Pre-Operative

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PROSPECT Recommendations

  •  Pre-operative local anaesthetic infiltration at the proposed site of incision is not recommended for abdominal hysterectomy because of its lower benefit compared with post-incisional infiltration for reducing postoperative pain in hysterectomy (grade A). Post-incisional wound infiltration is recommended (see Intra-operative Wound Infiltration)

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

  • Pre-incisional wound infiltration of local anaesthetic had a lower analgesic efficacy than post-incisional infiltration: mean 100-mm VAS score was 59 mm and 51 mm, respectively; and the proportion of patients requiring postoperative analgesics was 50 and 28%, respectively, in patients undergoing laparoscopic cholecystectomy (n=45) Sarac et al 1996

Abdominal Hysterectomy-Specific Evidence - Study information

  • Pre-incisional wound infiltration provided a significant benefit over placebo for reducing supplementary analgesic consumption, in two of three studies Eriksson-Mjoberg et al 1997a Click here for more information
  • Pre-incisional wound infiltration and placebo were associated with a similar incidence of PONV in five of the studies reporting this parameter Hannibal et al 1996
  • Pre-incisional wound infiltration provided no significant benefit over placebo for reducing postoperative pain scores in three studies (n=19, n=41, n=40) Eriksson-Mjoberg et al 1997a
  • Pre-incisional wound infiltration provided no significant benefit over placebo for extending the time to first analgesic request in one study (n=41) Hannibal et al 1996
  • Pre-incisional wound infiltration was not significantly different from post-incisional administration for reducing postoperative pain scores within 0–96 h in two studies Click here for more information
  • Pre-incisional wound infiltration was not significantly different from post-incisional administration for reducing supplementary analgesic consumption within 0–96 h in two studies Click here for more information

PROSPECT Recommendations

  • Pre-operative cognitive intervention for patients undergoing hysterectomy is recommended based on its effect on reducing postoperative pain, analgesic consumption and anxiety as well as increasing patient satisfaction (grade A)
  • Homeopathic arnica and self-relaxation techniques are not recommended based on their lack of analgesic efficacy (grade A)

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

  • [None cited]

Abdominal Hysterectomy-Specific Evidence - Study information

  • Cognitive intervention reduced postoperative pain scores and the duration of pain compared with no cognitive intervention Cheung et al 2003 Click here for more information
  • Cognitive intervention was superior to placebo for reducing supplementary analgesics Ridgeway et al 1982 Click here for more information
  • One study reported that state and trait anxiety scores were significantly lower for patients receiving pre-operative cognitive therapy than those not receiving cognitive intervention (p<0.05; n=96) Cheung et al 2003
  • One study reported that patient satisfaction was significantly higher in patients receiving pre-operative cognitive therapy than those not receiving cognitive intervention (p<0.05; n=96) Cheung et al 2003
  • Homeopathic arnica had no significant benefit compared with placebo for VAS pain scores or supplementary analgesia (n=73) Hart et al 1997
  • Self-relaxation provided no significant benefit over placebo for reducing postoperative pain scores or supplementary analgesic consumption (n=28) Mogan et al 1985

Pre-operative analgesia

Data are available from studies that assessed pre-operative analgesia versus pre-operative placebo, as well as those that examine the concept of pre-emptive – or preventive – analgesia, assessed pre-operative analgesia versus the same analgesia given postoperatively. However, a previous systematic review of pre-emptive analgesia for acute or chronic postoperative pain relief in a variety of surgical procedures – such as orthopaedic, dental, gynaecological and abdominal – has concluded that there is no benefit of pre-emptive over postoperative administration (Møiniche 2002). Nevertheless, it is considered that analgesic medication needs to be initiated in time to ensure an adequate analgesic effect in the immediate postoperative period. This may necessitate administration prior to the postoperative period. 

