Background

There are approximately 1.2 million cesarean deliveries performed each year in the United States alone. While traditional postoperative pain management strategies previously relied heavily on opioids, practitioners are now moving toward opioid-sparing protocols using multiple classes of nonnarcotic analgesics. Multimodal pain management systems have been adopted by other surgical specialties including gynecology, although the data regarding their use for postoperative cesarean delivery pain management remain limited.

Objective

To determine if a multimodal pain management regimen after cesarean delivery reduces the required number of morphine milligram equivalents (a unit of measurement for opioids) compared with traditional morphine patient-controlled analgesia while adequately controlling postoperative pain.

Study Design

This was a prospective cohort study of postoperative pain management for women undergoing cesarean delivery at a large county hospital. It was conducted during a transition from a traditional morphine patient-controlled analgesia regimen to a multimodal regimen that included scheduled nonsteroidal anti-inflammatory drugs and acetaminophen, with opioids used as needed. The data were collected for a 6-week period before and after the transition. The primary outcome was postoperative opioid use defined as morphine milligram equivalents in the first 48 hours. The secondary outcomes included serial pain scores, time to discharge, and exclusive breastfeeding rates. Women who required general anesthesia or had a history of substance abuse disorder were excluded. The statistical analyses included the Student t test, Wilcoxon rank-sum, and Hodges–Lehman shift, with a P value <.05 being considered significant.

Results

During the study period, 877 women underwent cesarean delivery and 778 met the inclusion criteria—378 received the traditional morphine patient-controlled analgesia and 400 received the multimodal regimen. The implementation of a multimodal regimen resulted in a significant reduction in the morphine milligram equivalent use in the first 48 hours (28 [14–41] morphine milligram equivalents vs 128 [86–174] morphine milligram equivalents; P<.001). Compared with the traditional group, more women in the multimodal group reported a pain score ≤4 by 48 hours (88% vs 77%; P<.001). There was no difference in the time to discharge (P=.32). Of the women who exclusively planned to breastfeed, fewer used formula before discharge in the multimodal group than in the traditional group (9% vs 12%; P<.001).

Conclusion

Transition to a multimodal pain management regimen for women undergoing cesarean delivery resulted in a decrease in opioid use while adequately controlling postoperative pain. A multimodal regimen was associated with early successful exclusive breastfeeding.

中文翻译：

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剖宫产术后急性疼痛管理策略的比较

背景

仅在美国每年就有大约 120 万例剖宫产。虽然传统的术后疼痛管理策略以前严重依赖阿片类药物，但从业者现在正转向使用多种非麻醉性镇痛剂的阿片类药物节约方案。多模式疼痛管理系统已被包括妇科在内的其他外科专科采用，尽管有关其用于剖宫产术后疼痛管理的数据仍然有限。

客观的

确定与传统的吗啡患者自控镇痛相比，剖宫产后多模式疼痛管理方案是否减少所需的吗啡毫克当量（阿片类药物的计量单位），同时充分控制术后疼痛。

学习规划

这是一项关于在一家大型县医院进行剖宫产的妇女术后疼痛管理的前瞻性队列研究。它是在从传统的吗啡患者自控镇痛方案过渡到包括预定的非甾体抗炎药和对乙酰氨基酚的多模式方案的过渡期间进行的，并根据需要使用阿片类药物。这些数据是在过渡前后的 6 周内收集的。主要结果是术后阿片类药物的使用，定义为前 48 小时内的吗啡毫克当量。次要结果包括连续疼痛评分、出院时间和纯母乳喂养率。需要全身麻醉或有药物滥用史的女性被排除在外。统计分析包括学生t检验、Wilcoxon 秩和和 Hodges-Lehman 位移，P值 <.05 被认为是显着的。

结果

在研究期间，877 名妇女接受了剖宫产，其中 778 名符合纳入标准——378 名接受了传统的吗啡患者自控镇痛，400 名接受了多模式方案。多模式方案的实施导致最初 48 小时内吗啡毫克当量的使用显着减少（28 [14-41] 吗啡毫克当量 vs 128 [86-174] 吗啡毫克当量；P <.001）。与传统组相比，多模式组中更多的女性在 48 小时内报告疼痛评分≤4（88% vs 77%；P <.001）。出院时间无差异（P=.32)。在完全计划母乳喂养的女性中，多模式组出院前使用配方奶的比例低于传统组（9% vs 12%；P <.001）。

结论

对接受剖宫产的妇女过渡到多模式疼痛管理方案可减少阿片类药物的使用，同时充分控制术后疼痛。多模式方案与早期成功的纯母乳喂养有关。