Journal Reading

Enhanced Recovery After Cesarean: Current and Emerging Trends

Oleh:
SHAFIRA WIDIA PUTRI
2140312059

Preseptor:

dr. Emilzon Taslim, Sp.An, KIC, KAO, M.Kes, S.H

BAGIAN ANESTESI DAN TERAPI INTENSIF FAKULTAS KEDOKTERAN

UNIVERSITAS ANDALAS RSUP DR. M. DJAMIL PADANG

2022
 KATA PENGANTAR

Puji syukur penulis ucapkan atas nikmat Allah SWT karena berkat rahmat dan
karunia-Nya maka penulis dapat menyelesaikan tugas journal reading dengan judul
“Enhanced Recovery After Cesarean: Current and Emerging Trends”.
Journal reading ini merupakan salah satu syarat untuk menyelesaikan kepaniteraan
klinik di bagian Anestesi dan Terapi Intensif Fakultas Kedokteran Universitas Andalas RSUP
DR M. Djamil Padang. Dalam usaha menyelesaikan journal reading ini, penulis
mengucapkan terima kasih yang sebesar-besarnya kepada dr. Emilzon Taslim, Sp.An, KIC,
KAO, M.Kes, S.H selaku preseptor dalam penyusunan tugas journal reading ini yang telah
memberikan bimbingan dalam menyelesaikan tinjauan kepustakaan ini. Semoga amalan dan
kebaikan beliau dapat balasan dari Allah SWT.
Penulis menyadari bahwa didalam penulisan ini masih banyak kekurangan. Oleh
karena itu, dengan segala kerendahan hati penulis menerima semua saran dan kritik yang
membangun guna penyempurnaan tugas journal reading ini. Akhir kata, semoga tugas
journal reading ini dapat bermanfaat bagi para pembaca.

Padang, Januari 2022

Penulis
 Enhanced recovery after cesarean delivery (ERAC): Tren Saat ini dan yang Muncul
Kishan Patel & Mark Zakowski

ABSTRAK
Enhanced recovery after cesarean delivery (ERAC) menyediakan sistem berbasis
bukti untuk meningkatkan persalinan, pemulihan fungsional, ikatan antara ibu-bayi, dan
pengalaman pasien. Pemulihan pascaoperasi telah berkembang dari skor nyeri satu dimensi
menjadi pendekatan multidimensi holistik yang menekankan pemulihan fungsional yang
lebih cepat. ERAC melibatkan upaya multidisiplin dari ahli anestesi, dokter kandungan,
keperawatan, rumah sakit, dan pasien. Komponen ERAC termasuk edukasi pasien pra operasi,
batasan puasa, beban karbohidrat, membatasi opioid intra dan pasca operasi, menggunakan
analgesik nonopioid terjadwal dan melengkapi dengan terapi lanjutan untuk wanita berisiko
tinggi terhadap nyeri. Protokol ERAC mengurangi konsumsi opioid, mengurangi lama rawat
inap, dan meningkatkan hasil terhadap ibu dan bayi baru lahir.

Kesimpulan: Menerapkan perawatan standar ERAC kemungkinan akan menjadi perubahan

paling penting yang dapat dilakukan dalam praktik untuk meningkatkan hasil, meningkatkan
perawatan berkualitas, membantu mengatasi perbedaan ras, dan meminimalkan paparan
opioid dan potensi kecanduan.

Kata Kunci: Persalinan Caesar, Peningkatan Pemulihan, Disparitas rasial, Gangguan

penggunaan opioid, Hasil terhadap ibu, Lama rawat inap

PENDAHULUAN

Enhanced recovery after cesarean delivery (ERAC) menyediakan sistem berbasis

bukti untuk meningkatkan persalinan ibu, pemulihan fungsional, ikatan antara ibu-bayi, dan
pengalaman pasien. ERAC melibatkan upaya tim multidisiplin dari ahli anestesi, dokter
kandungan, perawat, rumah sakit, dan pasien. Persalinan sesar (SC) adalah operasi yang
paling umum di AS, dengan tingkat sesar 32% yang melibatkan 1,2 juta wanita setiap tahun
[1] sebanding dengan negara maju. Beban global pemulihan bedah obstetrik mencakup
sekitar 140.000.000 kelahiran setiap tahun [2] dengan perkiraan 23% rata-rata sesar secara
global [3]. Lama rawatan di rumah sakit untuk SC memiliki variasi yang besar di tingkat
penyedia dan fasilitas [4]. Nyeri kronis pascaoperasi untuk SC mempengaruhi hingga 11%
wanita 1 tahun kemudian dengan hampir 10% mengalami nyeri yang parah [3, 5, 6]. ERAC
bertujuan untuk menstandardisasi perawatan perioperatif pasien peripartum dan membantu
meningkatkan hasil ibu dan bayi baru lahir [7, 8, 9••]. ERAC dan strategi penghilang rasa
sakit saat ini dan yang muncul akan dibahas dalam artikel ini.

Nyeri kronis, yang sering dimulai sebagai nyeri akut, telah menjadi masalah
kesehatan masyarakat utama yang mempengaruhi 20,4% orang dewasa pada tahun 2019 [10].
Wanita lebih banyak mengalami nyeri kronis (21,7% vs 19%, P <0,05) dan lebih banyak
nyeri kronis yang berdampak tinggi (8,5% vs 6,3%, P < 0,05) dibandingkan pria, bahkan
mempengaruhi 9-15% dari usia 18-44 tahun [10]. Penelitian sebelumnya telah menunjukkan
hubungan antara skor nyeri yang lebih tinggi setelah melahirkan dengan insiden yang lebih
tinggi dari depresi postpartum dan perkembangan nyeri kronis [3, 6, 11••,12•]. Nyeri
pascapersalinan yang lebih tinggi telah dikaitkan dengan tingkat menyusui yang lebih rendah
serta insiden depresi postpartum dan nyeri kronis yang lebih tinggi [13]. Setiap 10%
peningkatan nyeri parah pasca operasi dikaitkan dengan peningkatan 30% nyeri kronis 1
tahun kemudian [14]. Konsumsi analgesik yang lebih tinggi dalam 48 jam pertama juga
dikaitkan dengan perkembangan nyeri kronis [15]. Disparitas perawatan kesehatan dalam
nyeri dan pengobatan nyeri juga ada [16].

Pemulihan pascaoperasi telah berkembang dari fokus pada tujuan satu dimensi dari
skor nyeri skala analog visual (VAS) ≤ 3/10 ke pendekatan multidimensi yang lebih holistik.
Tujuan mendasar untuk mengurangi rasa sakit tidak hanya mengurangi penderitaan individu
tetapi juga meningkatkan pemulihan fungsional dengan lebih cepat kembali ke aktivitas
sehari-hari, termasuk ikatan ibu-bayi, pulang ke rumah, dan kepuasan yang lebih tinggi.
ERAC menggunakan pendekatan interdisipliner yang membutuhkan pendaftaran pasien (dan
sistem pendukungnya), anestesiologi, kebidanan, pediatri, keperawatan, spesialis laktasi, dan
rumah sakit. Wanita hamil dan pasangannya harus di edukasi sebelum mengunjungi rumah
sakit untuk menyelaraskan harapan tentang apa yang harus dilakukan (misalnya, terapi cairan
/beban karbohidrat 2 jam sebelum operasi) dan untuk aktivitas fisik pascaoperasi. Anestesi
intraoperatif dan obat nyeri pascaoperasi adalah komponen ERAC yang paling mudah untuk
diubah oleh ahli anestesi. Pada pasca operasi membutuhkan lebih banyak perawatan pada 1-2
hari pertama untuk membantu memobilisasi ibu.
Penerapan perawatan ERAC yang terstandar kemungkinan akan menjadi perubahan
paling penting yang dapat dilakukan dalam praktik untuk meningkatkan hasil ibu,
meningkatkan perawatan berkualitas, membantu mengatasi perbedaan ras, dan
meminimalkan paparan dan kecanduan opioid.
Elemen Praoperasi

Kunci dari elemen pra operasi ERAC termasuk edukasi pasien, membatasi lama puasa,
dan pemuatan karbohidrat.

