Post-op enhanced recovery pathway cuts opioid use after C-section

Implementation of the enhanced recovery after surgery (ERAS) protocols incorporating the use of scheduled multimodal analgesia reduced the need for opioid use in patients undergoing caesarean section (C-section), reveals a retrospective study presented at the ACOG 2020 Meeting.

Patients who had C-section in the study hospital typically received opioids around the clock in-hospital and were prescribed with the drugs once discharged as outpatients, according to lead author Dr Nnamdi Gwacham of the Saint Barnabas Medical Center in Livingston, New Jersey, US. Gwacham and colleagues therefore set out to see if the ERAS protocols can help curb the use of opioids.

“[Our study found that] post-operative pain control can be achieved in a majority of patients undergoing C-section without routine use of opioids in a standardized ERAS pathway,” said Gwacham and co-authors.

Under the ERAS pathway, almost all patients (98 percent) undergoing C-section in the study were given transversus abdominis plane (TAP) blocks immediately after surgery. All patients also started on a scheduled multimodal analgesia comprising a combination of acetaminophen, ibuprofen, and dextromethorphan until discharge. Patients were only given opioids if their pain was still not well controlled with the above regimen. [ACOG 2020, abstract OP02-1B]

After the implementation of ERAS, significantly fewer patients required opioids after C-section compared with the historical cohort who received traditional perioperative care before ERAS was implemented (341 vs 1,766; p<0.001).

Also, less opioids were used after ERAS implementation compared with the historical comparator period before implementation (803 vs 8,082 units). 

Subjects in the analysis were 1,463 women undergoing planned C-section at a community teaching hospital in New Jersey after the ERAS pathway was implemented (January 2019 – current), who were compared against a historical cohort comprising 2,109 women who were in the hospital between January – June 2018, prior to ERAS implementation. No differences in age, race, or body mass index were seen between the two cohorts.

In addition to the reduction in opioid use, women under the ERAS pathway also had significantly shorter length of hospital stay compared with the historical cohort (2.63 vs 3.19 days; p<0.001).

Furthermore, the average direct cost for patients was significantly lower for women under the ERAS pathway than those in the historical cohort (US$3,957 vs US$4,290; p<0.001).

“ERAS protocols are mechanisms for obtaining value-based improvements in surgery and they have become embedded within multiple surgical disciplines including colorectal, urological, gynaecological, and hepatobiliary surgery,” said Gwacham and co-authors. “ERAS has been shown to result in both clinical and health system benefits [in multiple disciplines of medicine].”