Postoperative

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PROSPECT Recommendations

  • COX-2-selective inhibitors are recommended (Grade B) based on limited procedure-specific evidence (LoE 2) and transferable evidence (LoE 1). They should be given in combination with strong opioids for high-intensity pain, or with weak opioids for moderate- or low-intensity pain (Grade D, LoE 4), only for patients who do not receive epidural analgesia or with cessation of epidural analgesia (Grade D, LoE 4)
  • 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, transferable evidence, LoE1) or who have NSAID-induced asthma (transferable, LoE 1)
  • The use of COX-2-selective inhibitors should depend upon assessment of individual patient risks (Grade B), cardiovascular morbidity (transferable evidence, LoE 1), actual or recent gastroduodenal ulcer history (LoE 4), renal function and hepatic function (transferable evidence, LoE 3). In addition, the potential risk of anastomotic leakage should be considered (transferable evidence, LoE 3). Further observations are required regarding the potential risk of NSAIDs and COX-2-selective inhibitors o

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  • Rofecoxib has been withdrawn from the market, and marketing of valdecoxib has been suspended in most countries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
  • Parecoxib 20 or 40 mg IV every 12 h reduced supplementary analgesic consumption compared with placebo in patients undergoing major gynaecological surgery (p<0.05; n=60)
  • 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
  • Studies in healthy volunteers demonstrated that COX-2-selective inhibitors had no effect on platelet aggregation
  • 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
  • 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)
  • A meta-analysis that included data from 17 parecoxib and 15 parecoxib placebo-controlled trials in non-cardiac surgery, showed that there was no significant association between short-term treatment with parecoxib and/or valdecoxib and an increase in cardiovascular thromboembolic adverse events, compared with placebo (n=8511 overall)
  • A retrospective cohort study showed that the COX-2-selective inhibitors rofecoxib and celecoxib were associated with a lower risk of acute kidney infection than less-selective NSAIDs
  • Parecoxib 20 or 40 mg IV every 12 h did not significantly reduce postoperative pain scores compared with placebo in patients undergoing major gynaecological surgery (p<0.05; n=60)
  • 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
  • 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
  • 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
  • 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
  • COX-2-selective inhibitors and conventional NSAIDs may elevate blood pressure, particularly in hypertensive patients receiving antihypertensive medication
  • Although there is some concern that COX-2-selective inhibitors may impair wound healing, evidence from animal and clinical studies is conflicting
  • One study in patients undergoing fast-track colonic surgery found that postoperative analgesia with the COX-2-selective inhibitor celecoxib was associated with a higher risk of anastomotic leakage, compared with when celecoxib was not used

Open Colonic Resection-Specific Evidence

  • Pre-operative + postoperative oral valdecoxib was superior to placebo for reducing postoperative pain scores Click here for more information
  • Pre-operative + postoperative oral valdecoxib was superior to placebo for reducing postoperative morphine requirement Click here for more information
  • Pre-/postoperative oral valdecoxib was associated with superior patient-assessed global evaluation scores (p=0.001; n=79), compared with placebo, but not with surgeon-assessed global evaluation scores
  • The time until first flatus and first bowel movement was significantly shorter with pre-/postoperative oral valdecoxib, compared with placebo (p=0.003 and p=0.041, respectively)
  • The time taken to tolerate solids was significantly shorter with pre-operative + postoperative oral valdecoxib versus placebo (p=0.029)
  • The length of hospital stay was significantly shorter for patients in the pre-/ postoperative oral valdecoxib group, compared with the placebo group (p=0.009)
  • The incidence of postoperative sedation or nausea was similar with pre-/ postoperative oral valdecoxib, and placebo (n=79)
  • Pre-operative + postoperative oral valdecoxib had no significant effect on the time taken to tolerate intake of liquids compared with placebo
  • The hospital re-admission rate was similar for patients in the pre-/ postoperative oral valdecoxib and placebo groups

PROSPECT Recommendations

  • Conventional NSAIDs are recommended (Grade A), for their analgesic and opioid-sparing effect (procedure-specific evidence, LoE 1). They should be given in combination with strong opioids for high-intensity pain, or with weak opioids for moderate- or low-intensity pain (Grade D, LoE 4), only for patients who do not receive epidural analgesia or with cessation of epidural analgesia (Grade D, LoE 4)
  • 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, transferable 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)

