By: Rose Fontana BSN, RRNA and
Courtney Henderson BSN, RRNA
• Webster University
• Committee Members:
Michael Burns MS, CRNA
o Christopher Black MS, CRNA
o Jill Stulce PhD(c), CRNA
o
• Phelps County Regional Medical Center
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Most common surgical procedure
performed in U.S.
o
2012: 1,296,531
Major abdominal surgery
High postoperative pain
Pain delays ambulation, motherinfant bonding, and decreases
patient satisfaction
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Opioids: first line of treatment
Many adverse effects
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Harmful to mom and possibly to baby
Delays bonding and ambulation
A multimodal analgesic regimen decreases
the need for rescue opioids
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First synthesized in 1878 by Morse
First used in clinical practice in 1887
by Von Mering
N-acetyl-p-aminophenol
Non-salicylate antipyretic
Non-opioid analgesic
● Mechanisms of Action- not fully understood
Inhibits prostaglandin synthesis
○ Serotonergic pathway activation
○ Cannabinoid receptor stimulation
○ N-methyl-D-aspartate receptor
inhibition
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Even after spinal anesthesia and TAP blocks, patients
continue to experience breakthrough pain in the early post
cesarean delivery period. A multimodal analgesic regimen
can decrease the amount of rescue opioid medications
necessary for adequate pain control with less unwanted
opioid side effects.
• The purpose of this study was to determine if
the administration of intravenous
acetaminophen following cesarean delivery
leads to a decrease in postoperative opioid
requirements
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Null Hypothesis: The use of intravenous acetaminophen in
combination with a multimodal pain management regimen
will not decrease postoperative opioid requirements after
cesarean delivery
Alternative Hypothesis: The use of intravenous
acetaminophen in combination with a multimodal pain
management regimen will decrease postoperative opioid
requirements after cesarean delivery
• Each cesarean delivery patient will receive:
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Subarachnoid block with 0.75% bupivacaine in 8.25% dextrose
Intrathecal morphine 0.1mg
Intrathecal fentanyl 10-15 mcg
TAP block with 20-30 mL 0.5% ropivacaine
Ketorolac 30 mg every 6 hours for the first 24 hours
postoperatively
Does intravenous acetaminophen
decrease postoperative opioid
requirements following cesarean
delivery?
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Retrospective analysis of 329 patient charts
o 145 cases during January 1, 2012-November 2012
 Control Group= No Acetaminophen
o 182 cases during November 2012- December 31, 2013
 Experimental Group= 1 gram of IV Acetaminophen every six hours for
24 hours
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The opioid medication consumption for each patient was totaled and
converted to IV morphine equivalents using an opioid analgesic
converter from GlobalRPH
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Patients included in this study:
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Females undergoing elective cesarean delivery
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Each received entire pain management protocol:
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Subarachnoid block with 0.75% bupivacaine in 8.25% dextrose
Intrathecal morphine 0.1mg
Intrathecal fentanyl 10-15 mcg
TAP block with 20-30 mL 0.5% ropivacaine
Ketorolac 30 mg every 6 hours for the first 24 hours postoperatively
Acetaminophen group also received 1 g of IV acetaminophen
every 6 hours for the first 24 hours postoperatively
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Exclusion criteria for this study included:
Failure to receive the entire pain management
protocol
o General anesthetic
o ICU admission or another surgery within 24 hours
o Contraindication to regional anesthesia
o Additional gynecological surgeries
o Emergency cesarean delivery
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145 charts were reviewed
o 40 charts were excluded due to an incomplete pain management
protocol
o 27 charts were excluded due to additional gynecological procedures
o 13 charts were excluded due to conversion to general anesthesia,
intensive care unit admission or additional surgery within 24 hours
of cesarean delivery, or a multitude of factors
Total of 65 patients in the non-acetaminophen group
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184 charts were reviewed
o 55 charts were excluded due to an incomplete pain management
protocol
o 26 charts were excluded due to additional gynecological procedures
o 21 charts were excluded due to conversion to general anesthesia,
intensive care unit admission or additional surgery within 24 hours
of CD, or a multitude of factors
Total of 82 patients in the acetaminophen group
• Data was recorded in Microsoft Excel and
converted for analysis using GraphPad Prism
5.0
• A significance level of p<0.05 was used in all
analyses
