66.2% (49/74) in POST. Median total postoperative MMEs were 140.0 (interquartile range [IQR]: 87.5-182.5) in PRE compared with 0.0 (IQR: 0.0-72.5) in POST (p < 0.001). Median LOS in PRE was 4.02 days (IQR: 3.26-4.27) compared with 2.37 days (IQR: 2.21-3.26) in POST (p < 0.001). Mean maximum POD2 pain score was 5.28 (standard deviation [SD] = 1.86) in PRE compared with 4.67 (SD = 1.63) in POST (p = 0.04).

CONCLUSION

ERAS protocol was associated with decreased postoperative opioid use, shorter LOS, and decreased pain after CD.

KEY POINTS

· ERAS protocol was associated with decreased postoperative opioid use after CD.. · ERAS protocol was associated with shorter length of stay after CD.. · ERAS protocol was associated with decreased postoperative pain after CD..

Fluid loading therapy to prevent spinal hypotension in women undergoing elective caesarean section: Network meta-analysis, trial sequential analysis and meta-regression

BACKGROUND

Fluid loading is one of the recognised measures to prevent hypotension due to spinal anaesthesia in women scheduled for a caesarean section.

OBJECTIVE

We aimed to evaluate the current evidence on fluid loading in the prevention of spinal anaesthesia-induced hypotension.

DESIGN

Systematic review and network meta-analysis with trial sequential analysis and meta-regression.

DATA SOURCES

Medline, Epub, Embase.com (Embase and Medline), Cochrane Central, Web of Science and Google Scholar were used.

ELIGIBILITY CRITERIA

Only randomised controlled trials were used. Patients included women undergoing elective caesarean section who received either crystalloid or colloid fluid therapy as a preload or coload. The comparator was a combination of either a different fluid or time of infusion.

RESULTS

A total of 49 studies (4317 patients) were included. Network meta-analysis concluded that colloid coload and preload offered the highest chance of success (97 and 67%, respectively). Conventional meta-analysis showed that crystalloid preload is associated with a significantly higher incidence of maternal hypotension than colloid preload: risk ratio 1.48 (95% CI 1.29 to 1.69, P < 0.0001, I² = 60%). However, this result was not supported by Trial Sequential Analysis. There was a significant dose–response effect for crystalloid volume preload (regression coefficient = −0.073), which was not present in the analysis of only double-blind studies. There was no dose–response effect for the other fluid regimes.

CONCLUSION

Unlike previous meta-analysies, we found a lack of data obviating an evidence-based recommendation. In most studies, vasopressors were not given prophylactically as is recommended. Studies on the best fluid regimen in combination with prophylactic vasopressors are needed. Due to official european usage restrictions on the most studied colloid (HES), we recommend crystalloid coload as the most appropriate fluid regimen.

TRIAL REGISTRATION

CRD42018099347.

Enhanced Recovery After Cesarean: Current and Emerging Trends

Purpose of Review

What are the latest enhanced recovery elements for cesarean delivery?

Recent Findings

Enhanced recovery after cesarean delivery (ERAC) provides an evidenced-based system to improve maternal outcomes, functional recovery, maternal-infant bonding, and patient experience. Postsurgical recovery has evolved from a one-dimensional pain score to a holistic multidimensional approach emphasizing faster functional recovery. ERAC involves multidisciplinary efforts of the anesthesiologist, obstetrician, nursing, hospital, and patient. Components of ERAC include preoperative patient education, limited fasting, carbohydrate load, limiting opioids intra- and postoperatively, using scheduled non-opioid analgesics and supplementing with advanced therapies for women at higher risk for pain. ERAC protocols reduce opioid consumption, reduce length of stay, and improve maternal and neonatal outcomes.

Summary

Implementing ERAC standardized care will likely be the most important change you can make in your practice to improve outcomes, improve quality care, help address racial disparities, and minimize opioid exposure and potential for addiction.

Impact of a multimodal analgesic protocol modification on opioid consumption after cesarean delivery: a retrospective cohort study

INTRODUCTION

Adequate pain control is a mainstay in enhanced recovery after surgery (ERAS) protocols. ERAS protocols are widely accepted in colorectal and gynecologic surgeries and are increasingly implemented in the obstetric setting. Multimodal analgesia incorporating non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen is a mainstay of ERAS protocols for cesarean delivery, but little research has focused on the choice of NSAIDs or timing of initiation in women undergoing cesarean delivery. At our institution, patients undergoing cesarean delivery receive a standardized multimodal analgesic regimen consisting of neuraxial morphine with NSAIDs and acetaminophen. Our initial protocol involved starting the oral analgesics in the recovery room. There was variability in whether these medications were given in a timely manner or withheld in the setting of postoperative nausea and vomiting. We modified this protocol and performed a retrospective analysis to assess the impact of this change on postoperative opioid rescue requirements in women undergoing cesarean delivery under neuraxial anesthesia.