Edukasi Pasien

Edukasi pra operasi sebelum hari operasi itu penting untuk melibatkan pasien,
mengelola harapan, mengurangi kecemasan, dan membantu meningkatkan kepatuhan pasien
terhadap protokol ERAC. Ada banyak selebaran dan alat, termasuk contoh yang tersedia di
Society for Obstetric Anesthesia and Perinatology (SOAP) ERAC toolkit (www.soap.org).
Sebuah studi di Inggris tahun 2015 menemukan informasi sederhana pada pasien untuk
pemulangan dini dan tingkat yang lebih tinggi dari pemulangan sebelumnya bahkan sebelum
implementasi komponen ERAC lainnya [17••]. Keterlibatan pasien dan pengambilan
keputusan bersama dapat dimulai sebelum operasi dan meningkatkan kepuasan serta
mengurangi resep opioid [18].

Pembatasan Interval NPO dan Pemuatan Karbohidrat

Pedoman American Society of Anesthesiologists (ASA) merekomendasikan puasa

bedah (NPO) untuk lemak padat 8 jam sebelumnya, makanan ringan 6 jam sebelum, dan
minuman bening 2 jam sebelum operasi untuk mengurangi risiko aspirasi [19]. Interval NPO
yang berkepanjangan biasanya tidak diperlukan dan dapat menyebabkan hipovolemia dan
ketidakpuasan pasien [19]. Data dari peningkatan pemulihan untuk operasi kolorektal
menunjukkan bahwa karbohidrat kompleks (yaitu, maltodekstrin) diberikan malam
sebelumnya dan 2-3 jam sebelum anestesi dengan minuman bening dapat meminimalkan
respon stres metabolik, meningkatkan resistensi insulin pasca operasi, dan pemecahan protein
yang lebih rendah [20]. Ini mungkin tidak dilakukan untuk ibu dengan diabetes karena
potensi penundaan pengosongan lambung dan hiperglikemia. Protokol SOAP ERAC
menyarankan 16 ons (~ 500 mL) jus apel murni 2 jam sebelum penjadwalan sesar sebagai
pilihan yang mudah dan dapat diterima [21].

Elemen Intraoperatif

Analgesia multimodal telah menjadi komponen kunci untuk sebagian besar

operasi/anestesi dan semua protokol pemulihan yang ditingkatkan dalam melibatkan obat-
obatan dan teknik di luar operasi rutin anestesi. Obat analgesik dapat diberikan segera
sebelum operasi, intraop, dan dilanjutkan pasca operasi. Analgesik dan teknik non-opioid
digunakan untuk meminimalkan konsumsi opioid. Namun, ERAC melampaui analgesik (lihat
Tabel 1).

Tabel 1 Komponen utama dari meningkatkan pemulihan setelah operasi caesar.

Komponen intraoperatif ERAC termasuk mulai dari asetaminofen terjadwal (dapat

dimulai sebelum operasi), NSAID, membatasi jumlah opioid neuraksial (yaitu, morfin),
pencegahan hipotermia dan mual, dan mendukung hubungan ibu-bayi [9••]. Penggunaan rutin
infus vasopresor profilaksis (misalnya, fenilefrin 0,5-1 mcg/kg/min) membantu mengurangi
hipotensi akibat mual setelah anestesi spinal. Dua kelas profilaksis yang berbeda antiemetik
harus digunakan (misalnya, ondansetron antagonis 5HT3, glukokortikoid deksametason,
dan/atau antagonis reseptor D2 metoklopramid). Dosis morfin neuraksial yang disarankan
untuk sesar adalah 1-3 mg epidural atau 50-150 mcg intratekal (IT) untuk membatasi efek
samping opioid. asetaminofen terjadwal 1000 mg (TID atau QID) memulai preop atau intraop
dan NSAID (misalnya, ketorolak 30 mg IV setelah penutupan peritoneum, diikuti oleh
ketorolak (15-30 mg) Q6h, ibuprofen 600 mg Q6h, atau naproxen 500 mg Q12h (lihat Tabel
2). Perhatikan tanda-tanda awal pasien sebelum operasi dapat membantu mengurangi
hipotermia intraoperatif; tanda bahaya intraoperatif diperlukan, termasuk menjaga
OR >72 °F/23 °C [9••]. Dosis maksimum asetaminofen adalah 4000 mg/24 jam, sesuai
persetujuan FDA [22].
 Tabel 2 Contoh pengobatan utama meningkatkan pemulihan setelah operasi caesar.

Analgesia Multimodal

Analgesia multimodal mungkin melibatkan blok regional atau luka infus anestesi
lokal dan beberapa analgetik non-opioid untuk memodifikasi atau mengurangi transmisi saraf
nyeri, mengubah respons fisiologis terhadap rangsangan rasa sakit, dan mengurangi konsumsi
opioid, mengurangi potensi toleransi opioid pasca operasi dan pengembangan penggunaan
opioid persisten.

Gabapentinoid

Gabapentinoid (yaitu, gabapentin dan pregabalin) mengikat dan memblokir subunit

α2δ yang mengandung voltage-depending calsium channel yang mungkin efektif dalam
mengurangi nyeri pasca operasi. Satu meta-analisis pasien non-cesar menemukan dosis
gabapentin 900 mg dan 1200 mg atau pregabalin 150 mg dan 300 mg menurunkan
penggunaan opioid pascaoperasi dan skor nyeri [23].
Gabapentin sebelum dan selama 2 hari pasca SC sedikit mengurangi rasa sakit (4,0 vs
4,7 VAS, P < 0,05) dalam 24 jam, namun tidak ada perbedaan dalam penggunaan opiat atau
skor nyeri persisten [24]. Sebuah meta-analisis baru-baru ini menemukan bahwa
gabapentinoids dikaitkan dengan intensitas nyeri pasca operasi yang lebih rendah, tetapi
perbedaannya tidak signifikan secara klinis (≤ 1 VAS) dan terkait dengan efek samping
berupa pusing dan gangguan penglihatan yang lebih sering ditemukan [25•]. Gabapentinoid,
sementara tidak saat ini direkomendasikan untuk ERAC yang rutin, dapat bermanfaat bagi
ibu melahirkan yang berisiko tinggi dengan nyeri kronis, gangguan penggunaan opioid.

Blok Regional untuk Operasi Caesar

Blok regional yang berguna untuk operasi sesar termasuk blok truncus (TAP, QL)
atau infus. Secara keseluruhan, hal ini tidak terbukti adanya peningkatan yang signifikan saat
dilakukan triad morfin neuraksial dan penggunaan asetaminofen dan NSAID [9••]. Blok
regional berguna ketika morfin neuraksial tidak dapat diberikan, sebagai teknik penyelamatan
pada nyeri yang parah, atau untuk pasien berisiko tinggi pada nyeri yang parah [26••].

