The Advantage of Implementation of Enhanced Recovery After Surgery (ERAS) in Acute Pain Management During Elective Cesarean Delivery: A Prospective Randomized Controlled Trial

Figures & data

Table 1 Routine Protocol and ERAS Protocol

	Routine Protocol	ERAS Protocol
Education/Counseling	Perioperative information was not provided in advance.	Information on perioperative procedure, pain management plan, the necessity of early feeding and mobilization, lactation support services, discharge criteria, follow-up schedule, etc.
Preoperative oral intake	Fasting from midnight before surgery	Fluid up to 2 h prior to surgery Solid foods up to 6 h prior to surgery
Standard anesthetic protocol	Received CSEA, spinal 5% ropivacaine 12.5–13.5mg, and epidural 1% lidocaine 3mL, before PCEA started. Dexmedetomidine 0.5 μg/kg pump was administration only if heart rate >90 beats/min or anxiety, and without any contraindications.	Received CSEA, the same as the routine protocol. Dexmedetomidine 0.5 μg/kg pump was recommended after childbirth. It was avoided if there were contraindications, heart rate <60 beats/min or systolic blood pressure <100mmHg.
Postoperative pain management	PCEA for 2 days; 2 mg morphine initial bolus; 6–7mg morphine and 13.5 mg ropivacaine diluted into 100 mL in the pump, 2 mL/h basal rate, 0.5 mL bolus with a 15-minute lockout	Strict 6mg morphine in the pump; remaining points same as the routine protocol
Extra analgesics	When pain was of VAS>3, and the patient requested extra analgesics, Tramadol 100 mg intramuscular injection was administered	The same as routine protocol
Prevention of PONV	Tropisetron 5mg at the end of the surgery.	Tropisetron 5 mg immediately after the childbirth; other antiemetics as needed
Intraoperative oxytocin	Oxytocin 20 U dilute to 500 mL, immediately after cord clamping, continuous infusion 1–2 h Carboprost tromethamine 250 μg intramuscular injection, determined by the obstetrician	Oxytocin controlled at 40–60 drop/min Remaining points same as the routine protocol
Prophylactic antibiotics	Antibiotics administration after cord clamping immediately.	Same as the routine protocol
Perioperative fluid and blood pressure management	Preferred crystalloid infusion to reduce hypotension. Phenylephrine 50μg/bolus if necessary.	Avoid overhydration. Both fluids and vasopressors to counteract hypotension. Prophylactic phenylephrine 50μg followed by CSEA.
Preventing intraoperative hypothermia	Covering bedding without warm air blower.	The bedding was warmed with warm air blower before surgery.
Postoperative oral intake	Until the return of bowel function, such as flatus or stools	Early oral intake, started 2h after surgery, start with light diet less than 200 mL, and then gradually increased according to gastrointestinal tolerance
Postoperative mobilization	Mobilization as per patient’s discretion	Umbilical self-massage according to the tolerance. Actively turned over 6 hours after surgery. Mobilization at the bedside on the first day after surgery, followed by walking in the ward.
Skin to skin and breastfeeding	As per patient’s discretion, mostly after the anesthetic wore off	Recommend early skin-to-skin contact with the newborn, immediately after back to the ward. Breastfeeding within 1 hour after the surgery, according to the baby’s needs

Note: Hypotension was defined as mean arterial pressure decrease over 20% from the value before induction of anesthesia.

Abbreviations: PONV, postoperative nausea and vomiting; ERAS, enhanced recovery after surgery; CSEA, combined spinal and epidural anesthesia; PCEA, patient controlled epidural analgesia.

Table 2 Preoperative Characteristics of the Patients

Characteristics	Group Control n=104	Group ERAS n=112	P value
Age (years)	32.59 ± 4.14	33.21 ± 4.49	0.295
Body mass index (kg/m^2)	27.01 ± 3.21	27.09 ± 3.33	0.860
ASA score
1	31 (29.81%)	25 (22.32%)	0.218
2	73 (70.19%)	87 (77.68%)
Parity
1	28 (26.92%)	38 (33.93%)	0.302
2	68 (65.38%)	68 (60.71%)	0.485
3 and more	8 (7.84%)	6 (5.36%)	0.585
Gestational week	39.03 ± 0.91	38.96 ± 0.91	0.602
Gestation
Single	100 (96.15%)	106 (94.64%)	0.750
Twins	4 (3.85%)	6 (5.36%)
Preoperative complications
Thalassemia	27 (25.96%)	22 (19.64%)	0.330
Hepatitis	14 (13.46%)	22 (19.64%)	0.274
Diabetes	16 (15.38%)	20 (17.86%)	0.716
Blood loss during cesarean delivery
≤500mL	62 (59.62%)	70 (62.50%)	0.678
>500mL	42 (40.38%)	42 (37.50%)

Note: Data are expressed as mean ± SD, or numbers (%).

Abbreviation: ERAS, enhanced recovery after surgery.

Figure 1 Patient enrollment and randomization.

Table 3 Postoperative Pain VAS

Characteristics	Group Control n=104	Group ERAS n=112	P value
Rest in 24 h	3.50 ± 1.76	2.46 ± 1.58	<0.001
Motion in 24 h	4.74 ± 1.90	3.38 ± 2.10	<0.001
Rest in 48 h	2.60 ± 1.57	2.00 ± 1.65	0.007
Motion in 48 h	3.50 ± 1.65	2.77 ± 2.01	0.004
Requirement of extra analgesics	1 (0.96%)	1 (0.89%)	1.000

Note: Data are expressed as mean ± SD.

Abbreviations: VAS, visual analog scale; ERAS, enhanced recovery after surgery.

Figure 2 Visual analog scale (VAS) scores of pain in the two groups at rest and motion on the first and second postoperative days.

Figure 3 The proportion of postoperative pain of visual analog scale (VAS) grade >3 in the two groups.

Table 4 Intraoperative and Postoperative Conditions

Characteristics	Group Control n=104	Group ERAS n=112	P value
Intraoperative
Carboprost tromethamine	82 (78.85%)	76 (67.86%)	0.091
Dexmedetomidine	33 (31.73%)	66 (58.93%)	<0.001
Nausea	23 (22.12%)	3 (2.68%)	<0.001
Vomiting	6 (5.77%)	1 (0.89%)	0.058
Shivering	8 (7.69%)	9 (8.04%)	1.000
Hypotension	35 (33.65%)	31 (27.08%)	0.377
Postoperative discomfort in 48 h
Nausea	1 (0.96%)	4 (3.57%)	0.371
Pruritus	25 (24.04%)	28 (25.00%)	0.876

Table 5 Satisfaction VAS, Length of Stay, and the Cost of Hospitalization

Characteristics	Group Control n=104	Group ERAS n=112	P value
Satisfaction VAS	8.12 ± 1.08	8.42 ± 0.76	0.016
Length of stay (d)	4.61 ± 0.64	4.67 ± 0.49	0.412
Postoperative length of stay (d)	3.42 ± 0.55	3.45 ± 0.64	0.775
Average cost of hospitalization (RMB/d)	2140.4 ± 335.4	1568.2 ± 303.8	<0.001
The cost of anesthesia (RMB)	1047.9 ± 221.1	1045.6 ± 212.8	0.937