Postoperative

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PROSPECT Recommendations

  • Conventional NSAIDs are recommended (Grade A) because they reduce pain and opioid use (procedure-specific evidence, LoE 1)
  • The use of conventional NSAIDs should depend upon assessment of individual patient risks (Grade B), including bleeding complications, actual or recent gastroduodenal ulcer history (transferable evidence, LoE 1), cardiovascular morbidity (LoE 4), aspirin-sensitive asthma, renal function and hepatic function (transferable evidence, LoE 3)
  • It is not possible to make a recommendation for one route of administration in preference to any other on the basis of the available evidence
  • It is not possible to make a recommendation for one NSAID in preference to any other on the basis of the available evidence

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

  • Conventional NSAIDs have proven analgesic efficacy in a variety of surgical procedures Barden et al 2004
  • A meta-analysis of randomised controlled trials that was performed to evaluate the risk of morphine-related adverse effects in patients treated with NSAIDs demonstrated that NSAIDs decreased the incidence of nausea, vomiting and sedation, but not pruritis, urinary retention or respiratory depression Marret et al 2005
  • 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 trials in healthy elderly volunteers have shown that conventional NSAIDs are associated with a higher incidence of upper gastrointestinal ulceration compared with COX-2-selective inhibitors 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 control Marret et al 2003
  • A randomised trial in healthy volunteers showed that three conventional NSAIDs (diclofenac, ketorolac and ketoprofen) caused reversible platelet dysfunction Niemi et al 1997
  • A large 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

Laparoscopic Cholecystectomy-specific evidence

  • Eight studies out of ten showed a significant benefit of conventional NSAIDs over placebo or no treatment for reducing VAS pain scores Munro et al 1998 Click here for more information
  • Five studies out of ten showed a significant benefit of conventional NSAIDs compared with placebo or no treatment for reducing supplementary analgesic use Forse et al 1996 Click here for more information
  • One study measured parameters of pulmonary function and found that the values of FEV1 and FEF25–75 were significantly higher at 4 h after surgery in the ketorolac group compared with the placebo group (p<0.05) Liu et al 1993
  • One study out of one showed that tenoxicam (20 mg) + ondansetron (4 mg), administered in 20 ml saline before induction of anaesthesia, significantly reduced the time to first flatus compared with ondansetron alone (p<0.05) Elhakim et al 1995
  • One study showed that IP NSAID + IP LA significantly reduced abdominal VAS pain scores at 0, 1, 2 and 6 h compared with placebo, but not at 12 or 24 h, whereas IV NSAID + IP LA significantly reduced VAS pain scores at all time points (p<0.05, in all cases); IP NSAID + IP LA and IV NSAID + IP LA also significantly reduced shoulder VAS pain scores at 0 and 6 h and at 0, 1 and 6 h, respectively (p<0.05, in all cases) Jabbour-Khoury et al 2005
  • One study showed that the number of patients needing rescue analgesics (type, dose and time of administration not stated) was significantly lower in the IV NSAID + IP LA group, but not the IP NSAID + IP LA group, compared with the placebo group (p<0.05) Jabbour-Khoury et al 2005
  • The incidence of vomiting was significantly lower in the IV NSAID + IP LA group, but not the IP NSAID + IP LA group, compared with the placebo group (p<0.05) Jabbour-Khoury et al 2005
  • IV tenoxicam significantly reduced the time to bowel recovery compared with IP tenoxicam Elhakim et al 2000a
  • Two studies out of seven that recorded the incidence of nausea and/or vomiting showed that conventional NSAIDs significantly reduced the incidence of nausea and/or vomiting compared with placebo or no treatment Elhakim et al 1995 Click here for more information
  • One study out of one found no significant difference for the duration of hospital stay between IM ketorolac, administered intra-operatively pre- and post-procedure, and placebo Lane et al 1996
  • One study out of one found no significant difference for the time to hospital discharge between IM diclofenac, administered after induction of anaesthesia (n=26), and control (n=23) Wilson et al 1994
  • Postoperative ketoprofen significantly increased VAS pain scores compared with pre-operative ketoprofen during the first 12 h following surgery (p<0.05), with the effect being most evident during the first 3 h (p=0.001), although there was no significant difference between the two groups at 24 h Boccara et al 2005
  • Postoperative ketoprofen significantly decreased the time to first analgesic demand compared with pre-operative ketoprofen (p<0.05) Boccara et al 2005
  • Postoperative ketoprofen did not significantly reduce opioid use compared with pre-operative ketoprofen Boccara et al 2005
  • One study out of one showed that IM ketorolac (60 mg), administered intra-operatively post-procedure (n=20) significantly decreased the time to first analgesic request (p<0.05) compared with IM ketorolac, administered intra-operatively pre-procedure (n=31)  Lane et al 1996
  • One study showed no significant difference between IV and IP administration of tenoxicam for VAS pain scores (at rest, on movement or on coughing), opioid use (postoperative opioid was 20 mg IM nalbuphine, every 4 h, or on request), incidence of nausea or vomiting and length of hospital stay  Elhakim et al 2000a
  • A study which compared IV tenoxicam + intraperitoneal (IP) lidocaine + IP saline with IP tenoxicam + IP lidocaine + IV saline, administered at the end of surgery, showed no significant difference between IV and IP administration of tenoxicam for VAS pain scores, opioid use, incidence of nausea or vomiting and length of hospital stay  Elhakim et al 2000a
  • One study that compared IM ketorolac + glycerin suppository (n=17), administered after the induction of anaesthesia, with IM saline + indomethacin suppository, showed no significant difference in pain scores, opioid use and incidence of nausea/vomiting Forse et al 1996
  • Pre-operative ketoprofen significantly reduced opioid use compared with pre-operative propacetamol, but there was no significant difference between these agents given postoperatively Boccara et al 2005 Click here for more information
  • One study showed that there was no significant difference between postoperative ketoprofen and postoperative propacetamol for the time to first analgesic demand Boccara et al 2005
  • There were no significant differences between postoperative ketoprofen and postoperative propacetamol, for the incidence of nausea or vomiting Boccara et al 2005
  • Study details Boccara et al 2005 Click here for more information
  • Table 1. Systemic conventional NSAIDs versus placebo or no treatment: Study details Elhakim et al 1995 Click here for more information