Blok Transversus Abdominus Plane

Blok TAP telah diteliti untuk SC tetapi tidak memberikan manfaat rutin selain opioid
neuraksial, kecuali mengikuti anestesi umum atau ketika opioid neuraksial perlu dihilangkan
[9••]. Blok TAP posterior atau lateral untuk operasi caesar tidak memberikan manfaat
tambahan; hasilnya mirip dengan infiltrasi luka dan inferior jika dibandingkan dengan morfin
IT [27]. Infiltrasi bedah pada abdominusplane dapat memberikan: hasil yang sama [27].

Blok Quadratus Lumborum

Banyak penelitian telah meneliti efektivitas quadratus lumborum (QL) blok dalam
mengurangi nyeri pasca operasi perut. Blok QL (QL1) anterior bertindak seperti blok TAP
sementara blok QL (QL2) posterior dapat menyebarkan anestesi lokal lebih medial menuju
ruang paravertrebral dan menghambat nyeri visceral selain nyeri somatik [28]. Blok QL
mengurangi konsumsi opioid intraoperatif dan pascaoperasi pada pasien dibandingkan
dengan blok TAP untuk histerektomi abdomen dalam anestesi umum [29]. Dengan tidak
adanya IT morfin, pasien sesar yang diacak untuk blok QL2 memiliki penggunaan morfin
pasca operasi lebih sedikit daripada kelompok blok TAP [30], dan penggunaan morfin yang
lebih rendah dan skor nyeri VAS [28].

Namun, menambahkan blok QL pada pasien yang menerima neuraksial morfin tidak
secara signifikan mengubah skor nyeri atau mengurangi konsumsi opioid. Blok QL2 tidak
meningkatkan skor nyeri di atas morfin IT dan analgesik non-opioid terjadwal untuk SC [31•].
Anestesi Lokal Wound Infusions

Continoius wound infusions telah digunakan untuk membantu mengontrol nyeri pasca
operasi pada persalinan sesar dan lebih unggul daripada morfin epidural 2 mg setiap 12 jam
dengan penggunaan asetaminofen dan diklofenak sebagai penyelamat [32]. Pada pasien sesar
yang menerima 150 mcg morfin IT dengan penggunaan asetaminofen dan
ketorolac/ibuprofen sistemik, penambahan continuous wound infusions ropivacaine 0,2%
dengan ketorolak 30 mg/48 jam tidak memiliki perbedaan yang signifikan secara statistik
dalam skor nyeri hingga 48 jam, kepuasan pasien, penggunaan opioid, atau depresi
pascapersalinan [33]. Perbedaan manfaat dari continuous wound infusions antara kedua studi
ini adalah yang paling kemungkinan karena tidak adanya penggunaan NSAID sistemik di
studi pertama. Sebagian besar penelitian belum menemukan manfaat perifer blok saraf
anestesi lokal selain trias morfin neuraksial dan pemberian analgesik non-opioid dari
asetaminofen dan NSAID [9••, 34].

Bupivakain Liposomal

Formulasi liposomal memberikan pelepasan yang lambat dan karenanya efek

berkepanjangan dari anestesi lokal. Namun, hasil dengan liposomal bupivacaine dalam
persalinan sesar telah dicampur. Sebuah studi retrospektif menemukan bupivacaine liposomal
insisional mengurangi MMEQ [35]. Sebuah studi prospektif liposomal bupivakain pada
sayatan SC tidak menemukan penurunan skor nyeri atau MMEQ yang signifikan dalam 48
jam pertama [34]. Baru baru ini studi yang didanai oleh produsen menunjukkan liposomal
bupivakain 266 mg ditambah bupivakain 50 mg dalam blok TAP mengurangi konsumsi
opioid 72 jam sebesar 16,5 mg, P = 0,012, dan memiliki lebih banyak pasien yang terhindar
dari opioid (54% vs 25%, P = 0,001) dibandingkan dengan bupivakain 50 mg saja [36].
Namun, 6% blok TAP salah ditempatkan saat ditinjau, dan ketika semua pasien yang dirawat
dimasukkan dalam analisis, tidak ada perbedaan yang signifikan dalam konsumsi opioid
antara kelompok. Penambahan morfin intratekal ke liposomal blok bupivacaine TAP secara
signifikan mengurangi MMEQ di 24 jam pertama setelah SC, tetapi tidak ada perbedaan
dalam penggunaan opioid dalam periode waktu 24-72 jam, menunjukkan kurangnya manfaat
[37]. Sebuah meta-analisis baru-baru ini menemukan perineural liposomal bupivacaine tidak
memberikan manfaat klinis yang penting menggunakan area di bawah kurva skor nyeri 24-72
jam setelah injeksi atau di salah satu hasil sekunder nyeri saat istirahat, waktu untuk pertama
permintaan analgesik, atau konsumsi opioid hingga 72 jam [38]. Mengenai kerja liposomal
bupivacaine, artikel dan editorial terbaru lainnya mencatat bias risiko studi yang tinggi pada
84% artikel yang menunjukkan manfaat signifikan dari liposomal bupivakain dan hasil studi
utama, dibandingkan dengan hanya 14% artikel dengan risiko bias studi yang rendah [39,
40•].

Antagonis NMDA

Antagonis reseptor NMDA adalah analgesik potensial yang mencegah sensitisasi

sentral dan perkembangan nyeri kronis [41]. Perhatikan bahwa pencegahan nyeri neuropatik
dan pengobatan nyeri akut yang melibatkan mekanisme yang berbeda. Opioid dapat
menghasilkan hiperalgesia dalam dosis dan tergantung waktu paparan melalui stimulasi
reseptor NMDA [14].

Ketamin

Ketamin, suatu antagonis reseptor NMDA, memiliki efek analgesia dan telah
digunakan untuk pencegahan nyeri akut dan kronis, hiperalgesia, dan sensitisasi sentral dan
dapat mencegah toleransi opioid [12•, 42]. S-Ketamine (dosis 0,5 mg/kg IM diikuti dengan
infus IV 2 mcg/kg/menit selama 12 jam) secara signifikan menurunkan konsumsi morfin
setelah SC mulai dari 8 jam dan sebesar 31% selama 24 jam, peningkatan waktu untuk
penggunaan morfin pertama, dan cenderung mengurangi hiperalgesia di T10 [43].

Magnesium

Magnesium perioperatif, yang juga memiliki efek antagonis NMDA, mengurangi skor
nyeri pada 24 jam dalam meta-analisis dari pasien non obstetri dan dapat mengurangi
konsumsi analgesik dalam pasien kebidanan [44]. Magnesium 50-mg/kg mengurangi rasa
sakit skor dan penggunaan obat setelah anestesi umum untuk sesar [45, 46]. Namun, sebuah
studi tahun 2006 dengan magnesium 50 mg/kg dinaikan 2 g/jam, 25 mg/kg dinaikan 1 g/jam,
atau plasebo dimulai 1 jam sebelum sesar di bawah anestesi neuraksial tidak menemukan
perbedaan dalam keparahan nyeri [47]. Pada sistematik review tahun 2017 menemukan
magnesium dapat menurunkan kebutuhan analgesik dan menurunkan skor VAS setelah SC
[48].

