Evolution of postoperative care: marked reduction of opioid consumption when ERAC pathway added to wound soaker therapy for cesarean delivery

Figures & data

Table 1. Multimodal analgesic regimen by perioperative period.

	Control	Wound soaker	Early ERAC	Late ERAC
Intraoperative regimen	Spinal anesthetic with: Bupivacaine0.75%, 11 mg Fentanyl 15–25 µg Morphine PF 150 µg Acetaminophen 1000 mg IV Ketorolac 0.5 mg/kg IV, up to 30 mg max	Spinal anesthetic with: Bupivacaine 0.75%, 11 mg Fentanyl 15–25 µg Morphine PF 150 µg Acetaminophen 1000 mg IV Ketorolac 0.5 mg/kg IV, up to 30 mg max Wound catheter placement	Spinal anesthetic with: Bupivacaine 0.75%, 11 mg Fentanyl 15–25 µg Morphine PF 150 µg Acetaminophen 1000 mg IV Ketorolac 0.5 mg/kg IV, up to 30 mg max Wound catheter placement	Spinal anesthetic with: Bupivacaine 0.75%, 11 mg Fentanyl 15–25 µg Morphine PF 150 µg Acetaminophen 1000 mg IV Ketorolac 0.5 mg/kg IV, up to 30 mg max Wound catheter placement
Postoperative regimen	Acetaminophen 650 mg PO q6h PRN Ketorolac 0.5 mg/kg IV q6h PRN (up to 30 mg max) × 24 h followed by Ibuprofen 600 mg PO q6h PRN Oxycodone 5 mg PO q6h PRN	Acetaminophen 650 mg PO q6h PRN Ketorolac 0.5 mg/kg IV q6h PRN (up to 30 mg max) × 24 h followed by Ibuprofen 600 mg PO q6h PRN Acetaminophen and ketorolac/ibuprofen not given at any specific time interval in relation to each other^a Oxycodone 5 mg PO q6h PRN Wound catheter infusion of bupivacaine 0.5% at 2 ml/h for 48 h	Acetaminophen 650 mg PO q6h AND ketorolac 0.5 mg/kg IV q6h (up to 30 mg max × 24 h, followed by ibuprofen 600 mg PO q6h) alternating so that one is given every 3 h Oxycodone 5 mg PO q6hr PRN breakthrough pain only Wound catheter infusion of bupivacaine 0.5% at 2 ml/h for 48 h Early mobilization Early oral intake Early foley removal Breastfeeding support Promotion of return of bowel function	Acetaminophen 650 mg PO q6h AND ketorolac 0.5 mg/kg IV q6h (up to 30 mg max × 24 h, followed by ibuprofen 600 mg PO q6h) given together to promote 6 h intervals of rest Oxycodone 5 mg PO q6h PRN breakthrough pain only Wound catheter infusion of bupivacaine 0.5% at 2 ml/h for 48 h Early mobilization Early oral intake Early foley removal Breastfeeding support Promotion of return of bowel function Promotion of rest intervals

^aA small percentage of patients in each group underwent a trial of labor, but ultimately converted to cesarean delivery. If patients had an epidural in situ at the time of cesarean delivery, preservative-free morphine 3 mg was given through the epidural before removal at the end of the procedure.

Figure 1. Components of the enhanced recovery after cesarean delivery pathway. Preoperative, intraoperative, and postoperative components of the Enhanced Recovery After Cesarean Delivery Pathway

Figure 2. Opioid consumption for postoperative days 1–4. Average daily morphine milligram equivalents divided by subgroup (control, wound soaker, early ERAC and late ERAC group) as a function of postoperative days 1–4. The blue line represents the control group and red dashed line represents the wound soaker group. The green and black dashed lines represent the early and late ERAC groups, respectively.

Table 2. Comparison of demographics between groups.

