Opioid-sparing post-cesarean analgesia using intravenous diclofenac-acetaminophen combination: A prospective, randomized clinical trial

Background: Current research promotes opioid-sparing analgesia as an approach to enhanced recovery after cesarean (ERAC). In developing countries, non-opioid-based analgesia is routinely practiced in obstetric settings, as opioids are not freely accessible. There are no randomized trials evaluating intravenous diclofenac and acetaminophen for postoperative analgesia following elective cesarean section. Methods: Women scheduled for elective cesarean delivery under subarachnoid block were enrolled if they fulfilled the inclusion criteria. They were randomized to receive either intravenous diclofenac or intravenous diclofenac-acetaminophen combination at the end of surgery and at predefined time intervals during the 24-hour postoperative period. The primary outcome measure of our study was 24-hour rescue analgesic (tramadol) consumption. Secondary outcome measures included time to first request for rescue analgesia, postoperative pain at rest and on movement, episodes of nausea, retching, and vomiting during the 24-hour postoperative period and overall patient satisfaction. Results: The 24-hour rescue analgesic consumption was significantly lesser in the diclofenac-acetaminophen group compared to the diclofenac group (56.25 +/- 47.73 mg vs. 92.86 +/- 50.83 mg; P = 0.00). Time to first request for rescue analgesia was earlier in the diclofenac group compared to the diclofenac-acetaminophen group (3.96 +/- 2.40 h vs. 5.64 +/- 3.58 h, P = 0.01). Parturients given a combination of intravenous diclofenac and acetaminophen used 40% less tramadol in the first 24 hours following cesarean section and were more satisfied with their pain management when compared to those given intravenous diclofenac alone. Conclusion: Following cesarean section, intravenous diclofenac-acetaminophen combination provides superior analgesia with significantly lesser opioid consumption and higher patient satisfaction when compared to intravenous diclofenac alone. This combination is effective, easy to administer, opioid-sparing and is compatible with ERAC regimens.