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures - Study information

  • Conventional NSAIDs have proven analgesic efficacy in a variety of surgical procedures
  • 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 pruritus, urinary retention or respiratory depression
  • Six out of eight studies showed a significant benefit of postoperative conventional NSAIDs compared with placebo for reducing postoperative pain scores in patients undergoing hysterectomy Click here for more information
  • Conventional NSAIDs conferred a significant benefit over placebo for reducing supplementary analgesia requirements over 24 h or more in patients undergoing abdominal hysterectomy Click here for more information
  • Conventional NSAIDs were superior to placebo for reducing morphine consumption in abdominal surgery but did not consistently reduce pain scores in two studies in abdominal surgery Click here for more information
  • One randomised trial in patients undergoing transurethral prostatectomy showed that diclofenac did not affect total blood loss compared with placebo
  • Two of three studies showed no significant analgesic benefit of conventional NSAIDs plus epidural analgesia compared with epidural analgesia alone Click here for more information
  • Results were inconsistent for conventional NSAIDs compared with placebo for the time to first analgesic request following abdominal hysterectomy Click here for more information
  • Conventional NSAIDs and placebo were not significantly different for the incidence of PONV (all groups received background strong opioid) in patients undergoing abdominal surgery Click here for more information
  • Diclofenac 50 mg IM bolus pre-operatively then postoperatively at 4 and 10 h, plus epidural analgesia using bupivacaine 0.5% continually infused at 8 mL/h did not confer a benefit for extending the time to first analgesic request compared with epidural analgesia alone in patients undergoing abdominal hysterectomy (n=26)
  • 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
  • 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
  • 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
  • A randomised trial in healthy volunteers showed that three conventional NSAIDs (diclofenac, ketorolac and ketoprofen) caused a reversible platelet dysfunction
  • 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
  • Aspirin and conventional NSAIDs can induce asthma attacks in patients with aspirin-exacerbated respiratory disease. Aspirin-induced asthma occurs in approximately 4–10% of the adult asthmatic population
  • 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
  • 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
  • Conventional NSAIDs and COX-2-selective inhibitors may elevate blood pressure, particularly in hypertensive patients receiving antihypertensive medication
  • A restrospective, case-control study showed that postoperative analgesia with the conventional NSAID diclofenac (150 mg daily) was associated with a significantly higher number of anastomotic leakages than postoperative opioid analgesia in patients undergoing laparoscopic colorectal surgery

Open Colonic Resection-Specific Evidence - Study information

  • Pre-operative + postoperative IV flurbiprofen was superior to placebo for reducing postoperative pain scores Click here for more information
  • Pre-operative + postoperative IV flurbiprofen axetil was superior to placebo for reducing the time to first pass of flatus and first bowel movement (both p=0.01; n=40)
  • Regular IM ketorolac was superior to regular IV morphine for reducing supplementary PCA morphine use 0–24 h and total morphine consumption 0–72 h (p=0.001; n=30)
  • IM ketorolac (PRN) was superior to IM morphine (PCA or PRN) alone for reducing postoperative pain scores at 3–6 h and 18–110 h (dosing regimens not clear) (all p<0.05; n=90)
  • IM ketorolac (PRN) was superior to IM morphine (PCA or PRN) for reducing the time to first flatus (p<0.05) and length of hospital stay (dosing regimens not clear) (p<0.01; n=90)
  • IM ketorolac was superior to IM ketorolac plus IM or IV morphine on demand for reducing the length of time taken to recover from postoperative ileus (2.3 ± 0.5 days versus 4.2 ± 0.6 days; p<0.05; n=14)
  • IV PCA morphine + ketorolac was superior to IV PCA morphine alone for reducing total morphine consumption (p<0.05; n=74); however there was no significant difference between the groups for the duration of IV PCA morphine use
  • IV PCA morphine + ketorolac significantly reduced the time to first mobilisation, compared with IV PCA morphine alone (p<0.05; n=74)
  • IV PCA morphine + ketorolac significantly reduced the time to first bowel movement, compared with IV PCA morphine alone (P<0.05; n=74)
  • The incidence of postoperative nausea and vomiting was similar in the pre-operative + postoperative flurbiprofen axetil and placebo groups (n=40)
  • IM ketorolac plus PCA morphine conferred no significant benefit over PCA morphine alone for reducing postoperative pain scores, time to first flatus, time to first bowel movement and tolerance to liquids and regular diet (n=30)
  • There were no significant differences between the groups receiving IV PCA morphine or IV PCA morphine + ketorolac for VAS pain scores at rest or movement during postoperative Days 1–3 (n=74)
  • IV PCA morphine + ketorolac conferred no significant benefit over IV PCA morphine alone for reducing the time to first flatus (n=74)
  • The incidence of morphine-related side-effects (pruritus, nausea and vomiting and dizziness) was similar in the groups receiving IV PCA morphine + ketorolac or IV PCA morphine alone (n=74)
  • IV PCA morphine + ketorolac and IV PCA morphine alone were associated with a similar length of hospital stay (n=74)

