Intra-operative

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Intra-operative analgesia

To ensure an adequate analgesic effect in the immediate postoperative period, it may be necessary to administer analgesic medication prior to the postoperative period. Data included this section are from studies that assessed intra-operative analgesia versus intra-operative placebo, as well as those that assessed intra-operative analgesia versus the same analgesia given pre- or postoperatively. Where certain analgesics have been administered at various time points in studies (pre-operatively, intra-operatively or postoperatively), then these studies may be presented together in the same section to simplify the interpretation of the overall data (e.g. studies of pre- or intra-operative corticosteroid are presented together in both the Pre- and Intra-operative sections).

PROSPECT Recommendations

  • Corticosteroids are not recommended for analgesia in minor or major breast surgery (Grade D, LoE 4) due to insufficient procedure-specific evidence, but may be used to prevent PONV (procedure-specific and transferable evidence, both LoE 1)

Clinical practice

  • None cited

Transferable evidence

  • Dexamethasone significantly reduced pain scores compared with placebo following laparoscopic cholecystectomy Bisgaard 2003
  • Dexamethasone was shown to prevent postoperative nausea and vomiting after surgery in a systematic review Carlisle 2006b
  • A single prophylactic dose of dexamethasone (4–8 mg) is effective for preventing PONV in surgery associated with high emetic effects Henzi et al 2000
  • In one randomised placebo-controlled study, parecoxib and methylprednisolone had comparable analgesic and rescue analgesic sparing effects in breast augmentation surgery, although only methylprednisolone reduced nausea, vomiting, and fatigue Romundstad 2006

Breast surgery-specific evidence

  • Incidences of nausea (p<0.009) and vomiting (p<0.000005) were significantly lower with dexamethasone compared with placebo Abou Zeid 2002
  • Rescue anti-emetic consumption (dolasetron) was significantly lower with dexamethasone compared with placebo (p<0.001) Abou Zeid 2002
  • VAS pain scores were not significantly different with dexamethasone compared with placebo at all time points assessed (on arrival in the recovery room, at 30 and 60 mins, on leaving the recovery room, and at 4 hours) Abou Zeid 2002
  • Consumption of postoperative diclofenac was comparable in patients receiving dexamethasone and patients receiving placebo Abou Zeid 2002
  • Study details Abou Zeid 2002 Click here for more information
  • Major and minor breast surgery

PROSPECT Recommendations

  • Adenosine is not recommended for analgesia (Grade D, LoE 4) due to limited procedure-specific and transferable evidence (LoE 1)

Clinical practice

  • None cited

Transferable evidence

  • None cited

Breast surgery-specific evidence

  • Fewer patients receiving IV adenosine experienced wound pain on regaining consciousness compared with placebo (p<0.02) Segerdahl et al 1995
  • Opioid requirements (morphine or cetobemidone) during the first 24 h postoperatively were significantly lower with IV adenosine compared with placebo (p<0.03) Segerdahl et al 1995
  • Peri-operative blood loss was lower with IV adenosine compared with placebo (p<0.02) Segerdahl et al 1995
  • There were no significant differences in observer-assessed VAS wound pain between groups receiving IV adenosine versus placebo at 0–3 h or 18–24 h Segerdahl et al 1995
  • There were no significant differences in the incidence of spontaneous vomiting or nausea scores between groups receiving IV adenosine versus placebo Segerdahl et al 1995
  • There were no significant differences in the CFF test or VAS sedation scores between the groups receiving IV adenosine versus placebo at 30 min or 3 h Segerdahl et al 1995
  • Study details Segerdahl et al 1995 Click here for more information
  • Major breast surgery (and reduction mammoplasty)

PROSPECT Recommendations

  • Intercostal nerve block is not recommended for postoperative analgesia in minor or major breast surgery due to insufficient procedure-specific data (Grade D, LoE 4)

Clinical practice

  • The combination of ICB with brachial plexus block is not common practice
  • There is no study comparing intercostal nerve block alone with placebo in breast surgery
  • ICB is an invasive technique, and should not be used for minor breast surgery due to the risk of complications

Transferable evidence

  • The incidence of pneumothorax following intercostal nerve block in thoracic and upper abdominal surgery has been reported in the range of 0.073% to 19% Shanti et al 2001

