Implementation of a Standardized Post-Cesarean Delivery Order Set with Multimodal Combination Analgesia Reduces Inpatient Opioid Usage

Abstract

Background: Opioid use has emerged as a leading cause of death in the US. Given that 1 in 300 opioid-naive patients exposed to opioids after cesarean birth will become persistent users, hospitals should strive to limit exposure to these medications. We set out to evaluate whether transitioning to a standardized order set based on multimodal combination analgesic therapy decreases the exposure to opioids after cesarean delivery. Methods: Our health system’s post-cesarean pain management electronic medical record (EMR) order set was changed from standing NSAIDs (Ibuprofen 600 mg every 6 h) and additional acetaminophen and opioid medications (Oxycodone 5 mg/acetaminophen 325 mg every 3 h or Oxycodone 10 mg/acetaminophen 650 mg every 6 h for moderate and severe pain, respectively) as needed (PRN) to a multimodal combination therapy with acetaminophen (975 mg every 6 h) and NSAIDs (Ibuprofen 600 mg every 6 h) as primary analgesics and opioids PRN (Oxycodone immediate release (IR) 5 mg every 3 h for moderate to severe pain). We performed a retrospective analysis across seven hospitals comparing inpatient opioid use, administration of other analgesics, and severe pain episodes (pain score ≥ 7) between the patients who were treated before and after implementation of the multimodal order set. Chi square and Student t-test were used for statistical analysis with significance determined as p < 0.05. Results: A total of 12,898 cesarean births were included (8696 prior and 4202 after implementation). The multimodal order set was associated with marked decrease in the incidence of post cesarean opioid use (45.4% vs. 67.5%; p < 0.0001), lower average opioid dose (26.7 mg vs. 36.6 mg of oxycodone; p < 0.0001), and increased dose of acetaminophen (8422 mg vs. 4563 mg; p < 0.0001), while severe pain scores were less frequent (46.3% vs. 56.6%, p < 0.0001). Conclusions: Multimodal analgesic therapy for post-cesarean pain management reduces inpatient opioid use while improving pain control. Incorporation of a multimodal order set as a default in the EMR facilitates effective and widespread implementation on a large scale. Obstetric units should consider standardizing post-cesarean pain management orders to include routine (not PRN) multimodal combination therapy with acetaminophen and NSAIDs as primary analgesics.

Initiation of an Enhanced Recovery After Cesarean Delivery Protocol in a University Hospital in Serbia: A randomized comparison with existing management

“…Improved patient satisfaction is a very important goal of ERAS protocols and our results showed better overall satisfaction in group E than in group C; this resulted in higher reported recommendation levels among family and friends. This has also been previously noted in prior reporting about ERAS after cesarean delivery, as described by Bollag et al2 9 and Sultan et al 30 .…”

Interventions to Reduce Inpatient and Discharge Opioid Prescribing for Postpartum Patients: A Systematic Review

“…The 8 studies that evaluated multimodal stepwise interventions were all retrospective cohort studies 16–23 and included initiating scheduled ibuprofen and acetaminophen, with the administration of an opioid on an as‐needed basis for breakthrough pain. These interventions include multiple changes in a bundled fashion and specified stepwise approaches.…”

“…Sixteen studies identified interventions to reduce postpartum opioid use during the inpatient period. The majority included implementation of multimodal stepwise protocols (n = 8) [16][17][18][19][20][21][22][23] or changes in dosages or timing of medication administration (n = 4). [24][25][26][27] Four additional studies included interventions that compared nonopioid medication with placebo, 28 use of lidocaine patches, 29 abdominal binder, 30 and battlefield acupuncture, in which needles are placed only on the surface of the ear (Table 1 ).…”

Vpliv multimodalne analgezije na samostojnost otročnic pri osebni higieni, skrbi za novorojenčka in dojenja po carskem rezu

“…Obvladovanje poporodne bolečine je pomembno za kakovostno zdravstveno obravnavo, saj omogoča nemoteno povezovanje med otročnico in novorojenčkom in spodbuja dojenje (ACOG Committee Opinion, 2018;Wen, Yu, Kong, Liu, & Wei, 2020). Neustrezna analgezija po carskem rezu je lahko pomemben dejavnik tveganja za razvoj kronične bolečine, ki je povezana s poporodno depresijo in drugimi psihičnimi težavami (Eisenach et al, 2009;Holland et al, 2019;Bornstein et al, 2021). Večina analgetičnih režimov po carskem rezu vključuje opioidne analgetike.…”

“…Koncept multimodalne analgezije vključuje načrtno kombiniranje področnih tehnik lajšanja bolečine s sistemskimi analgetiki, različne farmakodinamične in farmakokinetične lastnosti z namenom doseganja sinergističnih analgetičnih učinkov (Holland et al, 2019;Smith, Young, Blosser, & Poole, 2019: Bornstein et al, 2021. Z multimodalnimi režimi analgezije lahko po carskem rezu pomembno zmanjšamo uporabo opioidnih analgetikov, ob tem pa še vedno zagotovimo ustrezno obvladovanje bolečine (Stopar-Pintarič et al, 2021;Višić, Stopar Pintarič, Albreht, Blajić, & Lučovnik, 2021).…”