PROSPECT Recommendations

  • Gabapentin/pregabalin cannot be recommended at this time (Grade D, LoE 4) due to a lack of procedure-specific evidence, although analgesic data from other procedures are promising

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

  • Four systematic reviews and a meta-analysis evaluated the use of gabapentinoids for postoperative analgesia and demonstrated significant reductions in postoperative pain and supplementary analgesic requirements compared with inactive controls
  • Two systematic reviews
  • Two systematic reviews

Open Colonic Resection-Specific Evidence

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

PROSPECT Recommendations

  • Postoperative IV lidocaine is recommended (Grade D, LoE 4) for open colonic resection when epidural analgesia is not feasible or contra-indicated (Grade B) based on transferable evidence (LoE 1) and limited procedure-specific evidence (LoE 2) for recovery benefits compared with control

Clinical Practice

  • IV lidocaine can be considered as an alternative when there are contra-indications to epidural analgesia techniques
  • If IV lidocaine is used it is recommended that safety data be taken into account
  • IV lidocaine may induce hypotension
  • Further evidence is needed to precisely define the role of IV lidocaine in this setting, including direct comparisons with epidural analgesia

Transferable Evidence from Other Procedures

  • A meta-analysis of randomised clinical trials performed to evaluate the effect of continuous IV lidocaine infusion during and after abdominal surgery reported that lidocaine significantly reduced postoperative VAS pain scores, duration of postoperative ileus, incidence of PONV, and length of hospital stay, compared with the controls

Open Colonic Resection-Specific Evidence - Study information

  • Peri-operative IV lidocaine significantly reduced the time to first flatus compared with the control group (p<0.05; n=60)
  • The time to first bowel movement was significantly shorter with peri-operative IV lidocaine compared with the control (p<0.05; n=60)
  • Peri-operative IV lidocaine significantly reduced the time taken to solid food intake compared with the control (p<0.001; n=60)
  • Peri-operative IV lidocaine significantly reduced the duration of hospital stay compared with control (p=0.004; n=60)
  • Peri-operative IV lidocaine conferred no significant benefit over the control for the reduction of VAS pain scores at rest or during movement at any of the time points assessed (n=60)
  • Peri-operative IV lidocaine conferred no significant benefit over control for reducing the consumption of PCA IV piritramide (2 mg dose with a lockout period of 10 min) (n= 60)

PROSPECT Recommendations

  • Postoperative NMDA receptor antagonists are not recommended (Grade D, LoE 4) because of limited procedure-specific evidence of analgesic efficacy

Clinical Practice

  • The maximum dose of ketamine that should be given to avoid side effects is 0.5 mg/kg
  • Clinical experience with NMDA receptor antagonists is lacking. Moreover, NMDA receptor antagonists are associated with adverse events, e.g. ketamine is known for its increased risk of CNS side effects

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
  • In patients undergoing laparoscopic cholecystectomy, dextromethorphan (pre- incisional and post gallbladder removal) was superior to control for reducing VAS scores, reducing the use of supplementary analgesics, and increasing the time to first analgesic request
  • Low-dose ketamine was associated with few and mild adverse effects, especially when administered in conjunction with general anaesthesia
  • A systematic review found that dextromethorphan did 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
  • Two systematic reviews of randomised controlled trials comparing magnesium with placebo demonstrated inconclusive results overall with regards to pain scores and supplemental analgesic use