PROSPECT Recommendations

  • Pre- and postoperative gabapentin is recommended (Grade A) for its procedure-specific effects in reducing postoperative opioid use and postoperative nausea
  • Further studies are required before it is possible to recommend a specific dose or regimen for administration (single or repeated doses)
  • Procedure-specific and transferable evidence suggests that gabapentin may be associated with sedation, and it is recommended (Grade B) that this side effect should be considered when determining the dose that will be administered

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

  • Two systematic reviews and a meta-analysis evaluated the use of gabapentin for postoperative analgesia and demonstrated significant reductions in postoperative pain and supplementary analgesic requirements compared with inactive controls Dahl et al 2004
  • One systematic review Ho et al 2006
  • One systematic review Ho et al 2006

Abdominal Hysterectomy-Specific Evidence – Study information

  • Three out of five studies demonstrated that pre- and postoperative oral gabapentin was superior compared with placebo for reducing pain scores Gilron et al 2005 Click here for more information
  • Two studies out of two showed a significant reduction in pain scores following pre- and postoperative oral gabapentin + rofecoxib administration compared with placebo following abdominal hysterectomy Gilron et al 2005 Click here for more information
  • Four out of five studies demonstrated a decrease in supplementary postoperative analgesic use following pre- and postoperative oral gabapentin administration compared with placebo Dierking et al 2004 Click here for more information
  • Two out of two studies demonstrated a decrease in supplementary postoperative analgesic use following pre- and postoperative oral gabapentin + rofecoxib administration compared with placebo Gilron et al 2005 Click here for more information
  • Qualitative analysis demonstrated that in three out of four studies there was no significant difference in the incidence of adverse effects following pre- and postoperative oral gabapentin administration compared with placebo Dierking et al 2004
  • Quantitative analysis showed that there was a significantly lower incidence of nausea in gabapentin group compared with the placebo group Click here for more information
  • The incidence of side effects following pre- and postoperative oral gabapentin + rofecoxib was significantly lower in two studies out of two when compared with placebo Gilron et al 2005 Click here for more information
  • Patient satisfaction with postoperative pain management was significantly higher at 24 h following pre- and postoperative oral gabapentin compared with placebo (p<0.001) Turan et al 2006
  • Patient satisfaction with postoperative pain management was significantly higher in the pre- and postoperative oral gabapentin + rofecoxib group compared with placebo at 24 (p<0.01), 48 (p<0.01) and 72 h (p value not stated) postoperatively Turan et al 2006
  • There was a significant inverse association between plasma levels of gabapentin at 2 h postoperatively, and morphine usage from 0–4 h postoperatively (R2=0.30, p=0.003, and R2=0.24, p=0.008, respectively), compared with placebo Dierking et al 2004
  • Peak expiratory flow was higher in the pre- and postoperative oral gabapentin group compared with the placebo group throughout postoperative days 1 and 2 (p=0.002-0.0032) Gilron et al 2005
  • Peak expiratory flow was higher in the pre- and postoperative oral gabapentin + rofecoxib group compared with the placebo group throughout postoperative days 1 and 2 (p<0.001) Gilron et al 2005

PROSPECT Recommendations

  • Pre-operative COX-2-selective inhibitors for hysterectomy are recommended because they have an analgesic effect postoperatively (grade A). However, there is no procedure-specific evidence that pre-operative administration of COX-2-selective inhibitors is more effective than postoperative administration
  • The use of COX-2-selective inhibitors should depend upon assessment of individual patient risks (cardiovascular morbidity, actual or recent gastroduodenal ulcer history, renal function and hepatic function [grade B] or aspirin-sensitive asthma [grade D])

Clinical Practice

  • Rofecoxib has been withdrawn from the market, and marketing of valdecoxib has been suspended in most countries

