1Department of Anesthesiology, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
2Department of Anesthesiology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
3Department of Obstetrics and Gynecology, Kaohsiung Municipal Siaogang Hospital, Kaohsiung, Taiwan
4Department of Anesthesiology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
Multimodal analgesia for acute pain provides better analgesia and fewer adverse effects of opioids. Propacetamol is a pro-drug of paracetamol that is the most widely used drug for acute pain. The study aimed to investigate the adjuvant analgesic effect of propacetamol in post-cesarean section pain relief within 48 hours.
We performed a prospective, randomized, placebo-controlled trial for single-dose intravenous propacetamol as an adjuvant to patient-controlled epidural analgesia (PCEA) after cesarean period. The parturients were allocated to additional propacetamol (Group P) or saline (Group C) injection immediately after the delivery of the placenta. Primary outcome was assessed by pain intensity at rest or during movement. We recorded postoperative pain scores by using the numeric rating scale (NRS 0-10) at postoperative care unit (PACU), 2, 6, 24 and 48 hours postoperatively. In addition, the total dosage of PCEA, rescue analgesic, motor block, adverse effects and maternal satisfaction were also recorded.
A total of 60 obstetric patients agreed to participate and 59 completed the study (n=30 in Group P and n=29 in Group C). Pain intensity at rest in Group P was significantly lower compared to Group C within the initial 2 hours(p=0.04). Overall dosage consumption of PCEA and patient-requested rescue analgesic did not differ significantly between the two groups (p>0.05). There was also no obvious difference between groups with respect to muscle tone, adverse effects and satisfaction (P>0.05).
The combination of single-bolus intravenous 1 g propacetamol plus PCEA provided better pain relief at rest within 2 hours of administration.
Multimodal analgesia, post-cesarean analgesia, propacetamol, patientcontrolled epidural analgesia.
Betran AP, Ye J, Moller AB, Zhang J, Gulmezoglu AM, and Torloni MR
The Increasing Trend in Caesarean Section Rates: Global, Regional and National Estimates: 1990-2014.
PLoS One, 2016 Feb;11(2):e0148343.
Bonnet MP, Mignon A, Mazoit JX, Ozier Y, and Marret E
Analgesic efficacy and adverse effects of epidural morphine compared to parenteral opioids after elective caesarean section: a systematic review.
Eur J Pain, 2010 Oct;14(9):894. e1-9.
Eisenach JC, Pan PH, Smiley R, Lavand’homme P, Landau R, and Houle TT
Severity of acute pain after childbirth, but not type of delivery, predicts persistent pain and postpartum depression.
Pain Nov, 2008;140(1):87-94.
Woods AB, Crist B, Kowalewski S, Carroll J, Warren J, and Robertson J
A cross-sectional analysis of the effect of patient-controlled epidural analgesia versus patient controlled analgesia on postcesarean pain and breastfeeding.
J Obstet Gynecol Neonatal Nurs, 2012 May- Jun;41(3):339-46.
Karlstrom A, Engstrom-Olofsson R, Norbergh KG, Sjoling M, and Hildingsson I
Postoperative pain after cesarean birth affects breastfeeding and infant care.
J Obstet Gynecol Neonatal Nurs, 2007 Sep- Oct;36(5):430-40.
Lowder JL, Shackelford DP, Holbert D, and Beste TM
A randomized, controlled trial to compare ketorolac tromethamine versus placebo after cesarean section to reduce pain and narcotic usage.
Am J Obstet Gynecol, 2003 Dec;189(6):1559-62; discussion 1562.
Wong JO, Tan TD, Cheu NW, Wang YR, Liao CH, Chuang FH, and Watts MP
Comparison of the efficacy of parecoxib versus ketorolac combined with morphine on patient-controlled analgesia for post-cesarean delivery pain management.
Acta Anaesthesiol Taiwan, 2010 Dec;48(4):174-7.
