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Evaluation of Opioid Use With Split Doses of Oral Opioids in a Postcesarean Delivery Analgesia Order Set

Nanji, Jalal A. MD, FRCPC; Guo, Nan PhD; Riley, Edward T. MD; Faulkner, Bethan DNP, MN; Do, Christina MSN, RN; Carvalho, Brendan MBBCh, FRCA

doi: 10.1097/AOG.0000000000003305
Contents: Cesarean Delivery: Clinical Practice and Quality

OBJECTIVE: To evaluate whether an order set change that halved the initial dose of oxycodone and allowed the remainder to be given 1 hour later, if requested, was associated with reduced opioid use and side effects after cesarean delivery.

METHODS: This retrospective, clinical practice study reviewed electronic medical records after implementation of a new order set for cesarean delivery. Oxycodone orders changed from 5 mg (for verbal pain score of 4/10 or lower) and 10 mg (for 5–10/10) to 2.5 mg (for verbal pain score 1–4/10) or 5 mg (for 5–10/10), and the patient requesting pain relief, with a nurse check within 1 hour to administer another 2.5 or 5 mg, respectively, if needed. The primary outcome was opioid use (in intravenous morphine equivalents) in the first 48 hours. Secondary outcomes included incidence and treatment of nausea or vomiting and pruritis, average and peak verbal pain scores within 48 hours, and satisfaction.

RESULTS: The records of 1,050 women were examined (542 before and 508 after the change). Opioid use in the first 48 hours was lower after the practice change (median [interquartile range] 10.0 [1.3–25.0] mg before vs 4.4 [0–12.5] mg after; P<.001). A small increase in average verbal pain score occurred (mean [SD] 1.8 [1.0] before vs 2.0 [1.3] after; difference −0.2; 95% CI −0.3 to −0.04). Peak verbal pain score (5.9 [2.0] before vs 6.0 [2.1] after; difference −0.1; 95% CI −0.4 to 0.1) and mean (SD) satisfaction score (97.7 [7.2] before vs 97.1 [7.5] after; difference 0.6, 95% CI −0.5 to 1.6) did not change. Fewer patients reported postoperative nausea or vomiting (30.9% before vs 19.3% after; odds ratio 0.5; 95% CI 0.4 to 0.7).

CONCLUSION: Split doses of oxycodone were associated with 56% reduction in 48 hours opioid use after cesarean delivery.

Halving doses of oxycodone, with the option to receive the remainder 1 hour later, was associated with reduced opioid consumption after cesarean delivery.

Department of Anesthesiology & Pain Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada; and the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, and Lucile Packard Children's Hospital Stanford, Stanford Children's Health, Stanford, California.

Corresponding author: Jalal A. Nanji, MD, FRCPC, Department of Anesthesiology & Pain Medicine, University of Alberta Faculty of Medicine & Dentistry, Royal Alexandra Hospital, Edmonton, AB, Canada; email:

Supported by the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California.

Financial Disclosure Dr. Nanji received travel/accommodation expense reimbursement from the University of Calgary for speaking at the 21st Annual Rural Anesthesia for GP Anesthesiologists conference in Banff, Alberta on January 18, 2019. The other authors did not report any potential conflicts of interest.

Presented as a poster at the Society for Maternal-Fetal Medicine's 39th Annual Pregnancy Meeting, February 11–16, 2019, Las Vegas, Nevada; and at the 51st Annual Meeting of the Society for Obstetric Anesthesia and Perinatology, May 1–5, 2019, Phoenix, Arizona.

The authors thank the Clinical Research Services Team at Stanford Health Care and Stanford Children's Health for their assistance in obtaining the data for this study.

Each author has confirmed compliance with the journal's requirements for authorship.

Peer reviews and author correspondence are available at

© 2019 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.