PROSPECT Recommendations

  • Postoperative COX-2-selective inhibitors are recommended (Grade A) because they reduce pain, opioid use and opioid side-effects (procedure-specific evidence, LoE 1)
  • COX-2-selective inhibitors may be more appropriate than 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 (transferable evidence, LoE 1)
  • It is recommended that the use of COX-2-selective inhibitors should depend upon assessment of individual patient risks (Grade B) (cardiovascular morbidity (transferable evidence, LoE 1), renal function and hepatic function (transferable evidence, LoE 3) or actual or recent gastroduodenal ulcer history (LoE 4)

Clinical Practice

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

Transferable Evidence from Other Procedures

  • Rofecoxib 50 mg and parecoxib 40 mg have an equipotent analgesic efficacy relative to traditional NSAIDs in postoperative pain after minor and major surgical procedures Rømsing et al 2004
  • Randomised trials in healthy elderly 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 or bleeding time Greenberg et al 2000 Click here for more information
  • 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) Nussmeier et al 2006
  • 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
  • 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
  • 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
  • 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

Laparoscopic Cholecystectomy-specific evidence

PROSPECT Recommendations

  • Postoperative ketamine by bolus or infusion is not recommended (Grade D) because procedure-specific evidence is limited, despite some analgesic efficacy in other procedures (LoE 1)
  • Postoperative magnesium by infusion is not recommended (Grade B), because there is evidence for a lack of analgesic efficacy (procedure-specific evidence, LoE 1)

Clinical Practice

  • 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 CNS adverse effects, toxicity and for causing dysphoria

