By: Rose Fontana BSN, RRNA and Courtney Henderson BSN, RRNA • Webster University • Committee Members: Michael Burns MS, CRNA o Christopher Black MS, CRNA o Jill Stulce PhD(c), CRNA o • Phelps County Regional Medical Center • • • • Most common surgical procedure performed in U.S. o 2012: 1,296,531 Major abdominal surgery High postoperative pain Pain delays ambulation, motherinfant bonding, and decreases patient satisfaction Opioids: first line of treatment Many adverse effects Harmful to mom and possibly to baby Delays bonding and ambulation A multimodal analgesic regimen decreases the need for rescue opioids • • • • • First synthesized in 1878 by Morse First used in clinical practice in 1887 by Von Mering N-acetyl-p-aminophenol Non-salicylate antipyretic Non-opioid analgesic ● Mechanisms of Action- not fully understood Inhibits prostaglandin synthesis ○ Serotonergic pathway activation ○ Cannabinoid receptor stimulation ○ N-methyl-D-aspartate receptor inhibition ○ • Even after spinal anesthesia and TAP blocks, patients continue to experience breakthrough pain in the early post cesarean delivery period. A multimodal analgesic regimen can decrease the amount of rescue opioid medications necessary for adequate pain control with less unwanted opioid side effects. • The purpose of this study was to determine if the administration of intravenous acetaminophen following cesarean delivery leads to a decrease in postoperative opioid requirements • • Null Hypothesis: The use of intravenous acetaminophen in combination with a multimodal pain management regimen will not decrease postoperative opioid requirements after cesarean delivery Alternative Hypothesis: The use of intravenous acetaminophen in combination with a multimodal pain management regimen will decrease postoperative opioid requirements after cesarean delivery • Each cesarean delivery patient will receive: o o o o o Subarachnoid block with 0.75% bupivacaine in 8.25% dextrose Intrathecal morphine 0.1mg Intrathecal fentanyl 10-15 mcg TAP block with 20-30 mL 0.5% ropivacaine Ketorolac 30 mg every 6 hours for the first 24 hours postoperatively Does intravenous acetaminophen decrease postoperative opioid requirements following cesarean delivery? • Retrospective analysis of 329 patient charts o 145 cases during January 1, 2012-November 2012 Control Group= No Acetaminophen o 182 cases during November 2012- December 31, 2013 Experimental Group= 1 gram of IV Acetaminophen every six hours for 24 hours • The opioid medication consumption for each patient was totaled and converted to IV morphine equivalents using an opioid analgesic converter from GlobalRPH • Patients included in this study: o Females undergoing elective cesarean delivery o Each received entire pain management protocol: o Subarachnoid block with 0.75% bupivacaine in 8.25% dextrose Intrathecal morphine 0.1mg Intrathecal fentanyl 10-15 mcg TAP block with 20-30 mL 0.5% ropivacaine Ketorolac 30 mg every 6 hours for the first 24 hours postoperatively Acetaminophen group also received 1 g of IV acetaminophen every 6 hours for the first 24 hours postoperatively • Exclusion criteria for this study included: Failure to receive the entire pain management protocol o General anesthetic o ICU admission or another surgery within 24 hours o Contraindication to regional anesthesia o Additional gynecological surgeries o Emergency cesarean delivery o • • 145 charts were reviewed o 40 charts were excluded due to an incomplete pain management protocol o 27 charts were excluded due to additional gynecological procedures o 13 charts were excluded due to conversion to general anesthesia, intensive care unit admission or additional surgery within 24 hours of cesarean delivery, or a multitude of factors Total of 65 patients in the non-acetaminophen group • • 184 charts were reviewed o 55 charts were excluded due to an incomplete pain management protocol o 26 charts were excluded due to additional gynecological procedures o 21 charts were excluded due to conversion to general anesthesia, intensive care unit admission or additional surgery within 24 hours of CD, or a multitude of factors Total of 82 patients in the acetaminophen group • Data was recorded