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Journal of Clinical Anesthesia (2016) 33, 51–57

Preoperative paracetamol improves post-cesarean


delivery pain management: a prospective, ran-
domized, double-blind, placebo-controlled trial
Ozlem Ozmete MD a,⁎,1 , Cagla Bali MD a,2 , Oya Yalcin Cok MD a,3 ,
Pinar Ergenoglu MD a,4 , Nesrin Bozdogan Ozyilkan MD a,5 , Sule Akin MD a,6 ,
Hakan Kalayci MD b,7 , Anis Aribogan MD a,8
a
Baskent University School of Medicine, Anesthesiology and Reanimation Department, Adana, Turkey
b
Baskent University School of Medicine, Obstetrics and Gynecology Department, Adana, Turkey

Received 1 September 2015; revised 28 January 2016; accepted 18 February 2016

Keywords:
Abstract
Preoperative analgesia;
Study Objective: To evaluate the analgesic effect of preoperative single dose intravenous paracetamol on
Paracetamol;
postoperative pain and analgesic consumption within 24 hours after elective cesarean surgery.
Cesarean delivery;
Design: Prospective, randomized, double-blind, placebo-controlled clinical trial.
General anesthesia
Setting: University Teaching Hospital.
Patients: American Society of Anesthesiologists (ASA) I and II 60 patients between 18–40 years of age
who were scheduled to undergo elective cesarean section.
Interventions: Patients were randomized into two groups to receive either intravenous 1 g paracetamol
(100 mL) (Group P) or 0.9% NaCl solution (100 mL) (Group C) 15 minutes before the induction of general

⁎ Corresponding author. Tel.: +90 322 3272727x2461, +90 536 696 51 14 (mobile); fax: +90 322 3271273.
E-mail addresses: ozlemyilma@yahoo.com (O. Ozmete), caglaetike@hotmail.com (C. Bali), oyacok01@yahoo.com (O.Y. Cok), pergenoglu@yahoo.com
(P. Ergenoglu), nesrinbozdogan@yahoo.com (N.B. Ozyilkan), sakin00@yahoo.com (S. Akin), hakankalay78@gmail.com (H. Kalayci), aaribogan@yahoo.com
(A. Aribogan).
1
Baskent Universitesi Tip Fakultesi Adana Uygulama ve Arastirma Merkezi Dadaloglu, Mh.39. Sk. No.6 01250, Yuregir/Adana, Turkiye.
2
Baskent Universitesi Tip Fakultesi Adana Uygulama ve Arastirma Merkezi Dadaloglu, Mh.39. Sk. No.6 01250, Yuregir/Adana, Turkiye. Tel.: + 90 322
3272727x1472, +90 532 0613026 (mobile); fax: +90 322 3271273.
3
Baskent Universitesi Tip Fakultesi Adana Uygulama ve Arastirma Merkezi Dadaloglu, Mh.39. Sk. No.6 01250, Yuregir/Adana, Turkiye. Tel.: + 90 322
3272727x1469, +90 533 4306963 (mobile); fax: +90 322 3271273.
4
Baskent Universitesi Tip Fakultesi Adana Uygulama ve Arastirma Merkezi Dadaloglu, Mh.39. Sk. No.6 01250, Yuregir/Adana, Turkiye. Tel.: + 90 322
3272727x2467, +90 532 4725697 (mobile); fax: +90 322 3271273.
5
Baskent Universitesi Tip Fakultesi Adana Uygulama ve Arastirma Merkezi Dadaloglu, Mh.39. Sk. No.6 01250, Yuregir/Adana, Turkiye. Tel.: + 90 322
3272727x1106, +90 532 5837333 (mobile); fax: +90 322 3271273.
6
Baskent Universitesi Tip Fakultesi Adana Uygulama ve Arastirma Merkezi, Gazi Paşa Mah. Baraj Cad. No.7 01110, Seyhan/Adana, Turkiye. Tel.: +90 322
3272727x1156, +90 533 3584414 (mobile); fax: +90 322 3271273.
7
Baskent Universitesi Tip Fakultesi Adana Uygulama ve Arastirma Merkezi, Gazi Paşa Mah. Baraj Cad. No.7 01110, Seyhan/Adana, Turkiye. Tel.: +90 322
4586868x2110, +90 532 6740037 (mobile); fax: +90 322 4592622.
8
Baskent Universitesi Tip Fakultesi Adana Uygulama ve Arastirma Merkezi Dadaloglu, Mh. 39. Sk. No.6 01250, Yuregir/Adana, Turkıye. Tel.: + 90 322
3272727/2002, +90 532 2148661 (mobile); fax: +90 322 3271273.