Dekstrometorfan

Dekstrometorfan, suatu antagonis NMDA non-kompetitif, dapat menurunkan

hiperalgesia baik lokasi cedera (situs primer) dan di luar cedera (situs sekunder) yang dapat
berkembang dari pembedahan atau trauma [41]. Dosis rendah (30 mg) dekstrometorfan
memberikan efek antihiperalgesik yang signifikan pada pasien untuk hiperalgesia primer dan
sekunder dan penurunan sensitisasi saraf perifer dan sentral pada cedera beku model nyeri
[49]. Sebuah meta-analisis dari 21 studi terutama bedah umum, ginekologi, dan ortopedi
menunjukkan dekstrometorfan perioperatif secara signifikan menurunkan konsumsi opioid
setara dengan 10 mg morfin dan skor nyeri sebesar hampir 1 (skala nyeri 10 poin) hingga 24
jam [50]. Namun, dekstrometorfan belum dipelajari secara khusus untuk sesar; penggunaan
pada wanita berisiko tinggi dapat dipertimbangkan.

Alpha-2 Adrenergik Agonis

Agonis alfa2-adrenergik clonidine dan dexmedetomidine memiliki sifat analgesik,

tetapi bukti terbatas untuk operasi caesar tidak menjamin dimasukkannya dalam protokol
ERAC. Namun, mungkin berguna pada pasien berisiko tinggi untuk nyeri atau toleransi
terhadap opioid. Klonidin 1,2 mcg/ml/bupivakain 0,1% infus epidural pasca sesar selama 24
jam memberikan analgesia yang baik tanpa perlu untuk opioid tambahan untuk 70% ibu
bersalin dengan gangguan penggunaan opioid pada buprenorfin [44, 51]. Dexmedetomidine 4
mg IT secara signifikan menurunkan skor VAS selama dan segera setelah (2,1 ± 1 vs 3,6 ± 1,
P <0,001) operasi sesar [52]. Dexmedetomidine sebagai infus IV 0,2-1,4 mcg/kg/jam setelah
beban 1 mcg/kg juga dapat membantu [26••].

Elemen pascaoperasi

Kunci elemen pasca operasi ERAC termasuk asupan oral awal, pelepasan kateter urin
dini (6-12 jam) dan mobilisasi dini dari tempat tidur dan upaya ambulasi dalam 24 jam
pertama.

Asupan Oral Awal

Asupan oral awal mempercepat kembalinya fungsi usus, meningkatkan kepuasan ibu,
dan mempercepat waktu untuk ambulasi dan keputihan tanpa meningkatkan komplikasi
seperti mual, muntah, atau infeksi. Ibu bersalin yang menjalani anestesi umum untuk
persalinan sesar memiliki pengembalian fungsi usus yang lebih cepat dan meningkatkan
kepuasan pasien dengan pemberian makanan oral dini di RCT [53]. RCT lain dengan pasien
anestesi umum dan neuraksial ditemukan waktu lebih cepat untuk ambulasi dan pelepasan
awal pada kelompok awal menyusui setelah sesar [54].
 Terakhir, ulasan Cochrane menemukan bahwa menyunyah permen karet di PACU
mempercepat kembalinya fungsi usus dan menurun lama rawatan, meskipun dengan bukti
tingkat rendah [55]. Penelitian ini juga tidak menemukan perbedaan komplikasi pasca operasi,
mual, dan kembung pada kelompok awal menyusui.

Pertimbangan Khusus

Penggunaan Opioid Pascaop

Implementasi ERAC menurunkan penggunaan opioid tanpa perubahan signifikan

pada tingkat komplikasi pascaoperasi, skor nyeri, atau tingkat penerimaan kembali.
Pengurangan konsumsi opioid dapat menjadi sangat penting selama krisis opioid saat ini.

Implementasi ERAC menghasilkan morfin 40% lebih rendah penggunaan setara (60
mg vs 104 mg), lebih sedikit pasien yang membutuhkan opioid dalam 24 jam setelah keluar
(41,1% vs 74,6%, P < 0,001), dan tidak ada perbedaan skor nyeri selama rawat inap [56].
ERAC mengurangi konsumsi oksikodon rata-rata 36 mg/pasien setelah sesar tanpa perbedaan
skor nyeri di seluruh misi iklan rumah sakit [57]. Demikian pula, protokol ERAC secara
signifikan mengurangi konsumsi opioid 38% dengan skor nyeri yang lebih rendah (7 vs 8 , P
= 0,007) dan lebih pendek (2,5 ± 0,5 vs 2,9 ± 1,2 hari, P < 0,001) lama tinggal [58•].

Lama Menginap/Penghematan Biaya

Protokol ERAC mengurangi LOS dan penghematan biaya tanpa meningkatkan efek
samping seperti tingkat penerimaan kembali 30 hari. Rumah sakit memiliki variasi besar
dalam LOS, dengan rata-rata pelepasan 47% pasien SC dalam 2 hari, dengan yang lebih awal
kelompok pemulangan menjadi sedikit lebih muda, riwayat SC sebelumnya, rumah sakit non-
pendidikan, dan memiliki lebih sedikit komorbiditas [4]. Sementara asuransi diwajibkan
untuk menanggung rawat inap 4 hari untuk sesar, pemulangan dini diperbolehkan jika pasien
dan penyedia perawatan setuju [59]. Sebuah RCT di New York City menunjukkan LOS yang
secara signifikan lebih pendek untuk wanita di ERAC kohort, dengan manfaat tambahan dari
peningkatan menyusui tingkat, kepuasan pasien yang lebih tinggi [60]. Di Inggris,
pengenalan komponen ERAC selama periode waktu 2 tahun secara signifikan meningkatkan
debit POD 1 dari 1,6 menjadi 25% dan mengurangi biaya [17••].
Kesenjangan Ras

Disparitas perawatan kesehatan ras dan etnis ada di AS tidak hanya untuk morbiditas
ibu yang parah dan tingkat persalinan sesar [61] tetapi juga untuk pengenalan dan pengobatan
nyeri [16]. Nyeri parah 7 VAS lebih sering terjadi pada orang kulit hitam dan wanita
Hispanik, dan mereka tidak diobati, menerima tablet oksikodon secara signifikan lebih sedikit
pada hari-hari pascapersalinan 1 dan 2 [62]. Wanita kulit hitam memiliki LOS yang lebih
panjang dan lebih tinggi Kecepatan SC [63]. Implementasi pemulihan yang ditingkatkan
menghilangkan disparitas rasial di LOS tanpa perbedaan dalam penerimaan kembali atau
kematian dan hasil yang lebih baik dari pneumonia dan ileus setelah operasi kolorektal [64•].

Bias implisit dalam profesional kesehatan dapat berkontribusi untuk perbedaan hasil
perawatan kesehatan [65•]. Penggunaan ERAS untuk persalinan sesar harus mengurangi
disparitas rasial dengan menggunakan protokol universal standar [66].

COVID-19

Pandemi Coronavirus (COVID-19) berdampak pada ERAC sebagai dengan baik.

NSAID aman digunakan pada pasien COVID-19 [67]. COVID-19 dapat menyebabkan
hiperkoagulabilitas, dan profilaksis VTE mungkin perlu dilanjutkan selama 2-6 minggu [68].
Pandemi telah mempercepat keinginan pasien untuk meninggalkan rumah sakit lebih awal;
pasca-ERAC kami, dan pasca-COVID-19 2 malam LOS meningkat dari 12 menjadi 41%,
tanpa membahayakan ibu atau bayi [69]. Harapan pasien dan keinginan untuk dipulangkan
lebih awal telah menurunkan LOS secara signifikan selama pandemi.