Transferable Evidence from Other Procedures

  • Studies of intravenous or neuraxial ketamine in a variety of surgeries, including abdominal, gynaecological, orthopaedic, gastric, hepatic, and genitourinary surgery, showed a reduction in postoperative pain and opioid use when used as an adjunct to morphine Bell et al 2006
  • A study in gynaecological surgery that compared magnesium with placebo (placebo group received saline, magnesium groups received 40 mg/kg at induction, followed by either saline, or magnesium infusion 10 mg/kg or 20 mg/kg), showed that morphine consumption was higher in the placebo group compared with the magnesium groups (total n=80) Seyhan et al 2006
  • A quantitative systematic review found that dextromethorphan does not reduce postoperative pain scores with a clinically significant magnitude, and although significant decreases in supplemental opioid consumption were observed, these were of questionable clinical importance in most cases Duedahl et al 2006
  • In abdominal hysterectomy, NMDA-receptor antagonists provided no significant benefit over placebo for 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

Laparoscopic Cholecystectomy-specific evidence

  • IV ketamine infusion significantly reduced pain compared with placebo: VAS pain scores at rest at 2–4 h (p<0.05 in each case), but not at 0, 1, 8 or 20 h; VRS pain scores at 2 and 3 h (p<0.05 in both cases), but not at other time points Ayoglu et al 2005
  • Postoperative, but not pre-operative, IV ketamine (bolus dose) reduced postoperative pain compared with placebo Mathisen et al 1999 Click here for more information
  • IV ketamine infusion significantly reduced VAS pain scores at rest compared with magnesium at 4 and 20 h (p<0.05 in both cases), but not at 0–4 h or at 8 h; ketamine also significantly reduced VRS pain scores compared with magnesium at 4 h (p<0.05), but not at other time points Ayoglu et al 2005
  • IV ketamine infusion significantly reduced cumulative opioid use compared with placebo at 2 and 3 h (p<0.05 in both cases), but not at 4 or 20 h (postoperative opioid was PCA bolus of 1 mg morphine, 10-minute lockout, maximum 4 h dose 20 mg) Ayoglu et al 2005
  • IV ketamine reduced the amount of rescue tramadol used and the number of patients requesting rescue tramadol compared with tramadol (p values not given) (a rescue dose was administered when VAS >5 on the 0–10 scale) Launo et al 2004
  • IV ketamine and tramadol were equally effective for reducing VAS pain scores 0–24 h after surgery; there were no significant differences between the two treatment groups for VRS pain scores Launo et al 2004
  • IV magnesium infusion did not significantly reduce VAS or VRS pain scores compared with placebo at any time during 0–20 h Ayoglu et al 2005
  • IV magnesium infusion did not significantly reduce cumulative opioid use compared with placebo at any time during 0–20 h (postoperative opioid was PCA bolus of 1 mg morphine, 10-minute lockout, maximum 4 h dose 20 mg) Ayoglu et al 2005
  • Pre-operative and postoperative (R)-ketamine (bolus dose) were similar to placebo for pethidine use in the first 4 h, and for use of paracetamol + codeine at 24 h and 7 days postoperatively (postoperative analgesia: bolus doses of 0.1 mg/kg pethidine, 5-minute lockout, for 4 h, and after discharge, 500 mg paracetamol + 30 mg codeine) Mathisen et al 1999
  • IV ketamine and IV magnesium infusion were associated with similar cumulative opioid use during 0–20 h (postoperative opioid was PCA bolus of 1 mg morphine, 10-minute lockout, maximum 4 h dose 20 mg)
  • IV ketamine and IV magnesium infusion and placebo were associated with a similar incidence of nausea and vomiting, and similar pulmonary function Ayoglu et al 2005
  • IV ketamine increased the incidence of nausea compared with tramadol (p value not given)  Launo et al 2004
  • Study details Mathisen et al 1999 Click here for more information