http://dx.doi.org/10.1016/j.jclinane.2016.02.030
0952-8180/© 2016 Elsevier Inc. All rights reserved.
52 O. Ozmete et al.

anesthesia. After delivery of newborn 0.15 mg kg-1 morphine was administered to all patients in both
groups. Postoperative analgesia was provided with patient-controlled intravenous analgesia with morphine
in the postoperative period.
Measurements: Pain which is the primary outcome measure was assessed at 15th, 30th minutes and 1st,
2nd, 4th, 6th, 12th, 24th hours by the Visual Analogue Scale. Patients' demographics, hemodynamics,
Apgar score, additional analgesic requirement, side effects, patients' satisfaction and postoperative total
morphine consumption within 24 hours were recorded.
Main Results: Median visual analogue scale for pain in Group P was significantly lower compared to Group
C at all time points except for the score at 24th h postoperatively (P b .05). Additional analgesic requirement
during postoperative first hour was lower in Group P (P b .05). Total morphine consumption was higher in
Group C compared with Group P (P b .05). There was no difference between groups with respect to Apgar
scores, side effects, and patient satisfaction (P N .05).
Conclusions: Preoperative use of single-dose intravenous 1 g paracetamol was found to be effective in re-
ducing the severity of pain and opioid requirements within 24 hours after cesarean section.
© 2016 Elsevier Inc. All rights reserved.

1. Introduction 2. Materials and methods

Pain is the most common complaint of women having ce- The Baskent University Institutional Review Board and
sarean deliveries [1]. Pain after a cesarean delivery blocks Ethics Committee approved this prospective, randomized,
the relationship between the mother, and newborn as well as double-blind study (Project KA 13-180). The study was
the care and feeding of the newborn. Furthermore, inadequate supported by Baskent University Research Fund and
pain management constitutes an important risk factor for post- was completed over a period of 4 months. The protocol
partum depression, and chronic pain development [2,3]. for this clinical trial was registered at ClinicalTrials.gov
Spinal anesthesia is the preferred anesthesia method for (NCT02369133).
elective and emergency cesarean surgeries. However, general Sixty pregnant women having an American Society of An-
anesthesia still has its place in patients with specific conditions esthesiologists (ASA) I and II between 18 and 40 years of age
including coagulopathy, fetal distress, bleeding, eclampsia, who were scheduled to undergo an elective cesarean surgery
HELLP syndrome (hemolysis, elevated liver enzymes, and under general anesthesia were enrolled in this study. Inclusion
low platelet count), and skin infections of the lumbar region criteria included a single-fetus pregnancy, more than 38 weeks
or the patient's unwillingness to receive regional methods. of gestational age, refusal to have regional anesthesia during
Treatment modalities widely used for postoperative analge- cesarean section and being scheduled for an elective cesarean
sia in patients undergoing general anesthesia include systemic section. The exclusion criteria included a body mass index
opioid administration (intramuscular or intravenous), oral- greater than 40 kg·m − 2 , being allergic to any of the study
rectal analgesics, and patient-controlled intravenous analgesia drugs, psychiatric or cardiopulmonary diseases, chronic use
(PCIA) methods. Non-opioids are commonly added to treat- of analgesics, complications during the cesarean section, and
ments to increase analgesic efficacy and reduce opioid con- being unable to use a PCIA device.
sumption and opioid side effects. Adjuvant medications such
as paracetamol and non-steroidal anti-inflammatory drugs 2.1. Intervention
(NSAID) are added to opioid therapy for this purpose.
Paracetamol is a non-opioid agent that affects the central Preoperatively, all patients were informed about the study
nervous system (CNS) primarily by inhibiting central cycloox- parameters including pain management methods to be used
ygenase (COX), and activating serotoninergic pathways via during the study including a visual analogue scale (VAS)
the inhibition of nociceptive signal transmission in the spinal and the use of the PCIA device. Written informed consent
cord [4]. was obtained from all patients. All patients refrained from eat-
This randomized, double-blind, placebo-controlled study ing and drinking for 8 hours before surgery.
was conducted to evaluate the efficacy of preoperative IV Patients were randomly divided into two groups by a closed
paracetamol to prevent and treat post-cesarean delivery pain. envelope method. A computer-generated table of random
We hypothesized that a single dose of IV paracetamol admin- numbers was obtained to randomly assign the patient into
istered before general anesthesia would significantly reduce one of the two groups. The assignment number was concealed
acute postoperative pain, and provide less total morphine con- in closed envelopes until the patient was approved to enroll in
sumption than the placebo over a 24-hour period. the study. These envelopes were prepared by an independent
53

