Pre-Operative

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Local Anaesthetic Techniques 

This section includes studies of local anaesthetics administered to provide postoperative analgesia (i.e. where each group received the same anaesthetic background). For studies of local anaesthesia versus other types of anaesthesia, see Intra-operative, Operative Anaesthetic Techniques

PROSPECT Recommendations

  • Local anaesthetic injection techniques (inguinal nerve block/field block/infiltration), administered pre-operatively or intra-operatively, or both, are recommended (Grade A) because they reduce early postoperative pain and supplementary analgesic use compared with placebo. The effect of pre-operative administration is comparable to post-incisional administration
  • There are insufficient data to recommend (Grade D) one injection technique (inguinal nerve block/field block/infiltration), or combination, in preference to another
  • Local anaesthetic instillation administered at closure cannot be recommended at this time, despite some evidence for its analgesic efficacy, because of limited data (grade D)
  • Long-acting local anaesthetics are recommended in preference to short-acting local anaesthetics (Grade D)
  • Addition of dextran or corticosteroid to local anaesthetic solution is not recommended (Grade D) because of limited procedure-specific evidence

Clinical Practice

  • Long-acting local anaesthetics are preferred to short-acting local anaesthetics for analgesia by local injection
  • In herniorraphy studies of local anaesthetic injection techniques, methodology is inconsistently described, and terminology is inconsistently used. In addition, studies directly comparing one local anaesthetic injection technique with another are lacking. For these reasons, no conclusion about the relative benefits of one technique, or combination of techniques (inguinal nerve block/field block/infiltration), can be made at this time

Transferable Evidence from Other Procedures

  • A systematic review of local anaesthesia infiltration showed inconclusive evidence of analgesic efficacy in hysterectomy, open cholecystectomy and a variety of other surgical procedures, but consistent and clinically relevant pain relief in herniorraphy Møiniche et al 1998
  • There is evidence from a variety of surgical procedures that the efficacy of local anaesthetics for postoperative analgesia is similar following pre-operative or post-incisional administration Møiniche et al 1998

Herniorraphy-Specific Evidence

PROSPECT Recommendations

  • Addition of epinephrine to local anaesthetic solution is not recommended because of a lack of additional or prolonged analgesic effect from limited procedure-specific data (Grade A)

Clinical Practice

  • Epinephrine may result in undesirable cardiovascular side-effects

Transferable Evidence from Other Procedures - Study information

Herniorraphy-Specific Evidence - Study information

  • Intra-operative wound instillation with epinephrine and local anaesthetic was of no significant benefit over local anaesthetic alone for reducing postoperative pain scores during 1–20 h, or for reducing analgesic requirements, for increasing the time to first analgesic request (n=17) Bays et al 1991

PROSPECT Recommendations

  • Paravertebral nerve block is not recommended (Grade D) because it has only a marginal analgesic benefit over other local anaesthetic techniques (nerve block/field block/infiltration) and is a more complex technique

Clinical Practice

  • Clinical experience with the paravertebral nerve block is not widespread. This technique is considered to be more complex, and thus it may be associated with a higher incidence of complications than other local anaesthetic techniques (nerve block/field block/infiltration)

Transferable Evidence from Other Procedures

  • [None cited]

Herniorraphy-Specific Evidence - Study information

  • Paravertebral nerve block was superior to peripheral nerve block for reducing the proportion of patients requiring supplementary analgesia in the PACU (p=0.002; n=46) Klein et al 2002
  • Paravertebral nerve block was superior to peripheral nerve block for reducing the incidence of PONV in the PACU (p<0.001; n=46) Klein et al 2002
  • Paravertebral nerve block and peripheral nerve block were not significantly different for VAS pain scores at rest, on movement and on coughing in the PACU, or at 2, 6, 12, 18, 24 and 48 h (n=46) Klein et al 2002
  • There was no significant difference between paravertebral nerve block and peripheral nerve block for the proportion of patients requiring supplementary analgesics in the 72-h follow-up period, or the time to first analgesic request (n=46) Klein et al 2002

PROSPECT Recommendations

  • Gabapentin/pregabalin cannot be recommended at this time due to the lack of procedure-specific evidence (Grade D), despite analgesic efficacy in other procedures

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

  • Studies of gabapentin and pregabalin in mastectomy, abdominal surgery, laparoscopic cholecystectomy and spinal surgery showed reductions in postoperative pain and supplementary analgesic requirements for at least 24 h Dahl et al 2004

Herniorraphy-Specific Evidence

  • [None cited]