Pasien Berisiko Tinggi

Gangguan Penggunaan Zat Ibu melahirkan dengan riwayat gangguan penggunaan zat
mungkin lebih sulit untuk mengelola rasa sakit, terutama setelah operasi. Template ERAC
standar berfungsi sebagai titik awal yang sangat baik untuk perawatan secara keseluruhan.
Selain itu triad standar morfin neuraksial, asetaminofen, dan NSAID, pendekatan
farmakologis lebih lanjut dapat membantu.

Kemungkinan termasuk infus pascapersalinan lokal epidural anestesi/narkotika,

agonis adrenergik alfa-2, agonis NMDA, blok TAP/QL, atau penggunaan gabapentinoid.
Mungkin salah satu aspek terpenting dari ERAC adalah mengurangi paparan opioid total dan
potensi ibu kecanduan opioid. Risiko ibu melahirkan naif opioid menjadi gangguan
penggunaan opioid kronis setelah operasi caesar adalah 1/300 [70], mewakili masalah
kesehatan masyarakat yang mempengaruhi perkiraan 4000 ibu baru per tahun. Implementasi
ERAC mengurangi morfin mg setara (MMEQ) sebesar 40%, dari 46 menjadi 28 mg, P
<0,001, selain penurunan nyeri puncak skor dengan 1 VAS (dari 8 sampai 7), P <0,01 [58•].
Persyaratan opioid rumah sakit yang lebih rendah menyebabkan pengurangan 35% pada
opioid resep pemulangan [71]. Negara telah memberlakukan undang-undang untuk
membatasi resep opioid, mengurangi resep opioid debit pasca operasi sebesar 20 MMEQ [72].
Penggunaan opioid untuk lebih banyak kemudian 5 hari meningkatkan peluang untuk tetap
menggunakan opioid 1 tahun nanti [73]. Dengan demikian, penerapan ERAC berkurang di
rumah sakit paparan opioid dan pelepasan opioid dan harus mengurangi insiden penggunaan
opioid kronis setelah operasi caesar.

Gangguan Penggunaan Opioid

Pasien dengan gangguan penggunaan opioid harus dilanjutkan dengan pengobatan

normal mereka (misalnya, metadon, buprenorfin) ditambah modalitas tambahan seperti yang
dibahas di atas [74]. Saran termasuk analgesia multimodal bertahap dengan pilihan
gabapentin oral 300-600 mg PO Q8h, ketamin 0,5 mg/kg bolus, infus 2 mcg/kg/mnt, dan/atau
infus dexmedetomidine 0,2-1,5 mcg / kg / jam setelah beban 1 mcg/kg/10–20 menit [26••,
51].

Kesimpulan

Peningkatan pemulihan setelah operasi caesar memberikan bukti berbasis perawatan

standar untuk periode perioperatif, dengan manfaat untuk penghilang rasa sakit ibu,
mobilisasi, peningkatan ikatan bayi ibu, penurunan konsumsi obat opioid dan penyelamatan,
dan lama tinggal yang lebih pendek. Dengan keterlibatan pasien dimulai sebelum operasi,
tujuan ERAC dapat dicapai, dan dengan potensi yang lebih besar untuk perbaikan dalam
penggunaan opioid kronis setelah sesar, penyesuaian untuk pasien berisiko tinggi, dan
peningkatan kesenjangan perawatan kesehatan rasial. Mungkin evolusi ERAC berikutnya
akan melibatkan pengujian farmakogenetik dan tentu saja manajemen analgesik yang
“dipersonalisasi” [75].

Kepatuhan dengan Standar Etika

Konflik Kepentingan Para penulis menyatakan bahwa mereka tidak memiliki konflik
minat.
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Current Anesthesiology Reports (2021) 11:136–144
https://doi.org/10.1007/s40140-021-00442-9

OBSTETRIC ANESTHESIA (LR LEFFERT, SECTION EDITOR)

Enhanced Recovery After Cesarean: Current and Emerging Trends

Kishan Patel 1 & Mark Zakowski 1

Accepted: 15 February 2021 / Published online: 2 March 2021

# The Author(s), under exclusive licence to Springer Science+Business Media, LLC part of Springer Nature 2021

Abstract
Purpose of Review What are the latest enhanced recovery elements for cesarean delivery?
Recent Findings Enhanced recovery after cesarean delivery (ERAC) provides an evidenced-based system to improve maternal
outcomes, functional recovery, maternal-infant bonding, and patient experience. Postsurgical recovery has evolved from a one-
dimensional pain score to a holistic multidimensional approach emphasizing faster functional recovery. ERAC involves multi-
disciplinary efforts of the anesthesiologist, obstetrician, nursing, hospital, and patient. Components of ERAC include preoper-
ative patient education, limited fasting, carbohydrate load, limiting opioids intra- and postoperatively, using scheduled non-
opioid analgesics and supplementing with advanced therapies for women at higher risk for pain. ERAC protocols reduce opioid
consumption, reduce length of stay, and improve maternal and neonatal outcomes.
Summary Implementing ERAC standardized care will likely be the most important change you can make in your practice to
improve outcomes, improve quality care, help address racial disparities, and minimize opioid exposure and potential for
addiction.

Keywords Cesarean delivery . Enhanced recovery . Racial disparity . Opioid use disorder . Maternal outcomes . Length of stay