Breast surgery-specific evidence

  • Two out of two studies reported significantly lower VAS pain scores at rest with intercostal nerve block plus other regional techniques compared with placebo Fassoulaki et al 2001 Click here for more information
  • One study out of two reported a significant reduction in postoperative rescue analgesia with intercostal nerve block plus other regional techniques compared with placebo Pakhira et al 2004 Click here for more information
  • One study reported that the duration of analgesia (time when the observer rated VAS pain scores at >/=40 mm and administered rescue analgesia) was significantly longer with ropivacaine intercostal nerve block and bupivacaine intercostal nerve block, plus other regional techniques, compared with placebo (p<0.01) Pakhira et al 2004
  • VAS pain scores were significantly lower with intercostal nerve block compared with GA for the first 45, 60 and 90 minutes following surgery (p<0.05) Atanassoff et al 1994
  • Significantly fewer patients required postoperative analgesia following intercostal nerve block compared with GA (paracetamol on demand, plus morphine if necessary; p<0.05), although total consumption of paracetamol in the first 24 h was not significantly different between groups Atanassoff et al 1994
  • The time to first request for rescue analgesia was significantly longer with intercostal nerve block compared with GA (p<0.05) Atanassoff et al 1994
  • VAS pain scores were significantly lower with 0.5% bupivacaine intercostal nerve block compared with 2% lidocaine + 5 µg/ml epinephrine intercostal nerve block from 90–120 min (p<0.05), but not at any other time points assessed (i.e. on admission to the recovery room, every 15 min until 2 h, then every 30 min until 4 h postoperatively) Atanassoff et al 1994
  • There were no significant differences in VAS pain scores between groups receiving ropivacaine intercostal nerve block versus bupivacaine intercostal nerve block at 1–12 or at 24 h Pakhira et al 2004
  • There were no significant differences between groups receiving 1.5% lidocaine + 3.75 µg/ml epinephrine versus 2% lidocaine + 5 µg/ml epinephrine versus 0.5% bupivacaine intercostal nerve block with regards to the number of patients requiring postoperative analgesia (paracetamol on demand, then morphine if necessary), time to first request for rescue analgesia, or the total consumption of paracetamol in the first 24 h Atanassoff et al 1994
  • Rescue analgesic requirements (tramadol) and the time to first request for rescue analgesic were similar with ropivacaine and bupivacaine intercostal nerve block Pakhira et al 2004
  • In one study out of one, there were no significant differences between groups receiving ropivacaine intercostal nerve block versus bupivacaine intercostal nerve block for the incidence of PONV Pakhira et al 2004
  • One out of one study showed no significant differences between groups receiving ropivacaine intercostal nerve block plus other regional techniques versus placebo in the frequency of chronic pain in the chest, axilla or arm, or in the overall pain frequency or intensity, at 3 months postoperatively Fassoulaki et al 2001
  • One study out of one showed that the time to first request for rescue analgesic was similar with ropivacaine intercostal nerve block plus other regional techniques and placebo Fassoulaki et al 2001
  • One study out of one reported no significant differences between groups receiving ropivacaine intercostal nerve block plus other regional techniques, bupivacaine intercostal nerve block plus other regional techniques, and placebo for the incidence of PONV Pakhira et al 2004
  • Intercostal nerve block plus other regional techniques versus placebo (GA in both groups)
  • Study details Fassoulaki et al 2001 Click here for more information
  • Minor and major breast surgery
  • Intercostal nerve block (no GA) versus GA
  • Study details Atanassoff et al 1994 Click here for more information
  • Minor breast surgery
  • Intercostal nerve block: LA versus other LA
  • Study details Atanassoff et al 1994 Click here for more information
  • Minor and major breast surgery

PROSPECT Recommendations

  • High concentrations of oxygen cannot be recommended for postoperative analgesia (Grade B) due to negative procedure-specific evidence (LoE 1)

Clinical practice

  • None cited

Transferable evidence

  • None cited

Breast surgery-specific evidence

  • There was no significant difference in pain scores (measured on a linear scale) between treatment groups receiving different concentrations of oxygen Purhonen et al 2006
  • There was no significant difference between treatment groups receiving varying oxygen concentrations in postoperative rescue analgesic consumption (IM or IV oxycodone), or the time to first request for rescue analgesia Purhonen et al 2006
  • There was no significant difference in the incidence of vomiting between groups receiving 30% versus 80% oxygen Purhonen et al 2006
  • There was no significant difference between groups receiving different concentrations of oxygen with regards to consumption of rescue anti-emetics, incidence of nausea, number of emetic episodes, nausea scores, time from the end of surgery to the first PONV, and time to first request for rescue ondansetron Purhonen et al 2006
  • One study reported no significant difference in the incidence of total response (no vomiting or retching and a nausea score of 0), between groups receiving 30% versus 80% oxygen Purhonen et al 2006
  • There was no significant difference in postoperative blood loss between patients receiving 30% and 80% oxygen Purhonen et al 2006
  • One study reported no significant difference in patient satisfaction scores between groups receiving 30% and 80% oxygen Purhonen et al 2006
  • Study details Purhonen et al 2006 Click here for more information
  • Major breast surgery

PROSPECT Recommendations

  • There is insufficient procedure-specific evidence at this time to make a recommendation about the use of drains based on their effect on postoperative pain. The use of drains should depend on factors other than analgesia