Open Colonic Resection-Specific Evidence - Study information

  • IV magnesium provided no significant benefit over placebo for reducing the following postoperative outcomes: pain scores at rest or during movement; morphine requirements for 0–24 h; sedation scores 0–48 h; incidence of nausea and vomiting; time to first bowel movement; and time to first flatus (n=47)

PROSPECT Recommendations

  • Systemic strong opioids are recommended (Grade B) following colonic resection, based on transferable evidence for their efficacy in reducing high-intensity postoperative pain (VAS =50 mm) (LoE 1), with the following considerations:
  • In patients receiving epidural anaesthesia, epidural strong opioids are recommended 2–3 days postoperatively; after the catheter has been removed, systemic strong opioids can be administered for analgesia (Grade D, LoE 4)
  • Systemic strong opioids should only be used in combination with conventional NSAIDs or COX-2-selective inhibitors and paracetamol to reduce opioid use and its associated side-effects (Grade D, LoE 4)
  • Even though IV PCA strong opioids showed no analgesic benefit over IM PRN opioids in procedure-specific evidence (LoE 1), they are recommended (Grade B) based on greater patient satisfaction compared with regular (fixed-interval) or PRN dosing (transferable evidence, LoE 1); however, fixed-interval IV administration titrated to pain intensity is also recognised as an effective mode of administration (LoE 4)
  • IM strong opioids are not recommended because of the pain associated with these injections (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
  • The opioid antagonist alvimopan has been demonstrated to reduce the incidence of postoperative ileus and accelerate GI function without compromising opioid analgesia in patients undergoing bowel resection (Ludwig 2008)
  • 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 - Study information

  • Three out of five studies showed a significant benefit of IV PCA over IM regular/PRN administration of strong opioids for reducing postoperative pain scores in patients undergoing abdominal hysterectomy Click here for more information
  • Evidence for a benefit of PCA compared with regular/PRN IM administration of strong opioids for reducing overall opioid consumption is inconsistent, although one study suggests that they produced different patterns of dosing in patients undergoing abdominal hysterectomy Click here for more information
  • The incidence of PONV was not significantly different between PCA and IM morphine Click here for more information
  • Opioids administered by PCA improved analgesia, decreased the risk of pulmonary complications and patients preferred them compared with regular IM, IV or SC opioid treatment, as determined in a quantitative systematic review of randomised trials in various surgical procedures
  • Strong opioids are effective for reducing high- and moderate-intensity postoperative pain
  • Strong opioids are associated with adverse effects, including nausea, vomiting, sedation, confusion, paralytic ileus and urinary retention

Open Colonic Resection-Specific Evidence - Study information

  • IM regular or PRN morphine was superior to IV PCA morphine for reducing daily opioid use (both p<0.05) and the total amount of opioid used in two studies (no statistics provided, n=41; p<0.05, n=62)
  • IM morphine was similar to PCA morphine for the frequency of PONV in one study reporting this parameter (n=41)
  • IM morphine was similar to PCA morphine for the level of postoperative pain and activity (measured by patient questionnaire), frequency of PONV, level of sedation and the duration of ileus and of hospital stay. However, this study did not record pain on a linear scale (n=62)
  • PCA morphine had a similar effect to PRN or regular IM morphine for reducing postoperative pain scores in two studies Click here for more information
  • PCA morphine and IM morphine use were associated with similar length of hospital stay in two studies (n=41, n=62)
  • IM or IV morphine plus IM ketorolac prolonged the length of time taken to recover from postoperative ileus compared with IM ketorolac alone (2.3 ± 0.5 days versus 4.2 ± 0.6 days; p<0.05; n=14)

PROSPECT Recommendations

  • Weak opioids are not recommended for controlling high-intensity pain (Grade D, LoE 4)
  • Weak opioids are recommended to be used for moderate- or low-intensity pain if non-opioid analgesia is insufficient or is contra-indicated (Grade B, transferable evidence, LoE 1)
  • Weak opioids are recommended to be used in combination with non-opioid analgesics (Grade B, transferable evidence, LoE 1)

Clinical Practice

  • Tramadol 300 mg is considered to be a clinically effective dose, and therefore the 100 mg dose used in the study by Wordliczek et al. is probably too low to provide sufficient pain relief