Transferable Evidence from Other Procedures

  • Randomised endoscopic trials in healthy volunteers have shown that COX-2-selective inhibitors are associated with a lower incidence of upper gastrointestinal ulceration compared with conventional NSAIDs for short-term use Harris et al 2001
  • Studies in healthy volunteers demonstrated that COX-2-selective inhibitors had no effect on platelet aggregation Greenberg et al 2000
  • Clinical studies investigating the response to oral challenge with COX-2-selective inhibitors in patients with aspirin-induced asthma have demonstrated that COX-2-selective inhibitors do not have an effect on respiratory function Bavbek et al 2004
  • A study to assess the safety of the COX-2-selective inhibitors parecoxib and valdecoxib following noncardiac general surgery (including gastrointestinal, orthopaedic, gynaecological, urological, and thoracic surgeries) showed no difference in the incidence of cardiovascular thromboembolic events, renal dysfunction/failure, gastrointestinal ulcer complications, and surgical wound-healing complications, compared with placebo (n=1062) (in press, Anesthesiology)
  • Two clinical trials showed that in patients who had undergone CABG surgery COX-2-selective inhibitors (valdecoxib and parecoxib) were associated with a higher rate of serious cardiovascular thromboembolic events (including myocardial infarction) compared with placebo Nussmeier et al 2005
  • Hypersensitivity reactions and serious skin reactions (e.g. toxic epidermal necrolysis, Stevens-Johnson syndrome, and erythema multiforme) can occur with all COX-2-selective inhibitors. Serious skin reactions have been reported in association with valdecoxib at a higher rate than with other COX-2-selective agents EMEA 2004a
  • Conventional NSAIDs and COX-2-selective inhibitors have been associated with an increased risk of transient hepatotoxicity. Cases of acute hepatic failure have also been reported. Elderly females, with autoimmune disease, and taking other potentially hepatotoxic drugs, may be most susceptible O'Connor et al 2003
  • Short-term use of COX-2-selective inhibitors or conventional NSAIDs can increase the risk of transient renal impairment, especially in patients with existing renal dysfunction, and both types of agent have been associated with cases of acute renal failure in high-risk patients Cheng et al 2004
  • COX-2-selective inhibitors and conventional NSAIDs may elevate blood pressure, particularly in hypertensive patients receiving antihypertensive medication Cheng et al 2004
  • Although there is some concern that COX-2-selective inhibitors may impair wound healing, evidence from animal and clinical studies is conflicting Blomme et al 2003

Abdominal Hysterectomy-Specific Evidence - Study information

  • A pre-operative single bolus of IV parecoxib was superior to placebo for postoperative pain scores on sitting up over 24 h (p=0.02), providing a mean drop of 14 mm in VAS scores on a 100-mm scale (n=36) Ng et al 2003
  • A pre-operative single bolus of IV parecoxib or oral rofecoxib reduced morphine consumption over 24 h compared with placebo Ng et al 2003 Click here for more information
  • Pre-operative oral rofecoxib was associated with a lower incidence of PONV compared with placebo in one study (p<0.05; n=40) Celik et al 2003
  • Pre-operative oral COX-2-selective inhibitors were as effective as oral conventional NSAIDs for reducing postoperative pain scores in two studies (n=25; n=40) Celik et al 2003
  • COX-2-selective inhibitors are similarly effective compared with conventional NSAIDs for reducing postoperative opioid consumption Celik et al 2003 Click here for more information
  • Compared with the conventional NSAID diclofenac, pre-operative rofecoxib was associated with significantly less intra-operative blood loss (p=0.01) and a lower decrease in haemoglobin (p=0.01) in a group of patients undergoing abdominal or vaginal hysterectomy (n=25) Hegi et al 2004
  • A pre-operative single bolus of rofecoxib or parecoxib did not significantly reduce postoperative pain scores at rest compared with placebo within 0–24 h in two studies (n=40; n=36) Celik et al 2003

PROSPECT Recommendations

  • Pre-operative conventional NSAIDs are not recommended because there is evidence that pre-operative administration of conventional NSAIDs is no more effective than postoperative administration (grade A). Moreover, pre-operative administration of these agents can increase the risk of intra- and postoperative bleeding (grade A)

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

  • One randomised trial in patients undergoing transurethral prostatectomy showed that diclofenac did not affect total blood loss compared with placebo Bricker et al 1987
  • Randomised endoscopic trials in healthy volunteers have shown that COX-2-selective inhibitors are associated with a lower incidence of upper gastrointestinal ulceration compared with conventional NSAIDs for short-term use Harris et al 2001
  • Randomised trials in healthy volunteers showed that conventional NSAIDs (ketorolac, naproxen or diclofenac) reduced the platelet aggregation response compared with placebo; ketorolac and naproxen also prolonged bleeding time compared with placebo Greer et al 1999
  • Meta-analyses of randomised, controlled trials showed that peri-operative conventional NSAIDs increased the risk of postoperative bleeding requiring treatment and/or the risk of re-operation for haemostasis after tonsillectomy compared with controls Marret et al 2003
  • A randomised trial in healthy volunteers showed that three conventional NSAIDs (diclofenac, ketorolac and ketoprofen) caused a reversible platelet dysfunction Niemi et al 1997
  • A randomised controlled trial showed that three conventional NSAIDs (diclofenac, ketorolac and ketoprofen) were associated with a similar incidence of surgical site bleeding after elective surgery Forrest et al 2002
  • Aspirin and conventional NSAIDs can induce asthma attacks in patients with aspirin-exacerbated respiratory disease Stevenson 2004
  • Conventional NSAIDs and COX-2-selective inhibitors have been associated with an increased risk of transient hepatotoxicity. Cases of acute hepatic failure have also been reported. Elderly females, with autoimmune disease, and taking other potentially hepatotoxic drugs, may be most susceptible O'Connor et al 2003
  • Short-term use of conventional NSAIDs or COX-2-selective inhibitors can increase the risk of transient renal impairment, especially in patients with existing renal dysfunction, and both types of agent have been associated with cases of acute renal failure in high-risk patients Cheng et al 2004
  • Conventional NSAIDs and COX-2-selective inhibitors may elevate blood pressure, particularly in hypertensive patients receiving antihypertensive medication Cheng et al 2004

