1. Efficacy of Intravenous versus Oral Acetaminophen for Postoperative Pain Control Following Cesarean Delivery
Stefanie Robinson MD, Sylvia H Wilson MD, Bethany Wolf PhD, Latha Hebbar MBBS Department of Anesthesia and Perioperative Medicine
INTRODUCTION
RESULTS
Intravenous (IV) acetaminophen has established efficacy compared to placebo for several surgical procedures including total abdominal hysterectomy, tonsillectomy, and joint arthroplasty.1-2
Few studies have compared IV acetaminophen to active comparators including oral acetaminophen.1
Pain control in the parturient after a Cesarean delivery (CD) is of the utmost importance
Multimodal approach for analgesia with scheduled oral acetaminophen has been found to be superior compared to as needed oral acetaminophen post-CD.3
Primary aim: Examine efficacy of scheduled IV versus oral acetaminophen post-CD.
Demographic and intraoperative variable were similar among groups (Table 1).
Cumulative opiate consumption differed among groups at 24 hours (P=0.017) but not 48 hours (P=0.389; Table 2).
Median opiate consumption was reduced at 24 hours in the IV versus no acetaminophen group using pairwise comparisons and Bonferroni correction for multiple comparisons (P=0.015; Figure 1).
Opiate consumption did not differ when comparing IV to oral acetaminophen and oral to no acetaminophen.
IV acetaminophen (vs no acetaminophen) patients also were more likely to
Not consume postoperative opiates (P=0.022)
Report lower VAS with rest and ambulation (P=0.004; Figure 2)
VAS pain scores at rest and side effects were similar among groups at 24 and 48 hours
Table 1. Patient Characteristics
Table 2. Cumulative Opiate Consumption
None
Oral IV P
DemographicsΨ
Age (years)
31.2 (5.34)
30.5 (5.55)
28.7 (5.30)
0.078
Weight (kg)
94.5 (29.9)
90.2 (17.1)
89.4 (23.9)
0.561
Race (White)
23 (50.0)
31 (66.0)
27 (57.5)
0.296
Prior CD
36 (76.6)
32 (68.1)
40 (37.0)
0.15
Intraoperative*
IV Opiates
9 (19.2)
4 (8.51)
8 (17.0)
0.309
Fentanyl
7 (14.9)
0.454
Morphine
6 (12.8)
3 (6.38)
5 (10.6)
0.684
Postoperative
Time to First Opiate (Hours)Ψ
16.7 (14.3)
17.4 (14.1)
22.1 (10.9)
0.076
Time to Ambulate (Hours)Ψ
16.9 (7.01)
16.9 (5.72)
17.4 (8.57)
0.978
Side Effects*
17 (36.2)
23 (48.9)
18 (38.3)
0.403
Satisfaction†
95 (11, 100)
92.5 (45.5, 100)
95 (65, 100)
0.611
None
Oral IV P
24 Hours
5mg (7)
0mg (6.75)
0mg (4.34)
0.017
48 Hours
17.5mg (17.5)
15mg (16.25)
15mg (13.75)
0.389
Data are presented as median (IQR)
Opiates are presented as IV morphine equivalents.
Fig 1. Opiate Consumption: Pairwise Comparisons
24 Hours
48 Hours
P = 0.015
METHODS
Prospective, single-blinded, randomized trial
141 parturients scheduled for elective CD
Exclusions: Non-elective CD, contraindications to ketorolac, acetaminophen or spinal anesthesia with intrathecal opiates
Three randomized groups
IV acetaminophen: 1g every 8 hours for 24 hours
Oral acetaminophen: 1g every 8 hours for 24 hours
No acetaminophen
Standardization:
Spinal anesthesia for CD (bupivacaine 12mg, fentanyl 15µg, morphine 0.2mg)
Scheduled ketorolac 30mg IV every 6 hours for 24 hours
Oral and parenteral opiates prn.
Outcomes
Primary: Cumulative opiate consumption at 24 hours
Secondary: (24 and 48 hours)
VAS scores at rest and with ambulation (100mm scale)
Patient satisfaction scores (100mm scale)
Cumulative opiate consumption (at 48 hours)
Statistics
Continuous: ANOVA approach or Kruskal-Wallace test
Categorical: Chi-square or Fisher’s exact test.
Comparisons between groups in opiate consumption over time: generalized logistic-normal mixture model
IV Morphine Equivalents (mg)
Categorical variables are presented as n (%).*
Continuous variables are presented as mean (SD)Ψ or median (range).†
Side effects examined included nausea, vomiting and pruritus.
SUMMARY
Fig 2. Visual Analog Pain Scores (VAS) at Rest and with Ambulation (100mm Scale)
IV acetaminophen decreased 24 hour opiate consumption compared to no acetaminophen
IV acetaminophen did not decrease 24 hour opiate consumption compared to oral acetaminophen.
IV acetaminophen was associated with decreased VAS scores with ambulation
IV acetaminophen decreased the occurrence of consuming any opiates
24 Hours
48 Hours
24 Hours
48 Hours
P < 0.004
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VAS with Ambulation (mm)
VAS at Rest (mm)
REFERENCES
Pain Pract. 2011;11: PMID:
Pain Med. 2011;12: PMID:
Int J Obstet Anesth. 2015;24: PMID: