Enhanced recovery protocols have the potential to improve maternal outcomes after cesarean delivery.

That’s the conclusion of a new meta-analysis by a team of Stanford University researchers, which found that enhanced recovery after cesarean (ERAC) protocols can reduce opioid consumption, time to first mobilization and time to urinary catheter removal without increasing rates of hospital readmission after discharge. However, the meta-analysis also found that such protocols were not associated with reduced hospital length of stay.

“Enhanced recovery means different things to different people,” Pervez Sultan, MD, an associate professor of anesthesiology at Stanford, in California, said. “Although most clinicians consider it to be a series of preoperative, intraoperative and postoperative interventions, the specifics can vary widely between institutions, states and countries.

“We wanted to try to assimilate the current data and evaluate the impact of enhanced recovery on maternal outcomes after cesarean delivery.”

To do so, Sultan and his colleagues searched relevant databases for articles evaluating the efficacy of enhanced recovery protocols in the setting of cesarean delivery. Studies were included if they compared the implementation of ERAC protocols with a control group. Trials were eligible for inclusion if they implemented more than one intervention, included quantitative reporting and reported one or more predefined outcomes.

“There was significant heterogeneity among the studies we included,” Sultan said in an interview with Anesthesiology News. Because of that, the researchers performed a GRADE (Grading of Recommendations Assessment, Development and Evaluation) analysis, which looks at the quality of the evidence for every outcome.

Low Level of Evidence, but Nonetheless Important

Reporting in an abstract presented to the pandemic-canceled 2020 annual meeting of the International Anesthesia Research Society (abstract Obstetric Anesthesiology-8), the researchers noted that 11 studies were included in the meta-analysis, comprising 13,928 patients (7,522 without enhanced recovery programs and 6,406 with enhanced recovery programs).

Enhanced recovery protocols were associated with reduced opioid consumption (mean difference, –16.41 morphine milligram equivalents [MME]; 95% CI, –25.90 to –6.93 MME; P=0.001), time to first mobilization (–11.05 hours; 95% CI, –18.64 to –3.46 hours; P=0.004), and time to urinary catheter removal (–13.19 hours; 95% CI, –17.59 to –8.79 hours; P<0.001), without significantly affecting maternal readmission rates (odds ratio, 1.16; 95% CI, 0.78-1.71; P=0.47).

According to the investigators, the difference in mean MME consumption was notable. “Patients who went through the enhanced recovery protocols used almost 20 milligrams less than those who did not, which may be significant considering we’re in the midst of an opioid epidemic,” Sultan said.

“There’s a small but important population of women who undergo cesarean delivery who subsequently become opioid dependent after their surgery,” he continued. “So I think it’s important to note that by giving a neuraxial opioid, you can potentially reduce the postoperative systemic oral opioid requirement. Additionally, many enhanced recovery protocols are increasingly advising women to not go home with excessive amounts of opioid, in order to minimize the risk of dependence.”

On the other hand, enhanced recovery protocols were not associated with a reduction in hospital length of stay (–0.52 days; 95% CI, –1.04 to 0.01 days; P=0.052).

“Interestingly, length of stay was significantly reduced in the U.S. cohorts, but it wasn’t significantly different overall when we analyzed all the studies,” Sultan said.

According to the GRADE analysis, the level of evidence was rated as low or very low quality for all study outcomes. However, that didn’t stop Sultan from espousing the benefits of enhanced recovery protocols in these patients.

“Just because it’s a low level of evidence, there’s no evidence of harm from any of the interventions that we looked at,” he explained. “So on balance, the things that we’re instituting are standards of good care—each one makes good clinical sense.

“It’s almost a sum of marginal gains. If you can do each thing a little better, it might not be easy to show level I evidence that it’s better, but the overall satisfaction and experience can nevertheless be improved. And that can have huge implications on the quality of care provided within our health care system.”

Ruthi Landau, MD, the Virginia Apgar Professor of Anesthesiology and director of obstetric anesthesia at Columbia University Irving Medical Center, in New York City, called the study an important piece of work, noting that such enhanced recovery protocols are relatively new in obstetric anesthesia.

For Landau, the results of the trial would likely have been more pronounced if pregnant women were screened for eligibility for ERAC protocols.

“In my opinion, ERAC protocols have the best potential to be successful if eligible women are identified ahead of time for planned cesarean delivery and are informed about the pathway so they know what to expect, or on the day of delivery if the cesarean [delivery] was unplanned,” Landau continued. “And unless there are any intraoperative or postoperative issues, uncomplicated cases should be sent home within 48 to 72 hours.

“So the lack of difference in length of hospital stay with and without ERAC protocols is likely due not to the lack of effectiveness of such protocols,” she added. “Instead, we should tailor our approaches and target ERAC protocols to women who clearly can move at a faster pace and follow an optimized clinical trajectory.”

—Michael Vlessides