PROSPECT Recommendations

  • Strong opioids are not recommended for routine analgesia (Grade B) because of side-effects during recovery (transferable evidence, LoE 1)
  • Strong opioids are recommended for rescue analgesia (high-intensity pain) in addition to the use of other agents (Grade D, LoE 4)

Clinical Practice

  • Regular administration, titrated for pain intensity, is generally accepted as an effective method of administering strong opioids
  • Strong opioids are not associated with a ceiling effect, and thus can provide effective analgesia for most types of surgical procedures
  • Strong opioids may be used in a variety of preparations and routes of administration, enabling choice for onset, duration of action, and mode of delivery
  • Most clinical trials showing benefits of intramuscular strong opioids use nurse-administered regimens. In regular clinical practice, full adherence to nurse-administered regimens is not usually achievable, and the full analgesic benefits of intramuscular strong opioids are also not achieved
  • Intramuscular administration of strong opioids is considered to be more painful than intravenous administration; however, the dose and rapidity of intravenous administration should be assessed to minimise the risk of respiratory depression

Transferable Evidence from Other Procedures

  • Strong opioids are effective for reducing high- and moderate-intensity postoperative pain McQuay et al 1999
  • A systematic review comparing intravenous PCA opioids with intravenous, intramuscular or subcutaneous opioids by injection showed that PCA opioids were associated with greater pain relief, reduced supplementary analgesic requirements (analysis of eleven studies, total n=691), and more patients preferred PCA opioids (analysis of four trials, total n=352) compared with traditional opioid analgesia Walder et al 2001
  • Strong opioids are associated with adverse effects, including nausea, vomiting, sedation, confusion, paralytic ileus and urinary retention Wheeler et al 2002

Laparoscopic Cholecystectomy-specific evidence

  • Two studies showed that parenteral strong opioids reduced supplemental analgesic requirements compared with placebo Munoz et al 2002 Click here for more information
  • There were no significant differences between IV morphine and placebo for VAS pain scores at rest or on coughing at any time point (i.e. 0–180 minutes) Munoz et al 2002
  • There were no significant differences between groups receiving pre-operative, intra-operative or postoperative IV morphine for VAS pain scores at rest or on coughing at any time point Munoz et al 2002
  • Systemic opioid and placebo groups took a similar length of time to first analgesic request Munoz et al 2002
  • There was no significant difference between IV morphine and placebo for the incidence of postoperative emesis Munoz et al 2002
  • There was no significant difference between the IM pethidine and placebo groups for the duration of hospital stay Lane et al 1996
  • There were no significant differences between groups receiving pre-operative, intra-operative or postoperative IV morphine for opioid use or the incidence of emesis. All IV morphine groups took a similar length of time for first analgesia request Munoz et al 2002
  • Study details Munoz et al 2002 Click here for more information

PROSPECT Recommendations

  • Postoperative weak opioids are not recommended (Grade B) for routine analgesia because of side-effects during recovery (transferable evidence, LoE 1)
  • Weak opioids are recommended for rescue analgesia (low- to moderate-intensity pain) in addition to the use of other agents (Grade D, LoE 4)

Clinical Practice

  • Tramadol is a centrally acting analgesic with µ-opioid agonist (M1-metabolite) and aminergic mechanisms of action. For prescription purposes, it is considered a weak opioid or a non-narcotic in most countries
  • Tramadol is useful in the treatment of postoperative pain of moderate intensity (intravenous and oral administration), providing effective analgesia in the in-patient and ambulatory setting
  • The opioid-like effects of tramadol on gastrointestinal (transit, secretion) and sphincter function, are of a lesser magnitude than those of strong opioids
  • At recommended doses, tramadol has no clinically relevant effects on cardiovascular or respiratory parameters, thus the risk of respiratory depression is negligible
  • Tramadol is beneficial when NSAIDs are contraindicated
  • The oral solution (drops) of tramadol is useful as rescue medication when paracetamol/NSAID analgesic regimens are used
  • Opioid adverse effects, especially nausea and dizziness, limit the usefulness of tramadol, but many of the effects are less than for strong opioids
  • When ondansetron is used for the treatment/prophylaxis of tramadol-induced nausea and vomiting, a decrease in analgesic efficacy has been reported

