Integrative Review of Opioid Use and Protocol Adherence in Hospitals After Implementing Enhanced Recovery After Surgery Protocols for Cesarean Birth

Objective: To evaluate the enhanced recovery after surgery (ERAS) protocols used and amount of opioids administered during hospitalization for cesarean birth after the ERAS protocols were implemented. Data Sources: A search was conducted in CINAHL Complete, Scopus, and PubMed for sources published in English between January 2018 and December 2023. Search terms were cesarean AND opioid* AND eras OR erac OR enhanced recovery. Study Selection: Eligible studies were conducted in the United States, used key pain management components from the ERAS guidelines, and reported results for in-patient postsurgical opioid use. Data Extraction: Data obtained were for post-ERAS implementation only and included authors, date, sample size, study location, participant inclusion and exclusion criteria, methods, interventions used (ERAS guideline components), and morphine milligram equivalents (MME) used during the hospital stay. Data Synthesis: Weighted averages were calculated for results reported as means and percentages. Descriptive summaries were used for the remainder of the results. Results: Twenty-six studies were found, accounting for 19,961 individuals'post-ERAS experiences. Although 30% of participants experienced a scheduled cesarean birth, 70% experienced all types of cesarean births, including scheduled, urgent, or emergent. There was substantial heterogeneity of the data reported, especially for how opioid use was measured and analyzed and time frames for opioid use. In 11 studies that reported MME as means, the weighted average for in-patient opioid use was 54 MME per stay. In only 17 studies, researchers reported the number of women who experienced an opioid-free recovery, which averaged 40% of the women. Conclusion: While implementation of key components of the ERAS protocol is associated with reduced opioid exposure for women experiencing scheduled and nonscheduled cesarean births, a benchmark for the amount of in-patient opioid use was not established. Still, this review offers evidence regarding best practices, lessons learned, and outcome analysis strategies. These fi ndings can support perinatal teams who are considering implementing ERAS for cesarean birth, or those looking for further improvements.