PROSPECT Recommendations

  • Pre-operative ketamine cannot be recommended at this time due to a lack of procedure-specific evidence, and due to associated side-effects that may hinder early ambulation (Grade D), despite some evidence of analgesic efficacy in other procedures

Clinical Practice

  • Ketamine is associated with a risk of adverse effects on the central nervous system

Transferable Evidence from Other Procedures

  • Studies of ketamine in abdominal, orthopaedic, gastric, hepatic and renal surgery showed a reduction in postoperative pain and opioid use when used as an adjuvant to morphine, either epidurally or intravenously Subramaniam et al 2004

Herniorraphy-Specific Evidence

  • [None cited]

 PROSPECT Recommendations

  • Pre-operative systemic clonidine is not recommended because of limited procedure-specific evidence and potential side-effects, which may delay early ambulation (Grade D)

Clinical Practice

  • Clonidine is associated with side-effects, including hypotension, sedation, dizziness and bradycardia

Transferable Evidence from Other Procedures

  • [None cited]

Herniorraphy-Specific Evidence

PROSPECT Recommendations

  • Pre-operative corticosteroid is not recommended due to limited procedure-specific evidence and because herniorraphy per se is not associated with a high incidence of PONV (Grade D)

Clinical Practice

  • Herniorraphy is not associated with a high incidence of PONV

Transferable Evidence from Other Procedures

  • Systemic corticosteroid administration is recommended to prevent PONV in procedures associated with high emetic effects Apfel et al 2004

Herniorraphy-Specific Evidence

  • Pre-operative intravenous dexamethasone showed no benefit over placebo for reducing VAS pain scores overall, and at 4, 8, 12, 16, 20 or 24 h (n=60) Tan et al 2001
  • Pre-operative intravenous dexamethasone was not significantly different from placebo for supplementary analgesic requirements or time to first analgesic request (n=60) Tan et al 2001
  • Pre-operative intravenous dexamethasone was of no benefit over placebo for reducing the incidence of PONV (n=60) Tan et al 2001

PROSPECT Recommendations

  • Pre-operative COX-2-selective inhibitors are recommended based on their analgesic efficacy (grade A) and, as with all analgesics, should be administered in time to secure sufficient analgesia following the procedure
  • Since pre-/intra-operative local anaesthetic techniques provide sufficient analgesia in the immediate postoperative period (grade A), COX-2-selective inhibitors can be initiated orally in the early (1-3 hours) postoperative period
  • COX-2-selective inhibitors may be preferred to conventional NSAIDs in the peri-operative setting, in patients who have an increased risk of bleeding, or who are at risk of gastroduodenal ulcer/erosion (grade B)
  • 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

  • COX-2-selective inhibitors provide similar postoperative analgesia to conventional NSAIDs Rømsing et al 2004
  • 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
  • A randomised clinical trial showed that the COX-2-selective inhibitor rofecoxib was associated with significantly less intra-operative blood loss than the conventional NSAID diclofenac in patients undergoing abdominal or vaginal hysterectomy or breast surgery Hegi et al 2004
  • 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

Herniorraphy-Specific Evidence

  • Oral rofecoxib administered pre- plus postoperatively significantly reduced postoperative pain scores, compared with placebo, at rest at 1 h (p<0.05) but there was no benefit at 30 min or at the time of first analgesic request (n=60) Ma et al 2004
  • Rofecoxib administered pre- plus postoperatively significantly reduced requirements for supplementary hydromorphone in the PACU (p<0.05) (n=60) Ma et al 2004
  • Rofecoxib administered pre- plus postoperatively did not significantly reduce the incidence of PONV compared with placebo (low incidence in both groups) (n=60) Ma et al 2004

PROSPECT Recommendations

  • Pre-operative conventional NSAIDs are recommended, based on their analgesic efficacy (grade A), and as with all analgesics should be administered in time to secure sufficient analgesia following the procedure
  • Since pre-/intra-operative local anaesthetic infiltration techniques provide sufficient analgesia in the immediate postoperative period (grade A), conventional NSAIDs can be initiated orally in the early (1-3 hours) postoperative period
  • Conventional NSAIDs are not recommended in patients who have an increased risk of bleeding, or who are at risk of gastroduodenal ulcer/erosion (grade B)
  • The use of conventional NSAIDs should depend upon assessment of individual patient risks (bleeding complications, cardiovascular morbidity, actual or recent gastroduodenal ulcer history, aspirin-sensitive asthma, renal function and hepatic function) (grade B)