Abdominal Hysterectomy-Specific Evidence - Study information

  • Pre-operative conventional NSAIDs significantly reduced postoperative pain scores compared with placebo, but a significant clinical benefit was only evident for up to 4 h Scott et al 1994 Click here for more information
  • The combination of paracetamol with a conventional NSAID was superior to a higher dose of paracetamol alone, administered as a single pre-operative rectal dose for VAS pain scores at rest at 4 h (p<0.05), but there was no significant difference at 2 h and 6–24 h (n=46) Beck et al 2000b
  • Conventional NSAIDs were equally as effective as COX-2-selective inhibitors for reducing postoperative pain scores in two studies Celik et al 2003
  • Pre-operative conventional NSAIDs showed no significant or clinically meaningful benefit over placebo in reducing supplementary analgesic consumption Beck et al 2000b Click here for more information
  • Pre-operative conventional NSAIDs provided no significant benefit over placebo for extending the time to first analgesic request in two out of the three studies that reported this parameter Scott et al 1994 Click here for more information
  • Pre-operative conventional NSAIDs and placebo were not significantly different for the incidence of PONV (all studies used postoperative PCA strong opioids) Beck et al 2000a Click here for more information
  • Conventional NSAIDs and COX-2-selective inhibitors similarly reduce the use of supplementary analgesics Celik et al 2003 Click here for more information
  • Compared with diclofenac, pre-operative rofecoxib caused significantly less intra-operative blood loss (p=0.01) and a lower decrease in haemoglobin (p=0.01) following abdominal hysterectomy (n=25) Hegi et al 2004
  • There was no significant benefit of pre-incisional conventional NSAIDs over post-incisional conventional NSAIDs in two of three studies for reducing postoperative pain scores Nakayama et al 2001b Click here for more information
  • Of three studies, all showed no significant difference between pre-incisional and post-incisional conventional NSAIDs for supplementary analgesic consumption (n=65; n=77; n=30) Gabbott et al 1997
  • Pre-incisional administration of flurbiprofen was associated with a shorter time to first analgesic request compared with post-incisional administration of a conventional NSAID, in one study (p<0.05; n=30) Nakayama et al 2001b
  • Pre-incisional administration of conventional NSAIDs conferred no significant benefit over post-incisional administration for the incidence of PONV in two studies (n=65, n=30) Gabbott et al 1997

PROSPECT Recommendations

  • Pre-incisional administration of strong opioids is not recommended because of the lack of effect in reducing postoperative pain and supplementary analgesic consumption compared with placebo, and the lack of benefit over post-incisional administration of strong opioids (grade A). Moreover, post-incisional strong opioids are significantly more effective for reducing postoperative pain compared with a similar dose of pre-incisional strong opioids (grade A)

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

  • [None cited]

Abdominal Hysterectomy-Specific Evidence - Study information

PROSPECT Recommendations

  • Pre-operative clonidine is not recommended based on its limited analgesic efficacy (grade A) and risk of side effects (grade D)
  • NMDA-receptor antagonists are not recommended based on inconsistent evidence of their analgesic efficacy (grade A), lack of clinical understanding of these agents, and the risk of side effects (grade D)
  • Benzodiazepines are not recommended based on their lack of analgesic efficacy (grade A)