anesthesiologist who was not associated with the study. The consumption were performed by an investigator anesthesiolo-
envelopes were opened by the anesthesia technician who gist blinded to patient allocation and study drug. An anesthesia
also prepared the study drugs. The paracetamol group re- technician blinded to the study recorded all the data. Postoper-
ceived 1 g (100 mL) of paracetamol as an IV infusion 15 mi- ative pain levels were evaluated by VAS (0 = no pain; 10 =
nutes before the induction of anesthesia (Group P, n = 30). the worst pain possible) and recorded at the 15th and 30th
Participants in the control group received 0.9% NaCl solution minutes, and the 1st, 2nd, 4th, 6th, 12th, and 24th hours
(100 mL) IV as a placebo 15 minute before the induction of postoperatively.
anesthesia (Group C, n = 30). The anesthesiologist who Sedation levels were evaluated by using the Ramsey Seda-
performed the anesthesia, the participants, the care givers, tion Scale (1 = anxious and agitated; 2 = cooperative and
and those assessing the outcomes were all blinded to group calm; 3 = drowsy but responsive to orders; 4 = asleep but re-
assignments. sponsive to a glabellar tap; 5 = sleeping and slowly responsive
In the operating room, standard monitoring with electrocar- to tactile stimuli; and 6 = patient unresponsive to painful stim-
diography, pulse-oximetry and noninvasive blood pressure uli). HR, SBP, DBP, and SpO2 were evaluated at the same
were established. All patients enrolled in the study received a time points postoperatively. Postoperative adverse effects such
standardized general anesthesia regimen. Metoclopramide hy- as nausea, vomiting, deep sedation, hypotension, bradycardia,
drochloride and ranitidine hydrochloride were administered to and respiratory depression were also recorded.
the patients intravenously and no other premedication was ad- The same anesthesiologist who participated in the study
ministered before induction. After pre-oxygenation, induction questioned the patients to evaluate their overall satisfaction
was performed, 2 mg kg-1 propofol and 0.5 mg kg-1 rocuro- about pain relief for 24 hours postoperatively. All patients'
nium bromide were administered. Anesthesia was maintained satisfaction levels were scored at the end of 24 hours after sur-
with 0.5% sevoflurane in 30% nitrous oxide in oxygen follow- gery, as 1 = very satisfied, 2 = somewhat satisfied, 3 = some-
ing endotracheal intubation. The sevoflurane concentration what dissatisfied, 4 = very dissatisfied who was involved.
was increased to 1.5% and nitrous oxide was increased to
50% after delivery of the newborn. A 5 IU bolus of oxytocin 2.2. Statistical analysis
and 0.15 mg kg-1 morphine was administered to all patients
in both groups after the umbilical cord was clamped. No other The primary outcome parameter of this study was postoper-
opioids or analgesics were administered intraoperatively. The ative pain scores evaluated by VAS. Power analysis of the
neuromuscular block was reversed with 0.03 mg kg-1 neostig- study was based on a study by Moon et al. [5]. Win-Epi 2.0
