Association of an Enhanced Recovery After Cesarean Surgery Protocol With Postpartum Opioid Utilization: Analysis of a...

Research has shown that 1 of every 50 to 300 patients can develop chronic opioid use following treatment of acute pain, including after cesarean birth. Our hospital identified that our post-cesarean patients utilized high doses of systemic opioids. This study sought to determine whether implementation of a standardized enhanced recovery after cesarean surgery (ERAS) protocol decreased opioid utilization following cesarean birth.

An evidence-based ERAS protocol was created and implemented. This protocol included intrathecal morphine and a standardized approach to all phases of perioperative care for both scheduled and unscheduled cesarean deliveries. A before-and-after analysis compared oral morphine milligram equivalents (MME) for 9 months prior to and 9 months after implementation. People with chronic opioid use for any indication or postoperative intubation were excluded. The primary outcome was the cumulative MME utilization in the first 48 hours postoperatively. MME utilization and pain scores at other time points were compared.

Patients who underwent cesarean birth prior to implementation of the ERAS protocol (pre-ERAS) (n = 973) and after implementation (post-ERAS) (n = 1025) were included. The median cumulative opioid dose in the first 48 hours post-cesarean was 122 MME (interquartile range [IQR] 80-164) pre-ERAS compared to 8 MME (IQR 0-48) post-ERAS (P < 0.001). The median cumulative MME was higher in the pre-ERAS period compared to the post-ERAS period for all time points assessed. The prevalence of pain scores > 7 in the first 24 hours was decreased in the post-ERAS period as was the percentage of patients requiring any opioids.

An ERAS protocol for cesarean birth including intrathecal morphine was associated with a 93.8% reduction in cumulative opioid dose by MME and should be considered by all hospitals that offer obstetric services.