Kaufner L, Heimann S, Zander D, Weizsäcker K, Correns I, Sander M, Feldheiser A, Henkelmann A, Wernecke KD, and VON Heymann C
Neuraxial anesthesia for pain control after cesarean section: a prospective randomized trial comparing three different neuraxial techniques in clinical practice.
Minerva Anestesiol, 2016 May;82(5):514-24.
Paech MJ, McDonnell NJ, Sinha A, Baber C, and Nathan EA
A randomised controlled trial of parecoxib, celecoxib and paracetamol as adjuncts to patient-controlled epidural analgesia after caesarean delivery.
Anaesth Intensive Care, 2014 Jan;42(1):15-22.
Wittels B, Glosten B, Faure EA, Moawad AH, Ismail M, Hibbard J, Senal JA, Cox SM, Blackman SC, Karl L, and Thisted RA
Postcesarean analgesia with both epidural morphine and intravenous patient-controlled analgesia: neurobehavioral outcomes among nursing neonates.
Anesth Analg, 1997 Sep;85(3):600-6.
Carvalho B, Roland LM, Chu LF, Campitelli VA 3rd, and Riley ET
Single-dose, extended- release epidural morphine (DepoDur) compared to conventional epidural morphine for post-cesarean pain.
Anesth Analg, 2007 Jul;105(1):176-83.
Lim NL, Lo WK, Chong JL, and Pan AX
Single dose diclofenac suppository reduces post-Cesarean PCEA requirements.
Can J Anaesth, 2001 Apr;48(4):383-6.
Mikuni I, Hirai H, Toyama Y, Takahata O, and Iwasaki H
Efficacy of intrathecal morphine with epidural ropivacaine infusion for postcesarean analgesia.
J Clin Anesth, 2010 Jun;22(4):268-73.
Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D, Francis N, McNaught CE, Macfie J, Liberman AS, Soop M, Hill A, Kennedy RH, Lobo DN, Fearon K, and Ljungqvist O
Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS(®)) Society recommendations.
World J Surg, 2013 Feb; 37(2):259-84.
Eskicioglu C, Forbes SS, Aarts MA, Okrainec A, and McLeod RS
Enhanced recovery after surgery (ERAS) programs for patients having colorectal surgery: a meta-analysis of randomized trials.
J Gastrointest Surg, 2009 Dec;13(12):2321-9.
Wittels B, Scott DT, and Sinatra RS
Exogenous opioids in human breast milk and acute neonatal neurobehavior: a preliminary study.
Anesthesiology, 1990 Nov;73(5):864-9.
Jóźwiak-Bebenista M, Nowak JZ
Paracetamol: mechanism of action, applications and safety concern.
Acta Pol Pharm, 2014 Jan- Feb;71(1):11-23.
Dawood MY and Khan-Dawood FS
Clinical efficacy and differential inhibition of menstrual fluid prostaglandin F2alpha in a randomized, double-blind, crossover treatment with placebo, acetaminophen, and ibuprofen in primary dysmenorrhea.
Am J Obstet Gynecol, 2007 Jan;196(1):35 e1-5.
Saliba SW, Marcotegui AR, Fortwängler E, Ditrich J, Perazzo JC, Muñoz E, de Oliveira ACP, and Fiebich BL
AM404, paracetamol metabolite, prevents prostaglandin synthesis in activated microglia by inhibiting COX activity.
J Neuroinflammation, 2017 Dec; 14(1):246
McNicol ED, Tzortzopoulou A, Cepeda MS, Francia MB, Farhat T, and Schumann R
Single- dose intravenous paracetamol or propacetamol for prevention or treatment of postoperative pain : a systematic review and meta-analysis.
Br J Anaesth, 2011 Jun;106(6):764-75.
Altenau B, Crisp CC, Devaiah CG, and Lambers DS
Randomized controlled trial of intravenous acetaminophen for postcesarean delivery pain control.
Am J Obstet Gynecol, 2017 Sep;217(3):362 e1-362. e6.
Ozmete O, Bali C, Cok OY, Ergenoglu P, Ozyilkan NB, Akin S, Kalayci H, and Aribogan A
Preoperative paracetamol improves post- cesarean delivery pain management: a prospective, randomized, double-blind, placebo-controlled trial.