Introduction peripartum patient and helps improve maternal and neonatal

Enhanced recovery after cesarean (ERAC) provides an
evidenced-based system to improve maternal outcomes, func-
tional recovery, maternal-infant bonding, and patient experi-
ence. ERAC involves the multidisciplinary team efforts of the
anesthesiologist, obstetrician, nursing, hospital, and patient.
Cesarean delivery (CD) is the most common surgery in the
USA, with a 32% cesarean rate that involves 1.2 million wom-
en yearly [1] similar to the rate in many developed countries.
The global burden of obstetrical surgical recovery includes
approximately 140,000,000 births annually [2] with an esti-
mated 23% global cesarean rate [3]. Hospital length of stay
(LOS) for CD has large variations at the provider and facility
level [4]. Chronic postsurgical pain for CD affects up to 11%
of women 1 year later with nearly 10% having severe pain [3,
5, 6]. ERAC aims to standardize the perioperative care of the
This article is part of the Topical Collection on Obstetric Anesthesia
* Mark Zakowski
Mark.Zakowski@cshs.org
1
Department of Anesthesiology, Cedars-Sinai Medical Center, 8700
Beverly Blvd #8211, Los Angeles, CA 90048, USA
outcomes [7, 8, 9••]. Current and emerging ERAC and pain
relief strategies will be discussed in this article.
Chronic pain, which often starts as acute pain, has become
a major public health problem affecting 20.4% adults in 2019
[10]. Women have more chronic pain (21.7% vs. 19%, P <
0.05) and more high-impact chronic pain (8.5% vs. 6.3%, P <
.05) than men, even affecting 9-15% of 18-44 year olds [10].
Previous studies have shown an association between higher
pain scores after delivery with a higher incidence of postpar-
tum depression and development of chronic pain [3, 6, 11••,
12•]. Higher pain postdelivery has been associated with lower
rates of breastfeeding as well as a higher incidence of postpar-
tum depression and chronic pain [13]. Every 10% increase in
severe pain postoperatively was associated with a 30% in-
crease in chronic pain 1 year later [14]. Higher analgesic con-
sumption in the first 48 h also has been linked to development
of chronic pain [15]. Healthcare disparities in pain and the
treatment of pain exist as well [16].
Postsurgical recovery has evolved from focusing on a one-
dimensional goal of a visual analog scale (VAS) pain score
≤3/10 to a more holistic multidimensional approach. The fun-
damental goal of experiencing less pain not only reduces an
individual’s suffering but also improves functional recovery
with faster return to the activities of daily living, including
Curr Anesthesiol Rep (2021) 11:136–144
maternal-infant bonding, returning home, and higher satisfac-
tion. ERAC uses an interdisciplinary approach requiring the
enrollment of the patient (and her support system), anesthesi-
ology, obstetrics, pediatrics, nursing, lactation specialists, and
the hospital. Pregnant women and their partners must be edu-
cated prior to coming into the hospital to align expectations of
what to do (e.g., clear liquids/carbohydrate load 2 h prior to
surgery) and for postoperative physical activity. The intraop-
erative anesthetic and postoperative pain medications are the
easiest ERAC components to change for the anesthesiologist.
The postoperative course requires more nursing involvement
on the first 1–2 days to help mobilize the mother.
Implementing ERAC standardized care will likely be the
most important change you can do in your practice to improve
maternal outcomes, improve quality care, help address racial
disparities, and minimize opioid exposure and addiction.
Preoperative Elements
Key ERAC preoperative elements include patient education,
limiting fasting intervals, and carbohydrate loading.
Patient Education
Preoperative education prior to the day of surgery is important
to engage the patient, manage expectations, reduce anxiety,
and help improve patient compliance with ERAC protocols.
Many handouts and tools exist, including examples available
in the Society for Obstetric Anesthesia and Perinatology
(SOAP) ERAC toolkit (www.soap.org). A 2015 UK study
found a simple patient information leaflet led to wider
patient acceptance of early discharge and a higher rate of
earlier discharges even before implementation of other
ERAC components [17••]. Patient engagement and shared-
decision making may start preoperatively and improve satis-
faction and reduce opioid prescriptions [18].
Limiting NPO Interval and Carbohydrate Loading
The American Society of Anesthesiologists (ASA) guidelines
recommend surgical fasting (NPO) for fatty solids 8 h prior, a
light meal 6 h prior, and clear liquids 2 h prior to surgery to
reduce aspiration risk [19]. Prolonged NPO intervals are usu-
ally unnecessary and can lead to hypovolemia and patient
dissatisfaction [19]. Data derived from enhanced recovery
for colorectal surgery showed that complex carbohydrate
(i.e., maltodextrin) loading the evening before and 2-3 h prior
to anesthesia with a non-particulate drink can minimize the
metabolic stress response, improve postoperative insulin re-
sistance, and lower protein breakdown [20]. This may be
omitted for diabetic mothers due to potential for delayed gas-
tric emptying and hyperglycemia. The SOAP ERAC protocol
137
suggests 16 ounces (~500 mL) of clear apple juice 2 h prior to
scheduled cesareans as an easy, acceptable choice [21].
Intraoperative Elements
Multimodal analgesia has become a key component for most
surgeries/anesthetics and all enhanced recovery protocols in-
volving medications and techniques beyond routine surgical
anesthesia. Analgesic medications may be administered im-
mediately preop, intraop, and continued postoperative. Non-
opioid analgesics and techniques are utilized to minimize opi-
oid consumption. However, ERAC goes beyond analgesics
(see Table 1).
The intraoperative components of ERAC include start of
scheduled acetaminophen (may start preoperatively),
NSAIDs, limiting the amount of neuraxial opioid (i.e., mor-
phine), prevention of hypothermia and nausea, and supporting
mother-infant bonding, among others [9••]. The routine use of
prophylactic vasopressor infusions (e.g., phenylephrine 0.5–1
mcg/kg/min) helps to reduce hypotension induced nausea fol-
lowing spinal anesthesia. Two different classes of prophylactic
antiemetics should be used (e.g., 5HT3 antagonist ondansetron,
glucocorticoid dexamethasone, and/or D2 receptor antagonist
metoclopramide). The suggested doses of neuraxial morphine
for cesarean are 1–3 mg epidural or 50–150 mcg intrathecal
(IT) to limit opioid side effects. Scheduled acetaminophen
1000 mg (TID or QID) starting preop or intraop and NSAIDs
(e.g., ketorolac 30 mg IV after peritoneal closure, followed by
either ketorolac (15-30 mg) Q6h, ibuprofen 600 mg Q6h, or
naproxen 500 mg Q12h (see Table 2). Prewarming patients
before surgery helps to reduce intraoperative hypothermia; in-
traoperative warming measures are required, including keeping
the OR >72 °F/23 °C [9••]. The maximum acetaminophen dose
is 4000 mg/24 h, as per FDA approval [22].
Multimodal Analgesia
Multimodal analgesia may involve regional blocks or wound
infusion of local anesthetics and multiple non-opioid analge-
sics to modify or decrease neuronal transmission of pain, alter
physiologic responses to painful stimuli, and reduce opioid
consumption, decreasing the potential for postoperative opi-
oid tolerance and development of persistent opioid use.
Gabapentinoids
Gabapentinoids (i.e., gabapentin and pregabalin) bind to and
block the α2δ subunit containing voltage-depending calcium
channel and may be effective in reducing postoperative pain.
One meta-analysis of non-cesarean patients found gabapentin
doses of 900 mg and 1200 mg or pregabalin 150 mg and
300 mg decreased postop opioid use and pain scores [23].
Gabapentin before and for 2 days post-CD decreased pain
138 Curr Anesthesiol Rep (2021) 11:136–144

Table 1 Key components of

enhanced recovery after cesarean Preoperative Intraoperative Postoperative

• Patient education • Prevent and treat spinal iduced hypotension • Early oral intake
• Limited fasting • Maintain normothermia • Early mobilization
interval • Intra- and postop nausea and vomiting • Promote resting periods
• Carbohydrate prophylaxis • Early urinary catheter removal
loading • Optimal uterotonic administration • Venous thromboembolism
• Multimodal analgesia prophylaxis
• Promote breastfeeding and maternal-infant • Continue multimodal analgesia
bonding • Breastfeeding support
• Promote return of bowel function

Key components of an enhanced recovery after cesarean protocol, modified from Society for Obstetric Anesthesia
and Perinatology Consensus, Anesthesia Analgesia 2020, with permission

slightly (4.0 vs 4.7 VAS, P < .05) on movement at 24 h,
however with no difference in opiate use or persistent pain
scores [24]. A recent meta-analysis found that gabapentinoids
were associated with lower postoperative pain intensity, but
the difference was not clinically significant (≤ 1 VAS) and
associated with more frequent side effects of dizziness and
visual disturbances [25•]. Gabapentinoids, while not currently
recommended for routine ERAC, may benefit high-risk par-
turients such as those with chronic pain, opioid use disorders.
Regional Blocks for Cesarean Surgery
Regional blocks useful for cesarean surgery include truncal
blocks (TAP, QL) or wound infusion. Overall, these have
not been shown to have significant improvement when used
in addition to the triad of neuraxial morphine and scheduled
acetaminophen and NSAID [9••]. Regional blocks are useful
when neuraxial morphine cannot be given, as a rescue
technique for severe pain, or for patients at high risk for severe
pain [26••].
Transversus Abdominus Plane Block
TAP blocks have been studied for CD but do not provide a
routine benefit in addition to neuraxial opioids, except follow-
ing general anesthesia or when neuraxial opioids need to be
omitted [9••]. Posterior or lateral TAP block for cesarean did
not confer additional benefits; results are similar to wound
infiltration and inferior when compared with IT morphine
[27]. Surgical infiltration of the abdominus plane may provide
similar results [27].
Quadratus Lumborum Blocks
Many studies have examined the effectiveness of quadratus
lumborum (QL) blocks in decreasing post abdominal surgery

