Grand Rounds

How Well Does IV Acetaminophen Control Post-Op Cesarean Pain?

PURPOSE:

Reducing narcotics postoperatively is a national and professional initiative
- Multimodal pain management can help achieve this goal
IV acetaminophen dosing similar to oral: 1 g every 6 hours for a maximum dose of 4 g over 24 hours
Data on the use of IV acetaminophen in obstetrical care is limited
Altenau et al. (AJOG, 2017) designed an RCT to investigate whether the use of IV acetaminophen following routine cesarean section reduced the need for narcotics post operatively

Randomized, double-blind, placebo-controlled trial (2104-2016)
Scheduled cesarean section ≥ 37 weeks gestation
Eligibility: ≥ 18 years, singleton, planned regional anesthesia with intrathecal morphine sulfate and pfannenstiel skin incision
Drug administered preoperatively within 30–60 minutes of skin incision followed by IV doses every 8 hours for a total of 6 doses, over 48 hours (daily dosing of acetaminophen of 3 g)
Breakthrough pain
- Mild to moderate pain: oral ibuprofen up to 800 mg as needed every 8 hours
- Moderate to severe pain: oral oxycodone 5–10 mg as needed every 4 hours

Total of 133 patients consented
- 104 completed (57 intervention group; 47 placebo arm)
- No differences in baseline demographics
When comparing IV acetaminophen to controls
- Oral narcotic medications consumed by was significantly reduced (47 mg vs 65 mg of oxycodone; P = .034)
- Amount of ibuprofen not statistically different
- Pain scores not significantly different
- Narcotic side effects (nausea/emesis, respiratory depression, constipation) were not statistically different

Use of IV acetaminophen during the recovery period following cesarean section significantly decreased the total amount of narcotics
The authors state that consideration should be given to routinely incorporating IV acetaminophen into post–cesarean multimodal pain management

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