Clinical practice

  • The use of drains is related to the prevention of axillary seroma

Transferable evidence

  • None cited

Breast surgery-specific evidence

  • The mean duration of drainage in patients with a drain was significantly shorter than the mean duration of aspiration in patients without a drain (p=0.0067, n=23/14 for drain/no drain) Zavotsky 1998
  • Pain scores (rated on a scale of 1–10) were significantly higher in patients with a drain versus patients receiving no drain at postoperative week 0 (p=0.0062, n=18/16 for drain/no drain), but not at weeks 1, 2 or 3 Zavotsky 1998
  • Haematoma incidence was not significantly different between patients with a drain compared with patients receiving no drain Zavotsky 1998
  • The incidence of infection was not significantly different between drain and no drain groups Zavotsky 1998
  • VAS pain scores were significantly higher in patients with a suction drain versus patients receiving no drain + sealant or no drain + no sealant at 24 and 48 h (p<0.001, p=0.002, respectively) (the two groups without drains were reported as combined for this comparison) Jain et al 2004
  • The duration of hospital stay was significantly longer in patients with a suction drain compared with patients receiving no drain + sealant or no drain + no sealant (p<0.001) (the two groups without drains were reported as combined for this comparison) Jain et al 2004
  • There was no significant difference in the overall incidence of seromas between groups with a suction drain, a suction drain + sealant, and no drain + no sealant Jain et al 2004
  • Total volume of fluid aspirated from seromas was significantly greater in patients with no drain + no sealant compared with patients receiving a suction drain (p=0.008) and patients receiving no drain + sealant (p<0.02). The frequency of aspiration was significantly higher with no drain + no sealant compared with a suction drain (p<0.03) but not versus no drain + sealant Jain et al 2004
  • Drain versus no drain
  • Study details Zavotsky 1998 Click here for more information
  • Major breast surgery
  • Drain versus sealant versus no drain + no sealant
  • Study details Click here for more information
  • Major breast surgery

PROSPECT Recommendations

  • There is insufficient procedure-specific evidence at this time to make a recommendation about surgical techniques based on their effect on postoperative pain. The type of surgical technique should depend on factors other than analgesia

Clinical practice

  • None cited

Transferable evidence

  • None cited

Breast surgery-specific evidence

  • One out of two studies showed a benefit of laser surgery for reducing pain versus conventional surgery Ansanelli etal 1996 Click here for more information
  • Two out of two studies reported significantly reduced peri-operative blood loss with laser surgery compared with conventional scalpel surgery (p<0.001, Wyman et al 1993
  • In one study out of one, drain removal occurred significantly earlier following CO2 laser surgery versus conventional scalpel surgery (p<0.003), and total in-hospital drainage was significantly lower with CO2 laser surgery compared with conventional scalpel surgery (p<0.02) Ansanelli etal 1996
  • One out of two studies showed a benefit of laser surgery for reducing the length of hospital stay versus conventional surgery Ansanelli etal 1996 Click here for more information
  • There were no significant differences in VAS or VRS pain scores between groups undergoing electrocautery and scalpel surgery Chan et al 1997
  • PCA morphine consumption was similar with electrocautery and scalpel surgery (PCA system set to deliver 1 mg/ml) Chan et al 1997
  • One study out of one reported no significant differences between groups receiving laser scalpel surgery and conventional scalpel surgery in the time taken for useful shoulder mobility to return, in the total postoperative wound drainage volume, or the incidence of axillary seroma Wyman et al 1993
  • The length of postoperative hospital stay, peri-operative blood loss, and total drainage were all similar with electrocautery and scalpel surgery Chan et al 1997
  • Study details Ansanelli etal 1996 Click here for more information
  • Major breast surgery

PROSPECT Recommendations

  • Electro-acupoint stimulation is not recommended for analgesia (Grade D, LoE 4), due to limited procedure-specific and transferable evidence

Clinical practice

  • None cited

Transferable evidence

  • A randomised study in patients undergoing gynaecologic lower abdominal surgery demonstrated reduced morphine consumption with pre-operative electroacupuncture (EA) compared with placebo or postoperative EA in the early postoperative period, although VAS pain scores were not significantly different between groups Sim 2002

Breast surgery-specific evidence

  • VRS pain scores were significantly lower with electro-acupoint stimulation compared with sham (p=0.01). The number of patients experiencing severe pain (VRS >5 of 10) was also significantly lower with electro-acupoint stimulation compared with sham (p=0.02) Gan et al 2004
  • Incidence of nausea was significantly lower with electro-acupoint stimulation versus sham (p<0.0001) Gan et al 2004
  • Rescue anti-emetic requirement (dexamethasone 8 mg) in a group receiving electro-acupoint stimulation was significantly lower than in a group receiving sham (p=0.04) Gan et al 2004
  • The complete response rate (no nausea, emesis or use of rescue anti-emetic) was significantly higher with electro-acupoint stimulation compared with sham at 2 h (p=0.01) and 24 h (p=0.006) Gan et al 2004
  • Nausea scores at 30, 60, 90 and 120 min (p=0.03, p=0.005, p=0.0004, p=0.003, respectively) and the worst nausea score (p=0.0001) were significantly lower with electro-acupoint stimulation compared with sham Gan et al 2004
  • Patient satisfaction scores were higher with electro-acupoint stimulation compared with sham (p=0.007) Gan et al 2004
  • Postoperative analgesic consumption (IV fentanyl 25 µg) was similar with electro-acupoint stimulation and sham (p=0.01) Gan et al 2004
  • The incidence of emesis in groups receiving electro-acupoint stimulation and sham was not significantly different at 2 or 24 h Gan et al 2004
  • Study details Gan et al 2004 Click here for more information
  • Major breast surgery