Optimizing Cesarean delivery in 2020: How ERAS can improve hospital capacity, patient experience

Expectant mothers in need of cesarean delivery in 2020 are now benefiting from evolving care pathways as many hospitals are exploring what they can do to expedite cesarean delivery patients' recovery, including potentially reducing the need to stay in the hospital for several days after surgery. 

Several years ago, Texas Children’s Pavilion for Women (TCPFW) began to perform transversus abdominis plane (TAP) blocks with long-lasting EXPAREL as part of its enhanced recovery program for cesarean delivery patients. The TAP block with EXPAREL, along with multimodal pain management, is an effective approach to improve pain management after cesarean deliveries, according to research published in 2018 and conducted by B. Wycke Baker, MD, MHA, former Chief of Anesthesiology at TCPFW, Clinical Professor of Anesthesiology and Obstetrics and Gynecology at Houston-based Baylor College of Medicine, and medical consultant for Pacira Biosciences, along with Lea Villadiego, MSN, APRN, FNP-C. pain management nurse practitioner at Houston-based Texas Children’s Pavilion for Women.

Liposomal bupivacaine or EXPAREL® (bupivacaine liposome injectable suspension) has been approved by the FDA since 2011 for field blocks such as TAP, to deliver localized pain control for several days after surgery, including C-sections. Below, Dr. Baker and Ms. Villadiego discuss the results from their experience and how enhanced recovery after surgery protocols supported by this long-lasting localized approach with nonopioid analgesia can positively impact cesarean delivery patients’ recovery and return to normal function in the postpartum period.

Question: What is the current status of ERAS and multimodal protocols in the world of obstetrics? Where are we in the continuum of evolution?

Dr. B. Wycke Baker: While it varies by area, I think we’re early in the evolution. Some of this has to do with the historical origin of enhanced recovery after surgery, which began in the 1990s and centered around colorectal surgery. Though multimodal analgesia — ways of minimizing postoperative pain that don’t depend solely on opioids — has also evolved, there hasn’t been an early adoption of multimodal analgesia or ERAS in obstetrics on a national level. Clinical practices are always slow to change, in part due to a practice-what-you-know culture. This is especially true when treating mothers and infants. While most institutions and physicians have heard of ERAS, they haven’t thought about it through the cesarean surgery lens.

It’s 2020 — ERAS began a long time ago. Currently, the American College of Obstetricians and Gynecologists, Society for Obstetric Anesthesia and Perinatology, and Association of Women’s Health, Obstetric and Neonatal Nurses all have some guidelines or statements endorsing the application of ERAS and use of multimodal analgesia.

Lea Villadiego: ERAS and multimodal protocols in obstetrics are slowly becoming more common as providers learn about the benefits of minimizing opioids such as reducing or avoiding nausea and vomiting and allowing mothers to more quickly walk, eat and take care of their new baby.

Q: Why did Texas Children’s adopt enhanced recovery early on?

BB: When TCPFW opened in 2012, we wanted to improve pain management strategies and overall patient experience. In the first five years after opening, we experienced almost exponential growth and had a lot of complex, high-risk cases. We were so busy that administrative leaders sought new processes to reduce patient length of stay and to free up bed space. As a clinician, it became clear that a move away from opioids would reduce opioid-related adverse events and opioid side effects which can inhibit recovery after surgery.

We built our enhanced recovery protocols and program to meet these demands. As an evolution of our enhanced recovery program, in our study, we explored the addition of the TAP blocks with EXPAREL to last several days (versus traditional local anesthetics like ropivacaine or bupivacaine which last less than one day) for our cesarean delivery patients. Our results showed that pain scores, opioid requirements, and length of stay declined and readiness for discharge from PACU and the hospital improved. In the total population, fewer patients receiving multimodal pain management with the TAP block with EXPAREL reported an adverse effect.

Q: Why are enhanced recovery protocols in Obstetrics relevant now more than ever?

LV: ERAS, multimodal analgesia and the long-lasting effect of the TAP blocks with EXPAREL benefit patients even more as we think about 2020 and beyond. In the study conducted at TCPFW, C-section patients experienced positive results using the method, with repeat cesarean delivery patients describing a difference in recovery. In the repeat-cesarean subgroup, 15% of our patients treated with that received the TAP block with EXPAREL were opioid-free vs. none in the traditional enhanced recovery group.

BB: The TAP block using long-lasting EXPAREL aligns with the requirements of the time. As shown in our study, our patients have served as their own controls —  experienced moms with repeat cesarean deliveries using ERAS and multimodal analgesia and the TAP Block with EXPAREL significantly improved recovery after surgery. 

Indication
EXPAREL® (bupivacaine liposome injectable suspension) is indicated for single-dose infiltration in patients aged 6 years and older to produce postsurgical local analgesia and in adults as an interscalene brachial plexus nerve block to produce postsurgical regional analgesia. Safety and efficacy have not been established in other nerve blocks.
Important Safety Information
· EXPAREL is contraindicated in obstetrical paracervical block anesthesia.
· Adverse reactions reported in adults with an incidence greater than or equal to 10% following EXPAREL administration via infiltration were nausea, constipation, and vomiting; adverse reactions reported in adults with an incidence greater than or equal to 10% following EXPAREL administration via interscalene brachial plexus nerve block were nausea, pyrexia, and constipation.
· Adverse reactions with an incidence greater than or equal to 10% following EXPAREL administration via infiltration in pediatric patients six to less than 17 years of age were nausea, vomiting, constipation, hypotension, anemia, muscle twitching, vision blurred, pruritis, and tachycardia.
· If EXPAREL and other non-bupivacaine local anesthetics, including lidocaine, are administered at the same site, there may be an immediate release of bupivacaine from EXPAREL. Therefore, EXPAREL may be administered to the same site 20 minutes after injecting lidocaine.
· EXPAREL is not recommended to be used in the following patient populations: patients <6 years old for infiltration, patients younger than 18 years old for interscalene brachial plexus nerve block, and/or pregnant patients.
· Because amide-type local anesthetics, such as bupivacaine, are metabolized by the liver, EXPAREL should be used cautiously in patients with hepatic disease.
Warnings and Precautions Specific to EXPAREL
· Avoid additional use of local anesthetics within 96 hours following administration of EXPAREL.
· EXPAREL is not recommended for the following types or routes of administration: epidural, intrathecal, regional nerve blocks other than interscalene brachial plexus nerve block, or intravascular or intra-articular use.
· The potential sensory and/or motor loss with EXPAREL is temporary and varies in degree and duration depending on the site of injection and dosage administered and may last for up to 5 days, as seen in clinical trials.
Warnings and Precautions for Bupivacaine-Containing Products
· Central Nervous System (CNS) Reactions: There have been reports of adverse neurologic reactions with the use of local anesthetics. These include persistent anesthesia and paresthesia. CNS reactions are characterized by excitation and/or depression.
· Cardiovascular System Reactions: Toxic blood concentrations depress cardiac conductivity and excitability, which may lead to dysrhythmias, sometimes leading to death.
· Allergic Reactions: Allergic-type reactions (eg, anaphylaxis and angioedema) are rare and may occur as a result of hypersensitivity to the local anesthetic or to other formulation ingredients.
· Chondrolysis: There have been reports of chondrolysis (mostly in the shoulder joint) following intra-articular infusion of local anesthetics, which is an unapproved use.
· Methemoglobinemia: Cases of methemoglobinemia have been reported with local anesthetic use.
Please refer to EXPAREL.com for full Prescribing Information.
 

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