NON-ACETAMINOPHEN
(n=65)
ACETAMINOPHEN*
(n=82)
Mean ± Std. Deviation
Mean ± Std. Deviation
AGE
27.57 ± 6.060
26.39 ± 5.593
BMI
34.13 ± 7.040
33.93 ± 6.495
PREVIOUS
CD
0.7692 ± 0.9316
0.8171 ± 0.7050
ASA 1/2/3
2/60/3
4/74/4
*Experimental group received 4g IV acetaminophen in the first 24 hours postoperatively in addition to the pain management protocol
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Age: No significant difference (p=0.2237)
BMI: No significant difference (p=0.8600)
Previous Cesarean Delivery: No significant
difference (p=0.7319)
ASA I/II/III
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Non-Acetaminophen Group- 2/60/3
Acetaminophen Group- 4/74/4
• Assumptions relative to this study include
All anesthetic procedures were performed and
documented correctly
o Opioid medications and intravenous
acetaminophen were administered and
documented accurately
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Non-Acetaminophen: 3.33 mg of morphine
Acetaminophen: 3.07 mg of morphine
• Mean Morphine Consumption:
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One-tailed t-test showed:
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No significant decrease (p=0.3456)
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No statistically significant decrease in
postoperative morphine consumption with the
addition of IV acetaminophen to a multimodal pain
management regimen following cesarean delivery
The results are not conclusive for a benefit of the
addition of the IV acetaminophen
We accept the null hypothesis
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Multimodal pain management protocol without
acetaminophen
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A study by Girgin, Gurbet, Turker, Aksu, and Gulhan
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mean opioid consumption was 3.33mg
Intrathecal morphine 0.1-0.4mg + 0.5% bupivacaine
mean opioid consumption was 23.5mg
Supports use of this multimodal pain management
protocol
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A total of 28 patients from both the non-acetaminophen
and acetaminophen groups were excluded for no ketorolac
administration
These patients’ morphine consumption was calculated and
found to be greater than those that received the entire pain
management protocol
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n=147 all those included in the study
o mean opioid consumption: 3.187 mg
n=28 no ketorolac
o mean opioid consumption: 7.429 mg
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A Welch’s correction was applied to a t-test to analyze significance
o There was a significance found with p= 0.0043
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Although corrections were made for the variance in sample size, it
makes the significance of the p value unreliable
cannot be considered dependable results
warrants further study
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of the 28 that did not receive ketorolac
o n=11 non-acetaminophen group
 mean morphine consumption was: 6.955 mg
o n=17 acetaminophen group
 mean morphine consumption was: 7.735 mg
o p=0.7814
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No significance that intravenous acetaminophen lowers
postoperative opioid requirements in the absence of ketorolac
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Perform a prospective randomized double-blind
study evaluating the effect of ketorolac as part of a
multimodal analgesic regimen post cesarean delivery
o Incidental findings of this study suggest investigation of
ketorolac efficacy would be advantageous
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Limitations for this study include
o Only measured opioid consumption for 24 hours
o Did not evaluate
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pain scores
time to first ambulation
sedation scores
patient satisfaction
o Retrospective: no influence on multimodal pain management
regimen, already in place
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dependent on staff to give appropriate postoperative doses
o Intrathecal morphine shortage
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Perform this study as a prospective randomized
double-blind study with better controlled variables
o Same surgeon and anesthesia provider placing the spinal and
TAP block
o The same postoperative opioid medications
o Identical anesthetic and analgesic dosages
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Martin, J., Hamilton, B., Ventura S., Osterman M., Curtin, S., & Mathews,
T. J., (2013). Births: Final data for 2012. National Vital Statistics Reports;
National Center for Health Statistics, 62(9), 1-87.
● Mehta, V., & Shah, S. (2010). Paracetamol: the forgotten drug. British
Journal Of Hospital Medicine (London, England: 2005), 71(11), 606-607.
● Girgin, N., Gurbet, A., Turker, G., Aksu, H., & Gulhan, N. (2008).
Intrathecal morphine in anesthesia for cesarean delivery: dose-response
relationship for combinations of low-dose intrathecal morphine and
spinal bupivacaine. Journal of Clinical Anesthesia, 20(3), 180-185.