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

Persistent Postpartum Pain - A Somatic and Psychologic Perfect Storm

Persistent postpartum pain is common and has a complex etiology. It has both somatic and psychosocial provoking factors and has both functional and psychological ramifications following childbirth. Pain that limits the functional capacity of a person who has the daunting task to take care of all the demands of managing a growing newborn and infant can have debilitating consequences for several people simultaneously. We will review the incidence of persistent postpartum pain, analyze the risk factors, and discuss obstetric, anesthetic, and psychological tools for prevention and management. Based on the current knowledge, early antenatal screening and management is described as the most likely measure to identify patients at risk for persistent postpartum pain. Such antenatal management should be based on the close collaboration between obstetricians, anesthesiologists, and psychologists to tailor peripartum pain management and psychological support-based individual needs.

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.

Drivers of variation in postpartum opioid prescribing across hospitals participating in a statewide maternity care quality collaborative

BACKGROUND

We describe variation in postpartum opioid prescribing across a statewide quality collaborative and assess the proportion due to practitioner and hospital characteristics.

METHODS

We assessed postpartum prescribing data from nulliparous, term, singleton, vertex births between January 2020 and June 2021 included in the clinical registry of a statewide obstetric quality collaborative funded by Blue Cross Blue Shield of Michigan. Data were summarized using descriptive statistics. Mixed effect logistic regression and linear models adjusted for patient characteristics and assessed practitioner- and hospital-level predictors of receiving a postpartum opioid prescription and prescription size. Relative contributions of practitioner and hospital characteristics were assessed using the intraclass correlation coefficient.

RESULTS

Of 40,589 patients birthing at 68 hospitals, 3.0% (872/29,412) received an opioid prescription after vaginal birth and 87.8% (9812/11,177) received one after cesarean birth, with high variation across hospitals. In adjusted models, the strongest patient-level predictors of receiving a prescription were cesarean birth (aOR 899.1, 95% CI 752.8-1066.7) and third-/fourth-degree perineal laceration (aOR 25.7, 95% CI 17.4-37.9). Receiving care from a certified nurse-midwife (aOR 0.63, 95% CI 0.48-0.82) or family medicine physician (aOR 0.60, 95%CI 0.39-0.91) was associated with lower prescribing rates. Hospital-level predictors included receiving care at hospitals with <500 annual births (aOR 4.07, 95% CI 1.61-15.0). A positive safety culture was associated with lower prescribing rates (aOR 0.37, 95% CI 0.15-0.88). Much of the variation in postpartum prescribing was attributable to practitioners and hospitals (prescription receipt: practitioners 25.1%, hospitals 12.1%; prescription size: practitioners 5.4%, hospitals: 52.2%).

DISCUSSION

Variation in postpartum opioid prescribing after birth is high and driven largely by practitioner- and hospital-level factors. Opioid stewardship efforts targeted at both the practitioner and hospital level may be effective for reducing opioid prescribing harms.

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.

Positive Patient Postoperative Outcomes with Pharmacotherapy: A Narrative Review including Perioperative-Specialty Pharmacist Interviews

The influence of pharmacotherapy regimens on surgical patient outcomes is increasingly appreciated in the era of enhanced recovery protocols and institutional focus on reducing postoperative complications. Specifics related to medication selection, dosing, frequency of administration, and duration of therapy are evolving to optimize pharmacotherapeutic regimens for many enhanced recovery protocolized elements. This review provides a summary of recent pharmacotherapeutic strategies, including those configured within electronic health record (EHR) applications and functionalities, that are associated with the minimization of the frequency and severity of postoperative complications (POCs), shortened hospital length of stay (LOS), reduced readmission rates, and cost or revenue impacts. Further, it will highlight preventive pharmacotherapy regimens that are correlated with improved patient preparation, especially those related to surgical site infection (SSI), venous thromboembolism (VTE), nausea and vomiting (PONV), postoperative ileus (POI), and emergence delirium (PoD) as well as less commonly encountered POCs such as acute kidney injury (AKI) and atrial fibrillation (AF). The importance of interprofessional collaboration in all periprocedural phases, focusing on medication management through shared responsibilities for drug therapy outcomes, will be emphasized. Finally, examples of collaborative care through shared mental models of drug stewardship and non-medical practice agreements to improve operative throughput, reduce operative stress, and increase patient satisfaction are illustrated.

Influence of perioperative opioid-related patient education: A systematic review and meta-analysis

OBJECTIVE

To determine the role of perioperative protocolized opioid-specific patient education on opioid consumption for individuals undergoing surgical procedures.

METHODS

We searched Medline, Embase, and the Cochrane Central Register of Controlled Trials for randomized controlled trials (RCTs) that compared protocolized perioperative opioid-specific patient education to the usual care for adult individuals undergoing surgical interventions. The standardized mean difference (SMD) was used to represent continuous outcomes while the risk ratio (RR) was used to represent dichotomous outcomes.

RESULTS

In total, 15 RCTs that enrolled 2546 participants were deemed eligible. Protocolized opioid-specific patient education showed a significant reduction in postoperative opioid consumption and postoperative pain score compared to usual care (SMD= -0.15, 95% confidence interval [CI]: -0.28 to -0.03 and SMD= -0.17, 95% CI: -0.28 to -0.06, respectively). No significant difference was found between the protocolized opioid-specific patient education and the usual care in terms of the number of refill requests (RR=0.82, 95% CI: 0.50-1.34), patients with opioid leftovers (RR=0.92, 95% CI: 0.78-1.08), and patients taking opioids after hospital discharge.

CONCLUSIONS

This meta-analysis demonstrated that protocolized opioid-specific patient education significantly reduces postoperative opioid consumption and pain score but has no influence on the number of opioid refill requests, opioid leftovers, and opioid use after hospital discharge.

PRACTICE IMPLICATIONS

Healthcare professionals may offer opioid-related educational sessions for the surgical patients during the perioperative period through a video-based material that emphasizes the role of alternative analgesics to opioids, patients' expectations about the post-operative pain, and the potential side effects of opioid consumptions.

Educational Video on Pain Management and Subsequent Opioid Use After Cesarean Delivery: A Randomized Controlled Trial

OBJECTIVE

To evaluate whether viewing an educational video on pain management reduces opioid use after cesarean delivery.

METHODS

We conducted a randomized, controlled trial of women aged 18 years or older who underwent cesarean delivery at a tertiary care center. Eligible women were randomized in a 1:1 ratio to usual discharge pain medication instructions plus an educational video on pain management or to usual discharge pain medication instructions alone. All women received the same opioid prescription at discharge: Twenty 5-mg oxycodone tablets. Participants were contacted at 7 days and at 14 days after delivery to assess the number of oxycodone tablets used, adjunct medication (acetaminophen and ibuprofen) use, pain scores, and overall satisfaction of pain control. The primary outcome was the number of oxycodone tablets used from discharge through postpartum day 14. A sample size of 23 per group (n=46) was planned to detect a 25% difference in mean number of oxycodone tablets used between groups, as from 20 to 15.

RESULTS

From July 2019 through December 2019, 61 women were screened and 48 were enrolled-24 in each group. Women who viewed the educational video used significantly fewer opioid tablets from discharge through postpartum day 14 compared with women who received usual pain medication instructions (median 1.5, range 0-20 vs median 10, range 0-24, P<.001). Adjunct medication use, pain scores, and satisfaction with pain control did not differ significantly between groups.

CONCLUSION

Among women who underwent cesarean delivery, viewing an educational video on pain management reduced postdischarge opioid use.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT03959969.