Transferable Evidence from Other Procedures

  • Tramadol was more effective than placebo for pain relief in a meta-analysis of post-surgical patients Moore et al 1997
  • The combination of tramadol and paracetamol enhances analgesic efficacy compared with either agent alone McQuay H et al 2003
  • A systematic review found that the combination of dextropropoxyphene 65 mg with paracetamol 650 mg showed similar efficacy to tramadol 100 mg but with a lower incidence of adverse effects Collins et al 2000
  • A systematic review found that the combination of codeine with paracetamol provided additional pain relief compared with paracetamol alone Moore et al 2000
  • Adverse effects associated with tramadol include headache, nausea, vomiting, dizziness, somnolence. A meta-analysis of individual patient data from randomised controlled trials found a dose-response of adverse effects with tramadol; postsurgical patients had fewer side-effects than dental patients Moore et al 1997
  • A systematic review found that the combination of codeine with paracetamol was associated with an increase in drowsiness and dizziness compared with paracetamol alone Moore et al 2000
  • A systematic review found an increased incidence of central nervous system adverse effects with paracetamol plus dextropropoxyphene compared with placebo Collins et al 2000

Laparoscopic Cholecystectomy-specific evidence

  • Compared with placebo, tramadol significantly reduced VAS pain scores at 30, 45 and 60 minutes postoperatively (in all cases, p=0.01), but not at any other time point in the first 24 h (i.e. at 2, 4, 6, 8, 10, 12, 18 or 24 h Naguib et al 2000
  • Tramadol treatment was significantly superior to placebo treatment for reducing pain scores recorded by an observer at 30 and 45 minutes following surgery (p=0.01, in both cases)  Naguib et al 2000
  • Tramadol treatment significantly increased the time to first analgesic request and the proportion of patients not requesting PCA analgesia (postoperative PCA analgesia was 16 mg tramadol, 5-minute lockout; 4-h limit: 400 mg) compared with placebo (p<0.03) Naguib et al 2000
  • Tramadol significantly reduced supplementary tramadol use only at 30, 45 and 60 minutes postoperatively compared with placebo (p<0.03), but not at any other time point in the first 24 h Naguib et al 2000
  • One study that compared pre-operative IV tramadol + postoperative IV tramadol PCA with pre-operative IV morphine + postoperative IV morphine PCA, showed that morphine significantly reduced VAS pain scores at 30, 45 and 90 minutes following surgery compared with tramadol (in all cases, p<0.05), but not at any other time (recorded every 2 h until 24 h) or for pain scores recorded by an observer; but not at any other time  Naguib et al 1998
  • PCA drug consumption was significantly greater in the pre-operative IV tramadol + postoperative tramadol PCA group at 90 minutes and 4 h postoperatively, compared with the pre-operative IV morphine + postoperative morphine PCA group Naguib et al 1998 Click here for more information
  • There were no significant differences between pre-operative IV tramadol + postoperative IV tramadol PCA group and pre-operative IV morphine + postoperative IV morphine group for the time taken to the first analgesic demand or for the proportion of patients not requesting PCA analgesia Naguib et al 1998
  • The incidence of nausea and vomiting, as well as respiratory rate were similar in both tramadol and placebo groups Naguib et al 2000
  • The incidence of nausea and vomiting and cardiovascular adverse effects was similar in both pre-operative IV tramadol + postoperative IV tramadol PCA group and pre-operative IV morphine + postoperative IV morphine PCA group Naguib et al 1998
  • Study details Naguib et al 2000 Click here for more information

PROSPECT Recommendations

  • Paracetamol is recommended (Grade A) because analgesic efficacy is comparable with that of NSAIDs, based on procedure-specific evidence (LoE 1)

