Background: As a part of a quality improvement program, maternal postoperative
opioid use and
pain scores were compared between those receiving continuous infusion of
bupivacaine for local incisional
pain control with multimodal
pain management and neuraxial
morphine versus multimodal
pain management with neuraxial
morphine alone. Objective: We compared postoperative
opioid use and
pain scores between the multimodal
pain management group with neuraxial
morphine and the group receiving multimodal
pain management, neuraxial
morphine, and continuous infusion of
bupivacaine for local incisional
pain control. Study design: A retrospective cohort analysis of cesarean deliveries from January of 2015 through March of 2016 was undertaken. Deliveries were grouped by utilization of continuous infusion of
bupivacaine for local incisional
pain control. For each postoperative day, the average daily
opioid use,
antiemetic use and
pain scores were determined. Patients received 1-2
tablets oxycodone-acetaminophen (5-325 mg) every 4 h as needed with
oxycodone 5-10 mg immediate release
tablets every 4 h as needed for
breakthrough pain in addition to
acetaminophen and
ibuprofen. Total dose of
narcotic,
antiemetic use, and
pain scores was compared between groups utilizing t-test for continuous variables and chi square for categorical data. A linear mixed model with unstructured covariance was utilized to analyze the daily dose of
narcotic and
pain scores from postoperative day 1 through day 4. Results: Patients in the standard multimodal group with neuraxial
morphine used more
opioids versus those receiving continuous
wound infusion of
bupivacaine in total postoperative dosing (122.79 ± 61.92 mg versus 89.88 ± 51.38 mg, p = .0063). There was a statistically significant difference between the standard group and local infusion of
bupivacaine group on postoperative days 1 and 2 (32.79 ± 15.56 mg versus 22.13 ± 15.73 mg, p = .0011 and 40.25 ± 19.84 mg versus 29.13 ± 14.58 mg, p = .0018, respectively). There was no difference in
narcotic use for postoperative days 3 and 4. There was a higher mean number of
antiemetic doses in the standard group (0.31 ± 0.70 versus 0.10 ± 0.30, p = .0396).
Pain scores did not differ between groups, although there was a correlation between
opioid dosing and
pain scores. The standard group received more IV
ketorolac (87.72 ± 42.01 mg versus 64.50 ± 53.3 mg, p = .0165) and more IV
acetaminophen (634.89 ± 706.42 mg versus 375.0 ± 490.29 mg, p = .0315) within the first 24 h postoperatively. In addition, the standard group received more oral
acetaminophen (6969.67 ± 3230.14 mg versus 5248.75 ± 2711.71 mg, p = .0064). No difference was seen in regard to
ibuprofen between groups. These results remained constant when adjusted for differences in gestational age, variation in intraoperative
opioid dosing, as well as differences in uterine incision type. Conclusion: We found a significant reduction in postoperative
opioid use when continuous infusion of
bupivacaine for local incisional
pain control was added to our standard
pain management with neuraxial
morphine after cesarean delivery. As a result of this quality improvement initiative, we have implemented this intervention universally as a part of our multimodal
postoperative pain management strategy.