Table 2 Key medication

examples enhanced recovery after
cesarean
Preoperative
Carbohydrate load 2 h preop:
• Clear apple juice 500 ml
Multimodal analgesia:
• Acetaminophen 1g PO
Intraoperative Postoperative
Neuraxial morphine: Multimodal analgesia:
• ≤3 mg epidural or • Acetaminophen 1 g PO Q6h
• ≤150 mcg IT NSAID, choice of:
Nausea Prophylaxis ≥2 agents: • Ketorolac 30 mg IV Q6h or
• 4 mg ondansetron, • Ibuprofen 600 mg POQ6h or
• 10 mg metoclopramide, • Naproxen 500 mg PO Q12h
• 4 mg dexamethasone Opioid as PRN only:
Prevent hypotension: • Oxycodone 5 mg PO PRN
• Phenylephrine infusion 0.5
mcg/kg/min initial, titrate
Multimodal analgesia:
• Ketorolac 30-mg IV after
peritoneal closure

Key medication examples for enhanced recovery after cesarean of low-risk patients, by phase of care. May give
first dose of acetaminophen intraoperative or in PACU if did not receive prior to surgery
PO Per os, IT intrathecal, IV intravenous, PRN as needed, Q every
Curr Anesthesiol Rep (2021) 11:136–144
pain. The anterior QL (QL1) block acts like a TAP block
while a posterior QL (QL2) block may spread local anesthetic
more medially towards the paravertrebral spaces and inhibit
visceral pain in addition to somatic pain [28]. QL block de-
creased intraoperative and postoperative opioid consumption
in patients compared with TAP blocks for abdominal hyster-
ectomies under general anesthesia [29]. In the absence of IT
morphine, cesarean patients randomized to QL2 blocks had
less postoperative morphine use than the TAP block group
[30], and lower morphine usage and VAS pain scores [28].
However, adding QL blocks to patients receiving neuraxial
morphine did not significantly change pain scores or reduce
opioid consumption. QL2 block did not improve pain scores
above IT morphine and scheduled non-opioid analgesics for
CD [31•].
Local Anesthetic Wound Infusions
Continuous wound infusions have been used to help control
postoperative pain in cesarean delivery and were superior to
epidural morphine 2 mg every 12 h with scheduled acetamin-
ophen and diclofenac only as a rescue [32]. In cesarean pa-
tients receiving 150 mcg morphine IT with scheduled acet-
aminophen and systemic ketorolac/ibuprofen, the addition of
a continuous wound infusion of ropivacaine 0.2% with
ketorolac 30 mg/48 h had no statistically significant difference
in pain scores up to 48 h, patient satisfaction, opioid use, or
postpartum depression [33]. The difference in the benefit of
continuous wound infusion between these two studies is most
likely due to the absence of scheduled systemic NSAID in the
first study. Most studies have not found a benefit of peripheral
local anesthetic nerve blocks in addition to the triad of
neuraxial morphine and scheduled non-opioid analgesics of
both acetaminophen and NSAID [9••, 34].
Liposomal Bupivacaine
Liposomal formulations provide slow release and thus
prolonged effect of a local anesthetic. However, results with
liposomal bupivacaine in cesarean delivery have been mixed.
A retrospective study found incisional liposomal bupivacaine
reduced MMEQ [35]. A prospective study of liposomal
bupivacaine in the CD incision did not find significantly re-
duced pain scores or MMEQ in the first 48 h [34]. A recent
study funded by the manufacturer showed liposomal
bupivacaine 266 mg plus bupivacaine 50 mg in TAP block
reduced 72-h opioid consumption of −16.5 mg, P = 0.012, and
had more opioid-spared patients (54% vs 25%, P = 0.001)
compared with bupivacaine 50 mg alone [36]. However, 6%
of TAP blocks were incorrectly placed on review, and when
all treated patients were included in analysis, there was no
significant difference in opioid consumption between groups.
The additional of intrathecal morphine to liposomal
139
bupivacaine TAP block significantly reduced MMEQ in the
first 24 h after CD, but there were no differences in opioid use
in the 24–72-h time period, suggesting a lack of prolonged
benefit [37]. A recent meta-analysis found perineural liposo-
mal bupivacaine did not provide a clinically important benefit
using area under the curve pain scores 24–72 h after injection
or in any of the secondary outcomes of pain at rest, time to first
analgesic request, or opioid consumption up to 72 h [38].
Regarding the efficacy of liposomal bupivacaine, another re-
cent article and editorial noted a high risk of study bias in 84%
of articles showing significant benefits of liposomal
bupivacaine and primary study outcomes, compared with only
14% of articles with a low risk of study bias [39, 40•].
NMDA Antagonists
NMDA receptor antagonists are potential analgesics that pre-
vent central sensitization and development of chronic pain
[41]. Note that the prevention of neuropathic pain and treat-
ment of acute pain may involve different mechanisms.
Opioids may produce hyperalgesia in a dose and time
exposure–dependent fashion via NMDA receptor stimulation
[14].
Ketamine
Ketamine, an NMDA receptor antagonist, has analgesia effect
and has been used for prevention of acute and chronic pain,
hyperalgesia, and central sensitization and may prevent acute
opioid tolerance [12•, 42]. S-Ketamine (dose of 0.5 mg/kg IM
followed by 2 mcg/kg/min IV infusion for 12 h) significantly
decreased morphine consumption after CD starting at 8 h and
by 31% over 24 h, increased time to first morphine use, and
trended to reduced hyperalgesia at T10 [43].
Magnesium
Perioperative magnesium, which also has NMDA antagonist
effects, reduced pain scores at 24 h in a meta-analysis of non-
obstetric patients and may reduce analgesic consumption in
obstetric patients [44]. Magnesium 50-mg/kg decreased pain
scores and medication use after general anesthesia for cesare-
an [45, 46]. However, a 2006 study with magnesium 50
mg/kg load with 2 g/h, 25 mg/kg load with 1 g/h, or placebo
started 1 h prior to cesarean under neuraxial anesthesia did not
find a difference in pain severity [47]. A 2017 systematic
review found magnesium decreased analgesic requirements
and lowered VAS scores after CD [48].
Dextromethorphan
Dextromethorphan, a non-competitive NMDA antagonist,
may decrease both sites of injury pain (primary site) and
140
outside the injury (secondary site) hyperalgesia that can de-
velop from surgery or trauma [41]. Low dose (30 mg) dextro-
methorphan provided significant anti-hyperalgesic effects in
humans for primary and secondary hyperalgesia and decreases
peripheral and central neuronal sensitization in a freeze-injury
pain model [49]. A meta-analysis of 21 studies of primarily
general, gynecology, and orthopedic surgeries showed periop-
erative dextromethorphan significantly decreased opioid con-
sumption by 10-mg morphine equivalents and pain scores by
almost 1 (10-point pain scale) through 24 h [50]. However,
dextromethorphan has not been studied specifically for cesar-
ean; usage in high-risk women may be considered.
Alpha-2 Adrenergic Agonists
The alpha2-adrenergic agonists clonidine and dexmedetomidine
have analgesic properties, but the limited evidence for cesareans
did not warrant their inclusion in ERAC protocols. However,
they may be useful in high-risk patients for pain or tolerance to
opioids. Clonidine 1.2 mcg/ml/bupivacaine 0.1% infused epidu-
ral postcesarean for 24 h provided good analgesia with no need
for supplemental opioids for 70% of parturients with opioid use