in Microsoft Excel and converted for analysis using GraphPad Prism 5.0 • A significance level of p<0.05 was used in all analyses NON-ACETAMINOPHEN (n=65) ACETAMINOPHEN* (n=82) Mean ± Std. Deviation Mean ± Std. Deviation AGE 27.57 ± 6.060 26.39 ± 5.593 BMI 34.13 ± 7.040 33.93 ± 6.495 PREVIOUS CD 0.7692 ± 0.9316 0.8171 ± 0.7050 ASA 1/2/3 2/60/3 4/74/4 *Experimental group received 4g IV acetaminophen in the first 24 hours postoperatively in addition to the pain management protocol • • • • Age: No significant difference (p=0.2237) BMI: No significant difference (p=0.8600) Previous Cesarean Delivery: No significant difference (p=0.7319) ASA I/II/III • • Non-Acetaminophen Group- 2/60/3 Acetaminophen Group- 4/74/4 • Assumptions relative to this study include All anesthetic procedures were performed and documented correctly o Opioid medications and intravenous acetaminophen were administered and documented accurately o • • Non-Acetaminophen: 3.33 mg of morphine Acetaminophen: 3.07 mg of morphine • Mean Morphine Consumption: o One-tailed t-test showed: No significant decrease (p=0.3456) • • • No statistically significant decrease in postoperative morphine consumption with the addition of IV acetaminophen to a multimodal pain management regimen following cesarean delivery The results are not conclusive for a benefit of the addition of the IV acetaminophen We accept the null hypothesis • Multimodal pain management protocol without acetaminophen • • A study by Girgin, Gurbet, Turker, Aksu, and Gulhan • • • mean opioid consumption was 3.33mg Intrathecal morphine 0.1-0.4mg + 0.5% bupivacaine mean opioid consumption was 23.5mg Supports use of this multimodal pain management protocol • • A total of 28 patients from both the non-acetaminophen and acetaminophen groups were excluded for no ketorolac administration These patients’ morphine consumption was calculated and found to be greater than those that received the entire pain management protocol • • n=147 all those included in the study o mean opioid consumption: 3.187 mg n=28 no ketorolac o mean opioid consumption: 7.429 mg • A Welch’s correction was applied to a t-test to analyze significance o There was a significance found with p= 0.0043 • • • Although corrections were made for the variance in sample size, it makes the significance of the p value unreliable cannot be considered dependable results warrants further study • of the 28 that did not receive ketorolac o n=11 non-acetaminophen group mean morphine consumption was: 6.955 mg o n=17 acetaminophen group mean morphine consumption was: 7.735 mg o p=0.7814 • No significance that intravenous acetaminophen lowers postoperative opioid requirements in the absence of ketorolac • Perform a prospective randomized double-blind study evaluating the effect of ketorolac as part of a multimodal analgesic regimen post cesarean delivery o Incidental findings of this study suggest investigation of ketorolac efficacy would be advantageous • Limitations for this study include o Only measured opioid consumption for 24 hours o Did not evaluate pain scores time to first ambulation sedation scores patient satisfaction o Retrospective: no influence on multimodal pain management regimen, already in place dependent on staff to give appropriate postoperative doses o Intrathecal morphine shortage • Perform this study as a prospective randomized double-blind study with better controlled variables o Same surgeon and anesthesia provider placing the spinal and TAP block o The same postoperative opioid medications o Identical anesthetic and analgesic dosages • Martin, J., Hamilton, B., Ventura S., Osterman M., Curtin, S., & Mathews, T. J., (2013). Births: Final data for 2012. National Vital Statistics Reports; National Center for Health Statistics, 62(9), 1-87. ● Mehta, V., & Shah, S. (2010). Paracetamol: the forgotten drug. British Journal Of Hospital Medicine (London, England: 2005), 71(11), 606-607. ● Girgin, N., Gurbet, A., Turker, G., Aksu, H., & Gulhan, N. (2008). Intrathecal morphine in anesthesia for cesarean delivery: dose-response relationship for combinations of low-dose intrathecal morphine and spinal bupivacaine. Journal of Clinical Anesthesia, 20(3), 180-185.