Variable	Control n = 61 Mean (± SD)	Wound soaker n = 40 Mean (± SD)	Early ERAC n = 78 Mean (± SD)	Late ERAC n = 57 Mean (± SD)	p-Value
Age (years)	28.3 ± 6.1	27.3 ± 5.4	29.9 ± 6.5	28.8 ± 6.5	.179
Gestational age (weeks)	35.5 ± 4.0	36.9 ± 2.4	36.2 ± 3.6	35.8 ± 2.9	.176
Gravida	2.6 ± 1.7	2.5 ± 1.3	2.4 ± 1.7	2.8 ± 2.0	.513
Term	0.9 ± 1.0	0.8 ± 0.9	0.8 ± 1.1	0.8 ± 1.2	.942
Preterm	0.2 ± 0.5	0.1 ± 0.4	0.1 ± 0.3	0.2 ± 0.6	.46
Abortion	0.5 ± 0.9	0.6 ± 0.9	0.5 ± 0.9	0.8 ± 1.3	.432
Living	1.0 ± 1.1	0.9 ± 1.0	0.8 ± 1.2	1.0 ± 1.3	.836
Race	–	–	–	–	.0396
Hispanic or Latino	17 (27.87%)	10 (25%)	19 (24.36%)	14 (24.56%)
Not Hispanic or Latino	35 (57.38%)	23 (57.50%)	52 (66.67%)	25 (43.86%)
Unknown or not reported	9 (14.75%)	7 (17.50%)	7 (8.97%)	18 (31.58%)
Repeat cesarean delivery	6 (9.84%)	4 (10.00%)	15 (19.23%)	14 (24.56%)	.0981
History of chronic pain^a	0 (0.00%)	2 (5.00%)	0 (0.00%)	0 (0.00%)	.0196
History of anxiety/depression	8 (13.11%)	3 (7.50%)	24 (30.77%)	24 (42.11%)	.0000866
Smoker	8 (13.11%)	7 (17.50%)	4 (5.13%)	2 (3.51%)	.0385

^aFisher exact test is used due to small cells.

Table 3. Comparison of opioid consumption by group.

Variable	Control n = 61 Mean (± SD)	Wound soaker n = 40 Mean (± SD)	Early ERAC n = 78 Mean (± SD)	Late ERAC n = 57 Mean (± SD)	p-Value
Intraoperative fentanyl (mcg)	33.6 ± 25.2	28.4 ± 18.0	21.7 ± 19.8	23.2 ± 21.0	.011
Intraoperative morphine (mg)	1.1 ± 1.6	1.1 ± 1.6	0.7 ± 1.2	0.6 ± 1.0	.094
Total Intraoperative Opioid (MME)	4.1 ± 3.8	3.5 ± 2.7	2.9 ± 2.7	2.9 ± 2.7	.096
Intraoperative local anesthetic (mg)	91.8 ± 158.7	94.4 ± 170.4	78.4 ± 151.6	79.8 ± 167.1	.933
Total Opioid Consumption for entire postoperative length of stay^a	184.2 ± 92.9	134.8 ± 77.1	23.8 ± 31.0	29.5 ± 35.1	<.001
Opioid Consumption POD 1 (MME)	49.2 ± 23.3	33.2 ± 23.6	6.2 ± 9.0	6.4 ± 9.9	<.001
Opioid Consumption POD 2 (MME)	60.4 ± 29.8	43.7 ± 21.9	8.6 ± 12.0	11.8 ± 12.1	<.001
Opioid Consumption POD 3 (MME)	52.5 ± 27.3	44.6 ± 25.7	6.9 ± 11.5	8.8 ± 11.7	<.001
Opioid Consumption POD 4 (MME)	30.5 ± 17.7	30.6 ± 14.2	4.4 ± 8.1	4.5 ± 7.2	<.001

MME: Morphine Milligram Equivalents. ^aTotal opioid consumption for entire postoperative length of stay including POD 1–4.