Clinical Practice

  • Clonidine is not used routinely for postoperative analgesia, despite its analgesic efficacy, because of the risk of hypotension, sedation and bradycardia
  •  NMDA-receptor antagonists are not used routinely because of the current lack of understanding of their optimum dose, rate and route of administration as well as their cost-benefit relationship; in addition, they are associated with adverse side-effects, e.g. ketamine is known for its toxicity and for causing dysphoria

Transferable Evidence from Other Procedures

  • [None cited]

Abdominal Hysterectomy-Specific Evidence

  • Pre-operative clonidine provided no consistent significant benefit over placebo for reducing postoperative pain scores; and other postoperative pain outcomes were mixed Dimou et al 2003 Click here for more information
  • Pre-operative benzodiazepines provided no significant benefit in reducing postoperative pain scores, and there is evidence that they have a limited effect on reducing supplementary analgesic consumption Caumo et al 2002 Click here for more information
  • NMDA-receptor antagonists provided no significant benefit over placebo in reducing postoperative pain scores, supplementary analgesic consumption or PONV in the majority of studies, but the results were mixed and were independent of the specific type of agent and timing of administration Burstal et al 2001 Click here for more information

PROSPECT Recommendations

  • Pre-operative administration of single dose epidural analgesia, in addition to that required for anaesthetic purposes, is not recommended for the treatment of postoperative pain following hysterectomy, based on specific evidence that pre-operative epidural analgesia is not as effective as postoperative epidural analgesia (grade A)
  • A recommendation cannot be made for epidural anaesthesia based on its postoperative analgesic effect because there is no evidence for its relative postoperative analgesic benefits compared with other methods of anaesthesia. Moreover, the choice of anaesthetic regimen should be based on anaesthetic requirement and the relative risks and benefits of the anaesthetic related to the patient and the surgical procedure (grade D) (See Anaesthetic techniques section)
  • Despite the analgesic benefits of pre-operative epidural clonidine, it is not recommended for treating postoperative pain following abdominal hysterectomy because of the incidence of hypotension, sedation and bradycardia (grade D)

Clinical Practice

  • Epidural analgesia is associated with a relatively high degree of patient monitoring and rare major complications
  • Epidural clonidine is not used routinely because it is associated with an increased risk of hypotension, sedation and bradycardia

Transferable Evidence from Other Procedures

  • Epidural and spinal anaesthesia are not significantly different for: the need for postoperative pain relief, anaesthetic failure rate, need for additional intra-operative analgesia, need for conversion to general anaesthesia, and maternal satisfaction as determined in a systematic review of caesarean section Ng et al 2004

Abdominal Hysterectomy-Specific Evidence - Study information

  • Pre-operative epidural morphine bolus was superior to epidural saline placebo for reducing postoperative pain scores at rest and on movement at 1 and 6 h (p<0.05 for all comparisons; n=36) Goyagi et al 1999
  • Pre-operative epidural morphine bolus was superior to epidural saline placebo for reducing postoperative supplementary analgesic consumption at 6 and 12 h (p<0.05 for both times; n=36) Goyagi et al 1999
  • Pre-operative epidural morphine was superior to placebo for extending the time to first analgesic request (p<0.05; n=36) Goyagi et al 1999
  • Pre-operative plus postoperative treatment with epidural bupivacaine plus fentanyl was superior to postoperative treatment alone for reducing postoperative pain scores at rest and on coughing within 0–72 h (no p-values; n=41) Beilin et al 2003
  • Pre-operative epidural clonidine was superior to placebo for reducing postoperative pain scores in the PACU (p<0.003; n=40) Murga et al 1994
  • Pre-operative epidural clonidine was superior to placebo for reducing intra-operative anaesthetic requirement (p<0.0001; n=40) Murga et al 1994
  • There was no difference between epidural morphine and placebo (with rescue PCA morphine) for the incidence of postoperative nausea (n=36) Goyagi et al 1999
  • Pre-operative epidural ketamine conferred no significant benefit over placebo for reducing postoperative pain scores within 0–24 h (n=40) Murga et al 1994
  • Pre-operative epidural ketamine conferred no significant benefit over placebo for reducing supplementary analgesic consumption within 0–24 h (n=41) Abdel-Ghaffar et al 1998
  • Pre-incisional epidural analgesia provided no significant benefit over post-incisional administration for reducing postoperative pain scores in four out of four studies Garcia et al 2002 Click here for more information
  • Three of four studies showed no significant benefit of pre-incisional epidural analgesia compared with post-incisional administration for reducing supplementary analgesic consumption Espinet et al 1996 Click here for more information