Transferable Evidence from Other Procedures

  • Tramadol was more effective than placebo for pain relief in a meta-analysis of post-surgical patients
  • The combination of tramadol and paracetamol enhances analgesic efficacy compared with either agent alone
  • 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
  • A systematic review found that the combination of codeine with paracetamol provided additional pain relief compared with paracetamol alone
  • Two studies found that codeine 30mg + paracetamol 300 mg was associated with a higher incidence of constipation and vomiting than tramadol 37.5 mg + paracetamol 325 mg following arthroscopy
  • 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
  • A systematic review found that the combination of codeine with paracetamol was associated with an increase in drowsiness and dizziness compared with paracetamol alone
  • A systematic review found an increased incidence of central nervous system adverse effects with paracetamol plus dextropropoxyphene compared with placebo

Open Colonic Resection-Specific Evidence - Study information

  • Administration of IV tramadol immediately after peritoneal closure, or immediately following surgery extended the time to first analgesic request compared with pre-operative administration (p<0.01; n=90)
  • Pre-, intra- or postoperative IV tramadol 100 mg were similar for postoperative pain scores Click here for more information
  • Pre-, intra- or postoperative administration of tramadol 100 mg were similar for the incidence of PONV (n=90)
  • Pre-operative administration of IV tramadol was superior to administration immediately after peritoneal closure or postoperatively for reducing total tramadol consumption (p<0.05; n=90)

PROSPECT Recommendations

  • Paracetamol is recommended for pain of moderate- (>30 VAS <50) or low- (VAS =30) intensity, in combination with COX-2-selective inhibitors or conventional NSAIDs (Grade B), based on its mild analgesic and opioid-sparing effect in transferable evidence (LoE 1), only for patients who do not receive epidural analgesia or with cessation of epidural analgesia (Grade D, LoE 4)
  • However, paracetamol is not recommended for high-intensity pain (VAS =50 mm) (Grade B) because it has no additional analgesic benefit over that conferred by conventional NSAIDs in transferable evidence (LoE 1)

Clinical Practice

  • Paracetamol is a well-established analgesic for low- (VAS=30) or moderate- (VAS>30<50) intensity pain and has a favourable safety profile
  • If paracetamol is used as part of a multi-modal regimen, the anti-pyretic effect can mask complications such as anastomotic leakage

Transferable Evidence from Other Procedures - Study information

  • Paracetamol was superior to placebo for reducing postoperative pain scores, but produced reductions in VAS scores of <13 mm Click here for more information
  • Paracetamol was superior to placebo for reducing supplementary analgesic consumption within 0–24 h in patients undergoing abdominal hysterectomy Click here for more information
  • One study showed that IV paracetamol was equally as effective as IV ketorolac for reducing postoperative pain scores in patients undergoing abdominal hysterectomy (n=176)
  • Paracetamol combined with weak opioids (codeine, tramadol) is superior to weak opioids alone in a review of dental, gynaecological and orthopaedic surgery
  • 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
  • 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
  • One study showed a marginal but significant benefit of rectal diclofenac over rectal paracetamol for reducing average pain scores over 24 h, (p=0.008; n=44) in patients undergoing abdominal hysterectomy
  • In a systematic review of a variety of surgical procedures, paracetamol plus NSAID conferred no significant benefit over NSAID alone for reducing pain scores in orthopaedic and gynaecological operations. However, a significant benefit was seen in the lower-intensity pain associated with dental operations
  • Paracetamol 1.5 g plus diclofenac 100 mg was not significantly different from diclofenac 100 mg alone given once pre-operatively, for reducing postoperative pain in abdominal gynaecological surgery

Open Colonic Resection-Specific Evidence

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

PROSPECT Recommendations

  • Continuous epidural anaesthesia and postoperative analgesia is recommended for routine use in colonic resection (Grade A), based on its benefits for reducing postoperative pain, systemic opioid use and improving bowel recovery time (procedure-specific evidence, LoE 1)
  • A combination of epidural local anaesthetic (LA) and strong opioid is recommended for epidural analgesia (Grade A), based on procedure-specific evidence of their combined efficacy, in reducing postoperative pain and systemic opioid use, compared with LA alone (LoE 1). However, the addition of opioid to epidural LA results in an increase in time to first bowel movement (LoE 1)