METHODS

This retrospective analysis included patients who underwent cesarean deliveries from 1 July 2014 to 22 August 2017. With the initial analgesic protocol, patients received neuraxial morphine, followed by naproxen 500 mg PO Q12 hours and acetaminophen 650-975 mg PO Q6 hours initiated in the recovery room. After protocol revision in January 2016, the same neuraxial morphine dose was used in addition to acetaminophen 975 mg PR at the start of the case and ketorolac 15-30 mg IV at the end of the case. Postoperatively, patients received acetaminophen PO 975 mg Q6 hours, ketorolac IV 15 mg Q6 hours for 3 doses, transitioning to ibuprofen 600 mg Q6 hours. Fentanyl, oxycodone, and intravenous hydromorphone were given for breakthrough pain with both protocols. The primary outcome of the study is the need for rescue opioid analgesia. Secondary outcomes are total opioid usage, time to first rescue opioid, maximum reported pain scores, and need for rescue antiemetics. Univariate and multivariate analyses were performed controlling for variables significantly different between the two cohorts.

RESULTS

3250 patients were included in our analysis (1574 in the old protocol and 1676 in the new protocol). There was no significant difference in patient demographics or intraoperative characteristics between the two cohorts except for more primiparous women (25% vs. 17%), more Pfannenstiel incision (98% vs. 96%), and less repeat cesarean deliveries (40% vs. 44%) in the new protocol cohort. Need for rescue opioids was reduced with the new protocol at 2, 24, and 48 h [(36.46% vs. 75.73%, p < .0001), (74.28% vs 91.99%, p < .0001), (87.53% vs 95.49% p < .0001), respectively]. Among those who received opioids, opioid consumption over 48 h was reduced (median [IQR]: 55 [30, 95] vs. 40 [20, 70] mg oxycodone equivalents) after protocol revision (GMR 0.75, 95% CI 0.7, 0.80, p < .0001). The time to first rescue opioid medication was significantly longer in the new protocol compared to the old protocol (175 [79, 1057] min vs 51 [28, 104] min, p < .001).

CONCLUSION

There was a significant decrease in the need for and the dose of rescue opioid medications with the new protocol. This highlights the importance of optimizing the choice of agents, as well as route and timing of administration of the components of the postoperative multimodal analgesic regimen.

Systematic Review and Meta-Analysis of the Efficacy and Safety of Enhanced Recovery After Surgery vs. Conventional Recovery After Surgery on Perioperative Outcomes of Radical Cystectomy

Background and objective: Radical cystectomy has been characterized as the most difficult operation in urology because of the complex surgical procedures and postoperative complications. Enhanced recovery after surgery (ERAS), which reduces the incidence of perioperative complications, has been widely used in clinical surgery. Herein, we performed a meta-analysis to evaluate the efficacy and safety of ERAS vs. conventional recovery after surgery (CRAS) on perioperative outcomes of radical cystectomy. Methods: We performed a systematic search of randomized controlled trials (RCTs) in the following databases: Medline, Embase, and the Cochrane Controlled Trials Register, based on the PICOS strategy. The reference lists of the retrieved studies were further surveyed for relevant publications. Results: Our search yielded seven RCTs containing 813 patients. The ERAS group was found to have better performance in the following parameters: length of hospital stay [mean difference (MD) = -1.12, 95% confidence interval (CI): -1.80 to -0.45, P = 0.001], time to first flatus (MD = -0.70, 95% CI: -0.98 to 0.41, P < 0.00001), and time to regular diet (MD = -0.12, 95% CI: -1.76 to -0.28, P = 0.007). However, there were no significant differences between the two groups in major complications [odds ratio (OR) = 0.91, 95% CI: 0.63 to 1.34, P = 0.64], readmission (OR = 1.15, 95% CI: 0.65 to 2.01, P = 0.63), ileus (OR = 0.75, 95% CI: 0.44 to 1.28, P = 0.29), wound infection (OR = 0.56, 95% CI: 0.31 to 1.01, P = 0.05), mortality (OR = 0.69, 95% CI: 0.24 to 1.99, P = 0.49), or time to first bowel movement (MD = -0.55, 95% CI: -1.62 to 0.53, P = 0.32). Conclusion: ERAS reduced the length of hospital stay, time to first flatus, and time to regular diet after cystectomy. Compared to CRAS protocols, ERAS protocols do not increase the risk of adverse events.