disorder on buprenorphine [44, 51]. Dexmedetomidine 4 mg IT
significantly decreased VAS scores during and immediately af-
ter (2.1 ± 1 vs 3.6 ± 1, P < 0.001) cesarean surgery [52].
Dexmedetomidine as IV infusion of 0.2–1.4 mcg/kg/h after a
load of 1 mcg/kg may also be helpful [26••].
Postoperative Elements
Key postoperative elements of ERAC include early oral in-
take, early urinary catheter removal (6–12 h) and early mobi-
lization out of bed and attempted ambulation within the first
24 h.
Early Oral Intake
Early oral intake hastens return of bowel function, improves
maternal satisfaction, and quickens time to ambulation and
discharge without increasing complications such as nausea,
vomiting, or infection. Parturients undergoing general anes-
thesia for cesarean delivery had faster return of bowel function
and improved patient satisfaction with early oral feeding in a
RCT [53]. Another RCT with general and neuraxial anesthe-
sia patients found faster time to ambulation and earlier dis-
charge in the early feeding cohort following cesarean [54].
Lastly, a Cochrane review found that gum chewing in
PACU expedited return of bowel function and decreased
length of stay, albeit with low grade evidence [55]. These
studies also found no difference in postoperative complica-
tions, nausea, and bloating in the early feeding groups.
Curr Anesthesiol Rep (2021) 11:136–144
Special Considerations
Postop Opioid Use
ERAC implementations lowered opioid usage with no sig-
nificant change in postop complication rates, pain scores,
or readmission rates. Reduction of opioid consumption can
be especially important during the current opioid crisis.
ERAC implementation led to a 40% lower morphine
equivalent usage (60 mg vs 104 mg), fewer patients requir-
ing opioids within 24 h of discharge (41.1% vs 74.6%, P <
0.001), and no difference in pain scores during inpatient
hospitalization [56]. ERAC reduced oxycodone consump-
tion an average of 36 mg/patient after cesarean delivery
with no difference in pain scores throughout hospital ad-
mission [57]. Similarly, ERAC protocols significantly re-
duced opioid consumption 38% with lower pain scores (7
vs 8 , P = 0.007) and shorter (2.5 ± 0.5 vs 2.9 ± 1.2 days, P
< 0.001) length of stay [58•].
Length of Stay/Cost Savings
ERAC protocols reduce LOS and cost savings without in-
creasing adverse events such as 30-day readmission rates.
Hospitals have a large variation in LOS, with a median dis-
charge of 47% of CD patients within 2 days, with the earlier
discharge group being slightly younger, history of prior CD,
non-teaching hospital, and having fewer comorbidities [4].
While insurers are required to cover 4-day hospitalization
for cesarean, early discharge is allowed if the patient and at-
tending provider agree [59]. An RCT in New York City
showed a significantly shorter LOS for women in the ERAC
cohort, with the added benefits of increased breastfeeding
rates, higher patient satisfaction [60]. In the UK, introduction
of ERAC components over a 2-year period time significantly
increased POD 1 discharge from 1.6 to 25% and reduced costs
[17••].
Racial Disparities
Racial and ethnic healthcare disparities exist in the USA
not only for severe maternal morbidity and cesarean deliv-
ery rate [61] but also for the recognition and treatment of
pain [16]. Severe pain ≥7 VAS was more common in black
and Hispanic women, and they were undertreated, receiv-
ing significantly fewer oxycodone tablets postpartum days
1 and 2 [62]. Black women have a longer LOS and higher
CD rate [63]. Enhanced recovery implementation eliminat-
ed racial disparities in LOS with no differences in
readmissions or mortality and improved outcomes of pneu-
monia and ileus following colorectal surgery [64•].
Implicit bias in healthcare professionals may contribute to
differences in healthcare outcomes [65•]. Use of ERAS for
Curr Anesthesiol Rep (2021) 11:136–144
cesarean delivery should reduce racial disparities by using
standardized universal protocols [66].
COVID-19
The Coronavirus (COVID-19) pandemic impacted ERAC as
well. NSAIDs are safe to use in COVID-19 patients [67].
COVID-19 may cause hypercoagulability, and VTE prophy-
laxis may need to be continued for 2–6 weeks [68]. The pan-
demic has accelerated patients’ desire to leave the hospital
earlier; our post-ERAC, and post-COVID-19 2-night LOS
increased from 12 to 41%, with no harm to mother or baby
[69]. Patient expectations and desire to be discharged earlier
have significantly decreased LOS during the pandemic.
High-Risk Patients
Substance Use Disorder The parturient with a history of sub-
stance use disorder may be more difficult to manage pain,
especially after surgery. The standard ERAC template serves
as an excellent starting point for overall care. In addition to the
standard triad of neuraxial morphine, acetaminophen, and
NSAID, further pharmacologic approaches may be helpful.
Possibilities include postdelivery infusion of epidural local
anesthetics/narcotics, alpha-2 adrenergic agonists, NMDA ag-
onists, TAP/QL blocks, or use of gabapentinoids.
Perhaps one of the most important aspects of ERAC is
reducing total opioid exposure and the potential for maternal
opioid addiction. The risk of opioid naïve parturients becom-
ing chronic opioid use disorder following cesarean was 1/300
[70], representing public health issues affecting an estimated
4000 new mothers per year. Implementation of ERAC re-
duced morphine mg equivalents (MMEQ) by 40%, from 46
to 28 mg, P < 0.001, in addition to a decrease in peak pain
scores by 1 VAS (from 8 to 7), P < 0.01 [58•]. Lower in-
hospital opioids requirements led to a 35% reduction in opioid
discharge prescribing [71]. States have enacted laws to limit
opioid prescriptions, decreasing postcesarean discharge opi-
oid prescription by 20 MMEQ [72]. Use of opioids for greater
then 5 days increases chances for still using opioids 1 year
later [73]. Thus, implementation of ERAC reduces in hospital
opioid exposure and discharge opioids and should reduce the
incidence of chronic opioid use following cesareans.
Opioid Use Disorder Patients with opioid use disorder should
be continued on their normal medications (e.g., methadone,
buprenorphine) plus extra modalities as discussed above [74].
Suggestions include stepwise multimodal analgesia with op-
tions of oral gabapentin 300–600 mg PO Q8h, ketamine 0.5
mg/kg bolus, 2 mcg/kg/min infusion, and/or
dexmedetomidine infusion 0.2–1.5 mcg/kg/h after load 1
mcg/kg/10–20 min [26••, 51].
141
Conclusion
Enhanced recovery after cesarean provides evidenced-based
standardized care for the perioperative period, with benefits
for maternal pain relief, mobilization, improved maternal-
infant bonding, decreased opioid and rescue medication con-
sumption, and shorter length of stay. With patient engagement
started preoperatively, ERAC goals can be achieved, and with
greater potential for improvements in chronic opioid use after
cesarean, adjustments for higher risk patients, and improve-
ment in racial healthcare disparities. Perhaps the next evolu-
tion of ERAC will involve pharmacogenetic testing and cer-
tainly “personalized” analgesic management [75].
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflict of
interest.
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