Dual-opioid spinal anaesthesia in enhanced recovery after caesarean section: effects on postoperative opioid requirement and maternal recovery

BACKGROUND: Optimisation of post-caesarean delivery and perioperative outcomes have emerged as a pivotal concern in obstetrics. The primary aim of this study was to evaluate the effects of implementing Enhanced Recovery After Caesarean Section (ERAC) combined with a pre-existing dual-opioid subarachnoid anaesthesia technique on the decrease in rescue opioid doses needed for acute pain management after caesarean delivery. The secondary aim was to compare the postoperative outcomes before and after the implementation of the ERAC pathway. METHODS: We conducted an observational, retrospective single-centre study involving 322 pregnant women, 156 pre-ERAC, and 166 post-ERAC. The eligible women were > 18 years old, without invasive placental disorders, no prior abdominal surgery with longitudinal laparotomy, and no disease. All women received subarachnoid anaesthesia with sufentanil and morphine, in addition to local anaesthetic and postoperative analgesia with paracetamol and ketorolac. Acute pain assessment was performed with a numeric pain rating scale (NRS); if the NRS was ≥ 4, a rescue dose of tramadol was administered in both groups. RESULTS: Significant reductions in the need for rescue opioid analgesia were observed in the ERAC group, with logistic regression confirming an 84.5% reduction on postoperative day one. Additionally, outcomes, including early mobilisation, spontaneous diuresis, and return of gastrointestinal function, improved. The ERAC group also demonstrated a higher rate of discharge on the second postoperative day. CONCLUSIONS: The findings of our study suggest that implementing the ERAC strategy with a pre-existing dual-opioid subarachnoid anaesthesia technique may be associated with reduced opioid requirements following caesarean delivery and to improved maternal outcomes.