Clinical Practice

  • Paracetamol is not effective for severe pain

Transferable Evidence from Other Procedures

  • Paracetamol is an effective analgesic for the treatment of postoperative pain of moderate intensity Rømsing et al 2002
  • Paracetamol combined with weak opioids (codeine, tramadol) is superior to weak opioids alone in a review of dental, gynaecological and orthopaedic surgery McQuay H et al 2003
  • A meta-analysis of randomised controlled trials showed that paracetamol combined with PCA morphine induced a significant morphine-sparing effect but did not change the incidence of morphine-related adverse effects in the postoperative period Remy 2005
  • There is evidence that concurrent use of paracetamol and conventional NSAIDs improves pain relief compared with paracetamol alone, but there is no evidence for a superior analgesic effect of the combination compared with conventional NSAIDs alone Altman 2004

Laparoscopic Cholecystectomy-specific evidence

  • Postoperative administration of propacetamol significantly reduced VAS pain scores between 2 and 5 h postoperatively compared with pre-operative administration (p<0.05); the number of patients with severe pain (VAS 50 mm or greater) was significantly lower in the postoperative administration group compared with the pre-operative administration group (p<0.05) Boccara et al 2005
  • Two studies showed no significant difference for VAS pain scores between postoperative NSAIDs and postoperative propacetamol/paracetamol but pre-operative propacetamol was associated with significantly higher VAS pain scores compared with pre-operative ketoprofen Boccara et al 2005 Click here for more information
  • Ibuprofen sustained-release tablets and paracetamol were associated with similar VRS pain scores all time points (i.e. days 1–7) Owen et al 1997
  • Pre-operative propacetamol was associated with significantly greater opioid use compared with pre-operative ketoprofen, but there was no significant difference between these agents given postoperatively Boccara et al 2005 Click here for more information
  • The number of patients requiring supplemental nalbuphine, the total dose consumed and the time to first analgesic demand were similar in both pre-operative and postoperative propacetamol groups Boccara et al 2005
  • The incidence of nausea or vomiting was similar in both pre-operative and postoperative propacetamol groups Boccara et al 2005
  • There were no significant differences between the paracetamol + codeine and codeine alone groups for VAS pain scores (recorded at 0.5–4 h, then 3 times/day, until 48 h) Chung et al 2004
  • Supplemental opioid consumption, the time of onset of analgesia and the overall level of pain relief were similar in both paracetamol + codeine and codeine alone groups Chung et al 2004
  • There were no significant differences between the paracetamol + codeine and codeine alone groups for postoperative nausea; the time to discharge was also similar in both groups Chung et al 2004
  • Study details Boccara et al 2005 Click here for more information

PROSPECT Recommendations

  • Postoperative PCA IP LA is not recommended (Grade D) because of limited procedure-specific evidence (LoE 1)

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

  • [None cited]

Laparoscopic Cholecystectomy-specific evidence

  • One study that compared ropivacaine injected into the bed of the gall bladder and in all portals after surgery and then as intermittent self-administered postoperative PCA versus placebo, showed that ropivacaine significantly decreased VAS pain scores (deep intra-abdominal and coughing pain) compared with placebo, up to 4 hours postoperatively, but not at 8, 12, 16 or 20 h or between 1–7 days following surgery Gupta et al 2002
  • One study that compared ropivacaine injected into the bed of the gall bladder and in all portals after surgery and then as intermittent self-administered PCA versus placebo showed that opioid consumption 0–20 h postoperatively, and the total amount of analgesics consumed during the first week following surgery were similar in both groups Gupta et al 2002
  • One study that compared ropivacaine injected into the bed of the gall bladder and in all portals after surgery and then as intermittent self-administered postoperative PCA versus placebo, showed that there were no significant differences between the two groups for the incidence of nausea and vomiting Gupta et al 2002
  • A study that compared ropivacaine injected into the bed of the gall bladder and in all portals after surgery and then as intermittent self-administered postoperative PCA versus placebo, showed that the time to discharge and also the time to defecate were similar in both groups Gupta et al 2002
  • Study details Gupta et al 2005 Click here for more information
  • PCA IP local anaesthetic versus placebo

