Impact of Enhanced Recovery After Cesarean protocol in patients receiving Magnesium therapy

The impact of Enhanced Recovery After Cesarean (ERAC) pathways on patients receiving Magnesium (Mg) following cesarean delivery (CD) is not well studied. Patients receiving Mg tend to have less mobility and longer hospital stays following CD. We aimed to evaluate if implementation of an ERAC protocol improves these metrics in patients receiving post-operative Mg. This is a prospective cohort study of patients 18 and older undergoing CD at a single urban tertiary care center from October 2019 to September 2020. We excluded CD requiring general anesthesia, cases complicated by massive transfusion events, bowel injury, or ICU admission, and patients with chronic pain disorders, chronic opioid use, acute postpartum depression, or neonatal demise. Primary outcomes were time to ambulation and length of stay (LOS). Secondary outcome was patient satisfaction with independent movement as assessed by a validated patient questionnaire (ERAC-Q). Baseline demographics and outcomes were compared between pre-ERAC and post-ERAC cohorts. Data is reported as median and interquartile range (IQR). Outcomes of interest were stratified by Mg therapy. Of 308 patients undergoing CD, 32/196 (16.3%) in the pre-ERAC group received Mg and 14/112 (12.5%) in the post-ERAC group. Patients not receiving Mg after CD had shorter times to ambulation [14.4 hr. (10.5, 19.1) vs. 9.3 hr. (6.5, 14.5), p< 0.0001] and decreased LOS [74.9 hr. (69, 83.9) vs. 72.1 hr. (61.7, 79.7), p=0.003] after ERAC implementation. In contrast, there was no significant difference in time to ambulation and LOS pre- and post-ERAC in patients who received Mg (Table 1). Patients not receiving Mg reported increased post-operative mobility in the post-ERAC cohort (p < 0.001); however, there was no difference in mobility in patients receiving Mg (p=0.1). Although ERAC implementation demonstrated a significant decrease in time to ambulation and LOS in patients not on Mg, this did not apply in patients requiring post-operative Mg. Further evaluation of the impact of ERAC pathways in patients requiring Mg therapy is warranted.