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October 15, 2018
10/15/2018 1:00:00 PM - 10/15/2018 3:00:00 PM
Room North, Hall D, Area D
Post-cesarean Patient-controlled Epidural Analgesia to Decrease Intravenous and Oral Opioid Use
Ghislaine C. Echevarria, M.D., Andrew P. Agoliati, M.D., Jerome Lax, M.D., Gilbert J. Grant, M.D.
New York Univerity School of Medicine, New York, New York, United States
Disclosures: G.C. Echevarria: None. A.P. Agoliati: None. J. Lax: None. G.J. Grant: None.
BACKGROUND: The opioid overdose crisis accounts for 115 deaths per day in the US [1], and has occurred in parallel with an increase in legal opioid prescriptions [2]. Cesarean delivery is one of the most common surgical procedures in the US [3] and is associated with considerable pain for many women, being most severe during the first few days, and decreasing gradually as traumatized tissues heal. In our institution we routinely use patient-controlled epidural analgesia (PCEA) to manage postoperative cesarean pain, with patients choosing to continue their PCEA regimen for varying durations. We hypothesized that prolonged PCEA use would decrease in-hospital non-neuraxial oral opioid consumption. METHODS: We reviewed all scheduled cesarean deliveries performed under epidural or combined spinal-epidural anesthesia at our institution during 2017. Postoperative PCEA consisted of bupivacaine 0.015%, fentanyl 3 mcg/mL and epinephrine 0.5 mcg/mL, with a basal infusion of 10 mL/hr and a PCA dose of 3 mL every 10 minutes as needed. All patients also received around-the-clock ketorolac 30 mg or ibuprofen 600 mg and acetaminophen 650 mg at 6 hour intervals, alternating every 3 hours. Time of epidural catheter placement, catheter removal, discharge home, and quantity of in-hospital p.o. or i.v. opioids consumed while the PCEA was in use (PCEA on) and after the epidural catheter was removed (PCEA off) were extracted. All opioids were converted to morphine milligram equivalents (MME) to perform the analysis. RESULTS: A total of 576 cases were identified. The quantity of opioids used (MME) during PCEA (PCEA on) was a median of 0 (IQR: 0-20), compared to a median of 32.5 (IQR: 5-65) after the catheter was removed (PCEA off) (p<0.001). Regression analysis revealed that each hour the PCEA was on resulted in a 0.49 decrease in MME consumption (p<0.001). DISCUSSION: It is estimated that approximately 80% of heroin users first abused prescription opioids [4]. One means of addressing the opioid crisis should therefore focus on limiting the quantity of postoperative opioids prescribed. Since 1996, we have routinely used PCEA as the centerpiece of our post-cesarean multimodal analgesia regimen, with patients determining the duration of their therapy. Our findings in this retrospective study found that the longer the duration of PCEA, the lower the in-hospital requirement for i.v. and/or p.o. opioids. Extrapolation of these results suggests that maintaining the PCEA for the entire duration of hospitalization could potentially eliminate the need for in-hospital i.v. and/or p.o. opioids. Perhaps this could translate to a reduced need for opioids following discharge as well. REFERENCES: 1. CDC/NCHS, CDC Wonder, Atlanta, GA: US Dept HHS, CDC; 2017. 2. Kim N, et al. J Bone Joint Surg Am 2016;98:e89. 3. Centers for Disease Control and Prevention. Number of All-Listed Procedures for Discharges 4. National Institute on Drug Abuse. Prescription drugs: abuse and addiction. Bethesda (MD): NIDA; 2011:1-16
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