PROSPECT Recommendations

  • Epidural LA + strong opioid reduces postoperative pain (procedure-specific evidence, LoE 1), but is not recommended (Grade D), due to high cost and poor risk:benefit ratio (LoE 4)
  • Epidural analgesia is recommended in high-risk pulmonary patients (Grade D; LoE 4)

Clinical Practice

  • Epidural analgesia may be effective in open cholecystectomy
  • The risk of side-effects associated with epidural analgesia may outweigh the benefits of analgesia in laparoscopic cholecystectomy

Transferable Evidence from Other Procedures

  • A meta-analysis of randomised controlled trials found that both continuous epidural infusion and PCEA analgesia provided superior postoperative analgesia compared with intravenous PCA analgesia Wu et al 2005
  • A meta-analysis of randomised controlled trials found that compared with systemic opioids, epidural opioids significantly decreased the incidence of atelectasis and had a weak tendency to reduce the incidence of pulmonary infections and pulmonary complications overall, while epidural LAs significantly increased PaO2 and decreased the incidence of pulmonary infections and pulmonary complications overall Ballantyne et al 1998
  • Epidural administration of strong opioids is associated with side-effects including pruritis, PONV, urinary retention, and respiratory depression Chaney 1995

Laparoscopic Cholecystectomy-specific evidence

  • Epidural LA + strong opioid significantly reduced VAS pain scores at 24 h compared with placebo (p<0.05), but there were no differences between groups at 48 h Fujii et al 1998
  • Epidural LA + strong opioid significantly reduced analgesic use compared with placebo (50 mg indomethacin was given rectally, on request) at 0–24 h (p<0.05), but not at 24–48 h Fujii et al 1998
  • A study that compared postoperative epidural LA + strong opioid with placebo showed that the incidence of nausea and vomiting was similar in both groups Fujii et al 1998
  • Study details Fujii et al 1998 Click here for more information

PROSPECT Recommendations

  • Postoperative pain is not increased by early discharge (<24 hours) (procedure-specific evidence, LoE 1), which is recommended for other reasons (Grade D)

Clinical Practice

  • Early discharge is associated with greater patient satisfaction and reduced cost

Transferable evidence from Other Procedures

  • A study comparing costs and outcomes of inpatient versus outpatient hernia repair, showed that outpatient hernia repair was associated with lower costs and apparent absence of adverse outcomes; although there were no detectable differences between inpatients and outpatients for outcomes such as complication rates, deaths and hernia recurrence, the re-admission rates were higher for inpatients (n=27,036) Mitchell + Harrow 1994

Laparoscopic Cholecystectomy-specific evidence

  • Three out of three studies showed no significant differences between outpatient and inpatient management groups for reducing VAS pain scores Curet et al 2002 Click here for more information
  • In one study, VRS pain/discomfort at 1 week and 6 weeks follow-up was similar in the daycare and clinical observation groups Keulemans et al 1998
  • The outpatient management group consumed significantly more oral analgesic (oxycodone + paracetamol) compared with the inpatient management group prior to PACU discharge (p<0.05), but there were no significant differences between groups for total analgesia used (fentanyl, narcotics, oxycodone + paracetamol; details not given) Curet et al 2002
  • There were no significant differences in outpatient and inpatient management groups for analgesic consumption (a single dose of 5–10 mg IM morphine was given on request; 500 mg paracetamol + 20 mg codeine was given up to 6 times/day; 500 mg naproxen was also given, up to 3 times/day) during the first 48 h postoperatively Keulemans et al 1998
  • In two out of two studies, the incidence of PONV (assessed at 4 h and 24 h) Curet et al 2002
  • In one study out of one, there were no significant differences between inpatient and outpatient management groups for bowel movement Young and O'Connell 2001
  • Study details Curet et al 2002 Click here for more information