Not recommended for Non-cosmetic Breast Surgery

Pre-operative

not recommended

–      Conventional NSAIDs (Grade B) because of inconsistent procedure-specific and transferable evidence for benefit of pre- vs. postoperative administration, and increased risk of bleeding

–      Corticosteroids for analgesia (Grade D) due to insufficient procedure-specific evidence

–      COX-2-selective inhibitors (except in short breast surgery procedures) (Grade D) as transferable evidence shows inconsistent benefit of pre- vs. postoperative administration, and there is no procedure-specific evidence

–      NMDA antagonists

o         Dextromethorphan (Grade B) due to limited procedure-specific evidence

o         Magnesium for analgesia (Grade B) due to transferable evidence showing a lack of analgesic effects

–      Paracetamol (except in short breast surgery procedures) (Grade D) as there is no procedure-specific or transferable evidence to show whether pre-operative administration has any analgesic benefit compared with postoperative administration

–      Strong opioids (Grade D) due to no procedure-specific evidence of an analgesic benefit of pre- vs. postincisional administration

–      Thoracic epidural analgesia (Grade D) due to the risk of complications

–      Electro-acupoint stimulation (Grade D) due to limited procedure-specific and transferable evidence

–      Gabapentinoids (Grade D) because pain intensity is commonly not severe enough to justify an adjuvant to the usual analgesic agents

–      Conventional NSAIDs (Grade D) because of inconsistent procedure-specific and transferable evidence for benefit of pre- vs. postoperative administration

–      Corticosteroids for analgesia (Grade D) due to insufficient procedure-specific evidence

–      COX-2-selective inhibitors (except in short breast surgery procedures) (Grade D) as transferable evidence shows inconsistent benefit of pre- vs. postoperative administration, and there is no procedure-specific evidence

–      NMDA antagonists

o       Dextromethorphan (Grade B) due to limited procedure-specific evidence

o       Magnesium for analgesia (Grade B) due to transferable evidence showing a lack of analgesic effects

–      Paracetamol (except in short breast surgery procedures) (Grade D) as there is no procedure-specific or transferable evidence to show whether pre-operative administration has any analgesic benefit compared with postoperative administration

–      Strong opioids (Grade D) due to no procedure-specific evidence of an analgesic benefit of pre- vs. postincisional administration

–      Paravertebral block (Grade D) because of the risk of complications

–      Thoracic epidural analgesia (Grade D) due to the risk of complications

–      Electro-acupoint stimulation (Grade D) due to limited procedure-specific and transferable evidence

Intra-operative

not recommended

–      Corticosteroids for analgesia (Grade D) due to insufficient procedure-specific evidence

–      Adenosine (Grade D) because of limited procedure-specific and transferable evidence

–      Intercostal block (Grade D) because of insufficient procedure-specific evidence

–      High concentrations of oxygen (Grade B) due to negative procedure-specific evidence

–      Electro-acupoint stimulation (Grade D) due to limited procedure-specific and transferable evidence

–      Corticosteroids for analgesia (Grade D) due to insufficient procedure-specific evidence

–      Adenosine (Grade D) because of limited procedure-specific and transferable evidence

–      Intercostal block (Grade D) because of insufficient procedure-specific evidence

–      High concentrations of oxygen (Grade B) due to negative procedure-specific evidence

–      Electro-acupoint stimulation (Grade D) due to limited procedure-specific and transferable evidence

Postoperative

not recommended

–      Mexiletine (Grade D) because of limited and conflicting procedure-specific evidence

–      Paracetamol alone for high intensity pain (Grade B) due to insufficient analgesic efficacy

–      Strong opioids for low-moderate pain (Grade B) because of a risk of emetic and other side-effects

–      IM administration of strong opioids (Grade B) because of transferable evidence showing unfavourable pharmacokinetics, injection-associated pain, and patient dissatisfaction

–      Antibiotics for analgesia (Grade D) due to limited procedure-specific evidence showing inconsistent results

–      Continuous paravertebral block (Grade D) due to limited procedure-specific evidence

–      Thoracic epidural analgesia (Grade D) due to the risk of complications

–      Topical administration of local anaesthetics (Grade D) due to inconsistent procedure-specific evidence

–      Wound application of conventional NSAID via drain (Grade B) because of procedure-specific and transferable evidence showing a lack of analgesic benefit

–      High concentrations of oxygen (Grade B) due to negative procedure-specific evidence

–      Gabapentinoids (Grade B) because pain intensity is commonly not severe enough to justify an adjuvant to the usual analgesic agents

–      Mexiletine (Grade D) because of limited and conflicting procedure-specific evidence

–      Paracetamol alone for high intensity pain (Grade B) due to insufficient analgesic efficacy

–      Strong opioids for low-moderate pain (Grade B) because of a risk of emetic and other side-effects

–      IM administration of strong opioids (Grade B) because of transferable evidence showing unfavourable pharmacokinetics, injection-associated pain, and patient dissatisfaction

–      Antibiotics for analgesia (Grade D) due to limited procedure-specific evidence showing inconsistent results

–      Continuous paravertebral block (Grade D) because of the risk of complications

–      Thoracic epidural analgesia (Grade D) due to the risk of complications

–      Topical administration of local anaesthetics (Grade D) due to inconsistent procedure-specific data

–      Wound application of conventional NSAID via drain (Grade B) because of procedure-specific and transferable evidence showing a lack of analgesic benefit

–      High concentrations of oxygen (Grade B) due to negative procedure-specific evidence