A prospective randomized controlled trial to study the advantage of implementation of enhanced recovery after surgery (eras) in acute pain management during elective caesarean delivery.

Abstract

BACKGROUND AND AIMS: Indeed, giving birth to a child represents a profound joy for woman. But for those mothers whose choose to deliver by Cesarean section either by choice or maternal and fetal conditions, the happiness is short-lived due to various reasons. Post operative pain, sedation, other complications such as Shivering, nausea and vomiting prevents the mother from actively engaging with the newborn to hold, to feed which is not only a concern for the mother, but is also detrimental for the well-being of new born. To address these short comings associated with following traditional routine protocols in cesarean delivery, we decided to study the adaptation of Enhanced Recovery After Elective Cesarean section. The study aims to evaluate the impact of an Enhanced Recovery After Surgery (ERAS) protocol on the postoperative outcomes of patients undergoing elective cesarean delivery. METHODOLOGY: After the fulfillment of the inclusion criteria, patients were explained about the study and enrolled into the study after obtaining the written informed consent. Randomized into group EP or RP. Patients underwent thorough Pre-anaesthetic evaluation with detailed history, airway examination, systemic examination. Patient was explained about the protocols and sensitized about Visual analogue scale. Routine blood investigations were done. Patients randomized into group EP were encouraged to drink clear liquids two hours before surgery, whereas patients in group RP were kept nil by mouth for 6 hours. 14 Docusign Envelope ID: 833A84C4-8009-45BD-A545-F3C56FEE92E7 In preoperative holding area, patient details were checked, and a 20G iv cannula was secured. Before shifting the patient to operating room, the forced air warmers, fluid warmers and ultrasound machines were kept ready. Patients were monitored with ASA standards for intraoperative monitoring. Before positioning the patient for subarachnoid block, a bolus dose of Phenylephrine 100 mcg was given. Fluid warmers and forced air warmers were turned on. Ath the end of the surgery, bilateral Tap were given using ultrasound guidance. All the patients were followed up un till the time of discharge. Results: Among the 50 patients in each group, 5 patients in Group EP and 17 patients in Group RP had experienced shivering during intraoperative period. There is a significant decrease in intraoperative shivering in group EP (p<0.005). In Group EP, 10 patients out of total 50 patients had hypotension intraoperatively. In Group RP, 32 patients out of total 50 patients had Hypotension intraoperatively. The patients in Group RP had higher incidence of intraoperative Hypotension compared to Group EP. Postoperative pain was evaluated in patients 24 hours post-surgery at rest using the Visual Analog Scale (VAS). The mean VAS score in Group EP (1.76 ± 0.8221, P<0.005) was significantly lower than that in Group RP (2.96 ± 0.9467, P<0.005). Postoperative pain was evaluated in patients 24 hours post-surgery at motion using the Visual Analog Scale (VAS). The mean VAS score in Group EP (2.46 ± 0.8134, P<0.005) was significantly lower than that in Group RP (3.78 ± 0.8873, P<0.005). The number of patients required opioids at 24 hours in Group EP and Group RP was 2(4%) and 25 (50%) respectively. The number of patients required opioids in Group EP is significantly lower than that in Group RP with a P value less than 0.005. The Satisfaction VAS in Group EP (6.18 ± 0.8965) is significantly higher than that of in Group Rp (4.76 ± 0.6247) with a P value lesser than 0.005. The total length of stay (days) in hospital in Group EP (3.76 ± 0.7969) is significantly lower than that of in Group RP (4.68 ± 0.7126) with a P value of lesser than 0.005. 15 Docusign Envelope ID: 833A84C4-8009-45BD-A545-F3C56FEE92E7 The postoperative length of stay (Days) in hospital in Group EP (3.04 ± 0.7273) is significantly lower than that of in Group RP (3.94 ± 0.7117) with a P value lesser than 0.005. CONCLUSION The adaptation of Enhanced Recovery After Cesarean section protocol for perioperative care in elective cesarean delivery, showed better outcomes with maternal pain management, reduced intraoperative complications such as Hypotension and shivering, reduced opioid consumption, early mobilization, reduced length of stay and significantly better satisfaction among the patients. Thus, ERAS protocol can be continued to be a part of standard management for individuals undergoing cesarean delivery at our institution.