mine and 0.01 mg kg-1 atropine at the end of the operation. was used for the sample size calculation; a total of 60 patients
Hemodynamic variables including systolic and diastolic blood with 30 patients in each group were considered an appropriate
pressures (SBP and DBP, respectively), mean arterial pressure number following the sample size calculation for a 95% confi-
(MAP), heart rate (HR), and peripheral oxygen saturation dence interval and a power of 80%.
(SpO2) were recorded before induction, after induction, at in- The compact program SPSS 17.0 (SPSS Inc., Chicago, IL,
tubation, 5 minutes after intubation, and at 5-minute intervals USA) was used for statistical analysis of the data. Categorical
thereafter. All neonates were assessed by the same pediatrician variables were expressed as numbers and percentages, where-
who was blinded to patient allocation. Apgar scores at 1 and as numerical variables were expressed as a mean and standard
5 minutes were also recorded. deviation (and as a median and minimum–maximum, when
In the postanesthesia care unit (PACU), pain assessments necessary). The intergroup comparison of numerical variables
using by VAS were started in the immediate postoperative pe- was performed using Student t tests when the assumptions
riod when the patients were fully oriented, and conscious were fulfilled, and Mann–Whitney U tests when the assump-
enough to answer questions. For postoperative pain relief, IV tions were not fulfilled. For parameters with a normal distribu-
morphine was initiated by PCIA (0.015 mg kg-1 bolus, tion, repeated measures analysis and the paired t tests were
15 min lockout, no basal infusion, total dose of morphine used to compare dependent variables, whereas the Wilcoxon
was limited to 0.24 mg kg− 1 4 h− 1) for all patients. When test or the Friedman test were otherwise used. Pre-post mea-
the VAS scores were ≥ 3 at the postoperative period, the sures data were analyzed with repeated measure ANOVA.
PCIA was started. Patients received a 2 mg bolus of morphine The Bonferroni correction was used to adjust the P value for
intravenously as additional analgesic when VAS was ≥ 4 de- each hypothesis to .0056. Values of P b .0056 were consid-
spite using PCIA. Each patient was kept in PACU for one hour ered statistically significant.
after surgery and evaluated there at the 15th and 30th minutes,
1st hour, and visited at the 2nd, 4th, 6th, 12th, and 24th hours
after surgery. These visits were to assess pain to confirm the 3. Results
correct use of the PCIA and to evaluate the sedation levels
and side effects including respiratory depression, nausea, Sixty-eight patients were screened for inclusion in the study
vomiting, and presence of allergic reactions. During these (Fig. 1). Eight patients were excluded (exclusion criteria [n = 5]
visits all postoperative assessments including additional and refusal [n = 3]), leaving 60 patients for analysis. The
analgesic requirement, VAS score and total morphine groups had similar demographics including age, weight,
54 O. Ozmete et al.