J Clin Anesth, 2016 Sep;33:51-7.
Towers CV, Shelton S, van Nes J, Gregory E, Liske E, Smalley A, Mobley E, Faircloth B, and Fortner KB
Preoperative cesarean delivery intravenous acetaminophen treatment for postoperative pain control: a randomized double-blinded placebo control trial.
Am J Obstet Gynecol, 2018 Mar; 218(3):353 e1-353.e4.
Ruban P, Sia AT, and Chong JL
The effect of adding fentanyl to ropivacaine 0.125% on patient- controlled epidural analgesia during labour.
Anaesth Intensive Care, 2000 Oct;28(5):517-21.
Ortner CM, Posch M, Roessler B, Faybik P, Rützler K, Grabovica J, Kimberger O, and Gustorff B
On the ropivacaine-reducing effect of low-dose sufentanil in intrathecal labor analgesia.
Acta Anaesthesiol Scand, 2010 Sep;54(8):1000-6.
Matsota P, Batistaki C, Apostolaki S, and Kostopanagiotou G
Patient-controlled epidural analgesia after Caesarean section: levobupivacaine 0.15% versus ropivacaine 0.15% alone or combined with fentanyl 2 µg/ml: a comparative study
Arch Med Sci, 2011 Aug;7(4):685-93.
Wick EC, Grant MC, and Wu CL
Postoperative Multimodal Analgesia Pain Management With Nonopioid Analgesics and Techniques : A Review.
JAMA Surg, 2017 Jul;152(7):691-7.
Siddik SM, Aouad MT, Jalbout MI, Rizk LB, Kamar GH, and Baraka AS.
Diclofenac and/or propacetamol for postoperative pain management after cesarean delivery in patients receiving patient controlled analgesia morphine.
Reg Anesth Pain Med, 2001 Jul-Aug;26(4):310-5.
Carvalho B and Butwick AJ
Postcesarean delivery analgesia.
Best Pract Res Clin Anaesthesiol, 2017 Mar;31(1):69-79.
Pavy TJ, Paech MJ, and Evans SF
The effect of intravenous ketorolac on opioid requirement and pain after cesarean delivery.
Anesth Analg, 2001 Apr;92(4):1010-4.
Matsota P, Nakou M, Kalimeris K, Batistaki C, Pandazi A, and Kostopanagiotou G
A single dose of celecoxib 200 mg improves postoperative analgesia provided via patient-controlled epidural technique after caesarean section.
Arch Med Sci, 2013 Oct; 9(5):877-82.
Botting R and Ayoub SS
COX-3 and the mechanism of action of paracetamol/acetaminophen
Prostaglandins Leukot Essent Fatty Acids, 2005 Feb; 72(2):85-7.
Olbrecht VA, Ding L, Spruance K, Hossain M, Sadhasivam S, and Chidambaran V
Intravenous Acetaminophen Reduces Length of Stay Via Mediation of Postoperative Opioid Consumption After Posterior Spinal Fusion in a Pediatric Cohort.
Clin J Pain, 2018 Jul;34(7):593-9.
Gupta K, Mitra S, Kazal S, Saroa R, Ahuja V, and Goel P
I.V. paracetamol as an adjunct to patient- controlled epidural analgesia with levobupivacaine and fentanyl in labour: a randomized controlled study.
Br J Anaesth, 2016 Nov;117(5):617-22.
Schewe JC, Komusin A, Zinserling J, Nadstawek J, Hoeft A, and Hering R
Effects of spinal anaesthesia versus epidural anaesthesia for caesarean section on postoperative analgesic consumption and postoperative pain.
Eur J Anaesthesiol, 2009 Jan;26(1):52-9.
Paech MJ, Moore JS, and Evans SF
Meperidine for patient-controlled analgesia after cesarean section. Intravenous versus epidural administration.
Anesthesiology, 1994 Jun;80(6):1268-76.