PROSPECT Recommendations

  • Pre-operative single-shot spinal analgesia with local anaesthetic and strong opioid reduces postoperative pain scores and opioid consumption for up to 24 h (grade A). However, these benefits should be weighed against the risks associated with the invasive nature of this technique
  • Pre-operative single-shot spinal local anaesthetic plus strong opioid can be used, with or without sedation, as an alternative to general anaesthesia (Grade A). However, the choice of anaesthetic regimen should be based on anaesthetic requirement and the relative risks and benefits of the anaesthetic related to the patient and the surgical procedure (Grade D) (see Anaesthetic techniques section)
  • Spinal neostigmine is not recommended based on limited evidence for its analgesic efficacy, evidence of an associated increase in PONV (grade A) and a lack of clinical experience with this agent (grade D)

Clinical Practice

  • There is limited clinical experience of spinal neostigmine

Transferable Evidence from Other Procedures

  • Spinal and epidural anaesthesia are not significantly different for: the need for postoperative pain relief, anaesthetic failure rate, need for additional intra-operative analgesia, need for conversion to general anaesthesia, and maternal satisfaction as determined in a systematic review of caesarean section Ng et al 2004

Abdominal Hysterectomy-Specific Evidence - Study information

  • Pre-operative spinal analgesia (local anaesthetic, strong opioid or both) was superior to placebo for reducing postoperative pain scores within 0–24 h Vaida et al 2000 Click here for more information
  • Pre-operative spinal local anaesthetic or strong opioid provided a significant benefit over placebo for reducing supplementary analgesic consumption within 0–24 h (p<0.05; n=20) Lauretti et al 1998b
  • There was no significant difference between spinal strong opioid and placebo for the incidence of PONV in two studies (all groups received postoperative diclofenac) (n=20, n=30) Lauretti et al 1998b
  • Pre-operative spinal neostigmine (25, 50 or 75 µg) was superior to placebo for reducing postoperative pain scores at the following times: 30 and 60 min (p<0.05; n=92) Lauretti et al 1998a
  • Pre-operative spinal neostigmine (25, 50 or 75 µg) was superior to placebo for reducing supplementary analgesic consumption within 0–24 h (p<0.05; n=92, n=20) Lauretti et al 1998a
  • There is evidence from one of two studies showing a significant benefit of pre-operative spinal neostigmine over placebo for extending the time to first analgesic request (p<0.05; n=92) Lauretti et al 1998a
  • Spinal morphine was superior to IV analgesia for reducing postoperative pain scores Yokota et al 2000 Click here for more information
  • Pre-operative bolus dose of spinal morphine was superior to IV buprenorphine for extending the time to first analgesic request (p<0.01) in one study (n=29) Beltrutti et al 2002
  • Pre-operative spinal neostigmine was associated with a higher incidence of postoperative nausea than placebo Lauretti et al 1998a Click here for more information
  • Pre-operative spinal adenosine provided no significant benefit over placebo for reducing postoperative pain scores or supplementary analgesic consumption within 0–24 h (n=40) Rane et al 2000
  • Pre-induction spinal local anaesthetic was not significantly different to local anaesthetic given at extubation for postoperative pain scores within 0–12 h (n=38) Dakin et al 1996
  • Pre-induction spinal local anaesthetic was not significantly different to local anaesthetic given at extubation for postoperative pain scores within 0–12 h (n=38) Dakin et al 1996

PROSPECT Recommendations

  • The choice of anaesthetic regimen should be based on anaesthetic requirement and the relative risks and benefits of the anaesthetic related to the patient and the surgical procedure, rather than on the management of postoperative pain (grade D)
  • Combined spinal-epidural anaesthesia is a recommended alternative to epidural plus light general anaesthesia for hysterectomy in high-risk patients (grade D), and may have a greater analgesic efficacy compared with epidural alone as shown in caesarean section (grade B)

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

Abdominal Hysterectomy-Specific Evidence

  • [No data found within the parameters of this review]