Enrollment

Assessed for eligibility (n = 68)

Excluded (n = 8)
♦ Not meeting inclusion criteria (n = 5)
♦ Declined to participate (n = 3)

Randomized (n = 60)

Allocation
Allocated to Paracetamol Group (n = 30) Allocated to Control Group (n = 30)
♦ Received paracetamol (n = 30) ♦ Received SF (n =30)
♦ Did not receive paracetamol (give reasons) (n=0) ♦ Did not receive SF (give reasons) (n=0)

Follow-Up
Lost to follow-up (give reasons) (n=0) Lost to follow-up (give reasons) (n = 0)

Discontinued paracetamol (give reasons) (n = 0) Discontinued SF (give reasons) (n = 0)

Analysis
Analysed (n = 30) Analysed (n = 30)
♦ Excluded from analysis (give reasons) (n = 0) ♦ Excluded from analysis (give reasons) (n = 0)

Fig. 1 Flow chart of the study design.

height, ASA status, gestational age, gravidity, parity and dura- points except for the score at 24th h postoperatively (Fig. 2).
tion of surgery (Table 1). There was a reduction in VAS scores in both groups at the
There were no significant intergroup differences identified postoperative 24 hour time. However, VAS scores of Group
with regard to MAP, HR, and SpO2 values between groups P were significantly lower than those of Group C during this
at the beginning of the operation, intraoperatively, and postop- time (Fig. 2).
eratively. None of the patients showed hypotension, hyperten- We determined that morphine consumption was significant-
sion, bradycardia or tachycardia. ly lower in the paracetamol-administered group compared to the
Median VAS scores were significantly lower in Group P control group when the groups were compared with respect to
compared with Group C at all measured postoperative time total morphine consumption during the 24 postoperative period,
the only exception was at the 30th minute (P = .084) (Fig. 3).
Postoperative morphine consumption during 24 hours was
24 mg (14–31 mg) in Group P versus 38 mg (26–46 mg) in
Table 1 Characteristics of study participants Group C (P b .000).
Group P Group C Since no patients in either group required additional analge-
Age (y) 28.07 ± 4.01 29.07 ± 5.67
sics after the first postoperative hour, we included the data of
Weight (kg) 77.67 ± 7.08 80.33 ± 9.67 the first hour in Table 2. When the groups were compared in
Height (cm) 163.0 ± 5.22 161.9 ± 4.33 terms of additional analgesic requirements during the first
ASA (I-II) 20/10 19/11 hour, additional analgesic consumption in Group C was higher
Gestational age (wk) 38.4 (38–40) 38.25 (38–39) compared to that observed in Group P (Table 2).
Gravidity 2 (1–6) 2 (1–5) Apgar scores were similar between groups and within
Parity 1 (0–4) 1 (0–2) normal ranges.
Duration of surgery(min) 34.67 ± 4.86 35.5 ± 5.92 Sedation and vomiting was not observed in both groups
Data are expressed as mean ± SD for age, weight, height and duration of whereas nausea was found in one patient in Group P and six
surgery, absolute numbers for ASA and medians (minimum-maximum) patient in Group C at 6th and 12th hours (p6h = 0.492; p12h =
for gestational age, gravidity, parity. 0.353). This was not statistically different between groups.
55

Values are given as median (IQR)


* ; p = 0.000
; p = 0.003

Fig. 2 VAS differences among the groups.

The satisfaction level was high in both groups. However, opioid consumption over a 24-hour period. We also found that
no significant difference was obtained between the groups additional analgesic requirements were significantly lower in
with respect to patient satisfaction (P = .543). the paracetamol group compared with the control group in
the first postoperative hour.
The coadministration of opioids with non-opioids is widely
utilized to increase analgesic efficacy and to reduce opioid
4. Discussion consumption and opioid-related side effects for pain control
after cesarean sections [6,7]. Non-opioid drugs largely include
In this study, we evaluated the efficacy of preoperative NSAIDs and in recent years, paracetamol. NSAIDs have been
paracetamol in patients who underwent cesarean sections with shown to reduce pain caused by uterine cramping after cesar-
general anesthesia. We found that the preoperative IV admin- ean section and reducing opioid needs [1,8]. However, gastro-
istration of a single dose of paracetamol significantly reduced intestinal side effects, thrombocyte dysfunction with the
acute postoperative pain and resulted in less postoperative associated prolongation of bleeding time and newborn

16
Grup P
Morphine Consumption (mg)


14
Grup C
12

10

8 ¶
6

* ¶
4
*
2

0
0-15min 15-30min 30-60min 1-2 h 2-4 h 4-6 h 6-12 h 12-24 h
Postoperative Time

Fig. 3 Morphine consumptions of the patients during the given time intervals. Values are given as median (IQR) * P = 0.001, ¶ P = 0.000.
56 O. Ozmete et al.