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

  • Pre-operative ibuprofen was similar to intra-operative ketorolac for VAS pain scores over the first 24 h, at discharge and after discharge, and for the proportion of patients requiring postoperative supplementary analgesia (n=70) Mixter et al 1998
  • Conventional NSAIDs have proven analgesic efficacy in a variety of surgical procedures Barden et al 2004
  • 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
  • A randomised clinical trial showed that the conventional NSAID diclofenac was associated with significantly greater intra-operative blood loss than the COX-2-selective inhibitor rofecoxib in patients undergoing abdominal or vaginal hysterectomy or breast surgery Hegi et al 2004
  • 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

Herniorraphy-Specific Evidence

  • Pre-operative conventional NSAIDs reduced postoperative pain scores compared with placebo or no treatment Ben-David et al 1996 Click here for more information
  • Pre-operative conventional NSAIDs reduced supplementary analgesic requirements compared with placebo or no treatment Dueholm et al 1989 Click here for more information
  • Tenoxicam 10 mg was not significantly different from 20 mg for pain scores at rest or on movement at 2, 9 and 24 h and for supplementary analgesic requirements (n=30) Lin et al 1998
  • Pre-operative intravenous ketorolac and rectal diclofenac were similar for pain scores at 2, 6 and 24 h and on day 3, for use of supplementary diclofenac, and for the incidence of PONV (n=108) Lau et al 2002
  • Intravenous and intramuscular ketorolac were superior to oral ketorolac for reducing pain scores and supplementary analgesic requirements, but there was no significant difference between intravenous and intramuscular ketorolac or between rectal and intramuscular diclofenac Ben-David et al 1996 Click here for more information

PROSPECT Recommendations

  • Wound infiltration with clonidine is not recommended because of limited procedure-specific data and because of potential side-effects, which may delay early ambulation (Grade D)

Clinical Practice

  • Clonidine is associated with side-effects, including hypotension, sedation, dizziness and bradycardia

Transferable Evidence from Other Procedures

  • [None cited]

Herniorraphy-Specific Evidence - Study information

  • Wound infiltration with clonidine showed a significant benefit for reducing pain scores compared with placebo at 2 h, but there was no significant difference at other times Connelly et al 1999 Click here for more information
  • Wound infiltration with clonidine was of no significant benefit for reducing supplementary analgesic requirements compared with placebo (n=30) Connelly et al 1999
  • Wound infiltration with clonidine was of no significant benefit over systemic administration for reducing pain scores or supplementary analgesic requirements Connelly et al 1999 Click here for more information

PROSPECT Recommendations

  • Pre-operative wound infiltration with conventional NSAIDs is not recommended (grade A) because of inconclusive evidence of an analgesic benefit, compared with systemic administration

Clinical Practice

  • The potential for conventional NSAIDs, administered by wound infiltration, to adversely affect platelet function and wound healing must be considered

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
  • A systematic review of the postoperative analgesic effect of local infiltration with conventional NSAIDs showed little difference between wound infiltration and systemic administration Rømsing et al 2000
  • 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
  • A randomised clinical trial showed that the conventional NSAID diclofenac was associated with significantly greater intra-operative blood loss than the COX-2-selective inhibitor rofecoxib in patients undergoing abdominal or vaginal hysterectomy or breast surgery Hegi et al 2004

Herniorraphy-Specific Evidence - Study information

PROSPECT Recommendations

  • Pre-operative topical conventional NSAIDs cannot be recommended at this time (Grade D) because of limited procedure-specific data

Clinical Practice

  • The potential for conventional NSAIDs, administered topically, to adversely affect platelet function and wound healing must be considered

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
  • A systematic review of the postoperative analgesic effect of local infiltration with conventional NSAIDs showed little difference between wound infiltration and systemic administration Rømsing et al 2000
  • 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
  • A randomised clinical trial showed that the conventional NSAID diclofenac was associated with significantly greater intra-operative blood loss than the COX-2-selective inhibitor rofecoxib in patients undergoing abdominal or vaginal hysterectomy or breast surgery Hegi et al 2004

Herniorraphy-Specific Evidence - Study information

  • Topical piroxicam was superior to placebo for reducing VAS pain scores during 0–4 h (p<0.05) but there was no significant difference during 4–24 h (n=27) O'Hanlon et al 1996
  • Topical piroxicam was superior to placebo for reducing postoperative supplementary analgesic requirements during 0–24 h (p<0.005) but not during 4–24 h, and piroxicam did not increase the time to first analgesia (n=27) O'Hanlon et al 1996
  • Topical application of NSAIDs was equally effective compared with inguinal nerve block for reducing 0–24 h pain scores at rest, reducing analgesic requirements and for increasing the time to first analgesic request (n=30) O'Hanlon et al 1996