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Original article
Impact of patient choice for different postcesarean delivery analgesic protocols on opioid consumption: a randomized prospective clinical trial
  1. Brendan Carvalho1,
  2. Caitlin Dooley Sutton2,
  3. John J Kowalczyk3 and
  4. Pamela Dru Flood1
  1. 1Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
  2. 2Department of Anesthesiology, Baylor College of Medicine, Houston, Texas, USA
  3. 3Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, Massachusetts, USA
  1. Correspondence to Dr Brendan Carvalho, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA 94305-5119, USA; bcarvalho{at}stanford.edu

Abstract

Background Choice of postcesarean delivery analgesic protocol may improve pain experience and reduce analgesic requirements.

Methods Cesarean delivery patients were randomly assigned either to choose their postcesarean delivery analgesia protocol or to have no choice and receive routine care. Choices were low (50 μg intrathecal morphine), medium (identical to routine care: 150 μg intrathecal morphine), or high (300 μg intrathecal morphine with 600 mg oral gabapentin). All groups received scheduled acetaminophen and ibuprofen. The primary outcome was oxycodone requirements 0–48 hours postdelivery in those offered versus not offered a choice.

Results Of 160 women enrolled, 120 were offered a choice and 40 were not offered a choice. There was no difference in oxycodone requirements or pain associated with choice, but those who had a choice expressed more satisfaction than those who did not have a choice (mean (95% CI) difference 5% (0% to 10 %), p=0.005). In the choice group, the high dose group required more oxycodone (5 (0 to 15) mg 0–24 hours after delivery and 15 (10 to 25) mg at 24–48 hours; p=0.05 and p=0.001) versus the low and medium groups. The low dose group had less pruritus (p=0.001), while the high dose group had more vomiting (p=0.01) requiring antiemetic treatment (p=0.04).

Conclusion Having a choice compared with no choice routine care did not reduce oxycodone requirements or pain scores. However, women have insight into their analgesic needs; women offered a choice and who chose the higher dose analgesic protocol required more oxycodone, and women who chose the lower dose protocol required less oxycodone. Despite providing additional analgesic (six times more intrathecal morphine plus gabapentin in high dose vs low dose protocols), we still did not equalize postcesarean oxycodone requirement differences between groups.

Trial registration number NCT02605187.

  • obstetrics
  • postoperative pain
  • pain measurement
  • pain outcome measurement

https://doi.org/10.1136/rapm-2018-100206

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    Footnotes

    • Contributors BC developed the study design, analyzed the data, helped with study logistics, helped formulate and revise the manuscript critically, and approved the final manuscript. CDS and JJK developed the study design, performed data collection, helped formulate and revise the manuscript critically, and approved the final manuscript. PDF developed the study design, analyzed the data, helped formulate and revise the manuscript critically, and approved the final manuscript.

    • Funding The study was supported by the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California, USA. No external funding sources were used.

    • Competing interests None declared.

    • Patient consent for publication Not required.

    • Ethics approval The study received approval from the Stanford University Institutional Review Board (Stanford, California, USA; protocol: 34740; October 2015).

    • Provenance and peer review Not commissioned; externally peer reviewed.