Table 2 Additional analgesic requirements of the patients in the the intervention may or may not be initiated before surgery.
first hour after surgery In this study, preoperative group recieved 1 g iv paracetamol
Group P Group C 30 min before the surgery and preventive group received
p 30 min before the end of surgery. They found that preopera-
(n = 30) (n = 30)
tive paracetamol maintained better control of hemodynamic
PO 15. min, n (%) 2 (6.6%) 23 (76.6%) 0.000
PO 30. min 2 (6.7%) 13 (43.3%) 0.002
variables from intubation time until delivery of the baby. They
PO 1 hour 0 (0%) 6 (20%) 0.036 also observed lower doses of intraoperative opioid require-
ments, longer times for the next needed analgesia, and lower
Data are presented as the number (%) of patients.
PO = postoperative.
incidences of postoperative side-effects, but higher pain scores
in early postoperative periods and after 6 hours [20]. We think
that higher VAS scores in the first postoperative 6 hours in the
pulmonary hypertension due to premature closure of the duc- preemptive group is related to a greater amount of fentanyl use
tus arteriosus secondary to prenatal use, limit the utilization in the preventive group during the intraoperative period. In
of NSAIDs in pregnant subjects [9]. There are also a few case contrast with the previous two studies, we did not find any fa-
reports about uterus atonia following use of ketorolac and vorable effect in hemodynamic responses to tracheal intuba-
diclofenac [10,11]. tion with 1 g of paracetamol when administered preemptively.
Paracetamol is widely used for analgesia and its antipyretic A previous study that randomized 80 patients undergoing
effect in each of the three stages of pregnancy and during cesarean sections received 1 g of IV paracetamol and 75 mg
breastfeeding [12]. The drug crosses the placenta [13] but its of intramuscular diclofenac either before the operation or at
safety in therapeutic doses for both the mother and fetus has the end of the surgery. Both groups received 3 μg kg-1 fenta-
been established in the literature [14]. Its analgesic efficacy, nyl immediately after the delivery of the baby as a bolus dose.
and safety have also been well demonstrated in various surgi- They showed that the administration of paracetamol and diclo-
cal procedures [15–17]. NSAID-associated complaints, such as fenac combination preoperatively provides better analgesia, re-
bleeding and dyspepsia are not observed after paracetamol use. duces pain scores, and reduced narcotic consumption in
Furthermore, its availability in an IV form is an important feature patients [21].
that provides ease of administration in general anesthesia practices. Our study is consistent with other studies in the abdominal
Preemptive analgesia is a technique that provides a more ef- surgery and gynecologic fields that demonstrate a reduction in
fective postoperative pain control. It provides effective analge- pain and narcotic usage after surgery with the administration
sia before the development of exogenous detrimental stimuli of preemptive paracetamol [5,22]. Studies conducted in two
by reducing peripheral sensitization and also by interrupting different clinics on preemptive IV paracetamol use in total ab-
the conduction of perioperative stimuli that are harmful to dominal hysterectomy operations revealed that the postopera-
the medulla spinalis [18]. Preemptive analgesia is also recom- tive pain scores, additional analgesic need and opioid use were
mended as a contemporary method in the treatment of postop- significantly reduced and an effective and safe analgesia was
erative pain. However, a common observation is that in a great achieved in the patients [5,22]. Our results are similar to those
majority of the studies on pain management in cesarean sec- reported above. Additionally, an assessment of 24-hour total
tions, analgesic drugs are administered before the termination morphine consumption showed that it was 24 mg in the para-
of the operation or after the delivery of the newborn. In our cetamol group and 38 mg in the control group. An approxi-
study, preoperative IV paracetamol was administered in cesar- mate 36% reduction in total morphine consumption was
ean sections due to its applicability in pregnant subjects and achieved by a preoperative single dose of paracetamol, which
the availability of its IV form. in our opinion is an important finding.
According to our knowledge, only a few studies have in- Opioid analgesic use is an important risk factor for postop-
vestigated preoperative paracetamol use for postoperative ce- erative sedation, nausea, vomiting, constipation, urinary reten-
sarean section pain performed under general anesthesia. In tion, and itching. A reduction of systemic opioid usage would
one of these studies, 60 patients were evaluated for the effect be expected to reduce the incidence of these common side ef-
of preoperative IV administration of paracetamol on hemody- fects. In our study, the use of morphine was lower in the para-
namic variables relative to intubation, postoperative pain, and cetamol group compared with the control group, but there was
neonatal Apgar scores [19]. They suggested that IV paraceta- no significant difference in the incidence of side effects be-
mol is an efficacious agent to decrease hemodynamic re- tween the groups. A possible explanation for these findings
sponses to tracheal intubation while providing better might be that the sample size in our study was not large
postoperative pain management without considerable neonatal enough to detect subtle differences. Our power analysis was
complications. Similarly, our study showed more effective based on VAS but the number of patients may not have been
postoperative pain control and lower opioid consumption with sufficiently large enough to detect side effects.
the use of preoperative paracetamol. In our study, we found no adverse consequences associated
Hossam et al evaluated the effect of 1 g of preoperative IV with intraoperative, and postoperative hemodynamic parame-
paracetamol versus preventive analgesia in elective cesarean ters including MAP, HR, and SpO2. Also, no difference was
sections. Preventive analgesia is the method which means observed between the Apgar scores of the two group.
57

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