Clinical Practice

  • Thoracic epidural is considered to be more appropriate than lumbar epidural for anaesthesia and analgesia in open colon surgery
  • Epidural analgesia is associated with a relatively high degree of patient monitoring and rare major complications
  • Clonidine is not used routinely because it is associated with an increased risk of hypotension, sedation and bradycardia

Transferable Evidence from Other Procedures - Study information

  • Epidural analgesia using LA was superior to systemic strong opioid for reducing postoperative pain scores in six studies identified in a systematic review of abdominal surgery
  • Epidural analgesia using a combination of LA and strong opioid was superior to epidural LA alone for reducing postoperative pain – 15 mm reduction in VAS score on a 100-mm scale – in a meta-analysis of five studies in abdominal surgery
  • Epidural analgesia using LA was superior to epidural opioids or systemic opioids for reducing the incidence of postoperative gastrointestinal paralysis, in a systematic review in abdominal surgery
  • Epidural LA was superior to epidural LA plus opioid for reducing the time to first passage of stool Click here for more information
  • Epidural LA was suggested to be the most effective method of reducing ileus and improving postoperative catabolism in patients undergoing abdominal surgery Click here for more information
  • Results for the incidence of postoperative nausea were inconsistent for comparison of epidural LA with epidural LA plus opioid, and no significant difference for the incidence of vomiting was seen Click here for more information
  • Epidural clonidine is associated with an increased risk of hypotension, sedation and bradycardia Click here for more information

Open Colonic Resection-Specific Evidence - Study information

  • Epidural LA and opioid showed a significant benefit for reducing postoperative pain scores compared Click here for more information
  • Epidural LA plus opioid produced a significant reduction in the use of supplementary analgesia compared with GA plus systemic analgesia in two studies (p<0.05, n=64; p<0.001, n=20)
  • Epidural LA plus opioid was superior to GA plus systemic analgesia for increasing the time to first request of supplementary analgesia in one study (p<0.005; n=20)
  • Epidural LA plus opioid was associated with a similar length of hospital stay compared with GA plus systemic analgesia in two studies (n=42, n=20)
  • Epidural LA plus opioid produced a significantly quicker time for first flatus and time for first bowel movement compared with GA plus systemic analgesia in two studies (all p<0.05; n=64, n=42)
  • Epidural bupivacaine plus morphine was associated with recovery of gastrointestinal function and fulfilled discharge criteria approximately 1.5 days earlier compared with GA and IV plus postoperative PCA morphine (p<0.005; n=26)
  • Epidural bupivacaine plus morphine had a similar incidence of orthostatic hypotension compared with GA and IV plus postoperative PCA morphine (n=26)
  • Postoperative thoracic epidural analgesia was superior to postoperative PCA for reduction of VAS pain scores at Day 2 (p=0.01; n=59), but there was no significant difference between the groups at discharge, or on Days 1, 10 and 30
  • Two studies demonstrated that epidural bupivacaine conferred a benefit over general anaesthesia and systemic analgesia for reducing postoperative pain scores at rest for 1–72 h in one study (all p<0.05; n=116)
  • Epidural bupivacaine administration resulted in significantly fewer patients requiring supplementary analgesia compared with GA plus systemic analgesia for 1–48 h postoperatively (p<0.05; n=116)
  • Epidural bupivacaine administration resulted in significantly more patients having a bowel movement by Day 4 compared with GA plus systemic analgesia (p<0.05; n=116)
  • Epidural bupivacaine was associated with recovery of gastrointestinal function and fulfilled discharge criteria approximately 1.5 days earlier compared with GA and IV bolus plus postoperative PCA morphine (p<0.005; n=26)
  • A meta-analysis of randomised studies performed to compare the effect of local anaesthetic epidural analgesia with parenteral opioid analgesia in patients undergoing colorectal surgery, reported that epidural analgesia significantly reduced postoperative VAS pain scores at 24 h (11 studies analysed, n=630) and 48 h postoperatively (6 studies analysed, n=281) (p<0.001 for both comparisons)
  • Continuous epidural infusion of opioids was superior to systemic regimens for reducing postoperative pain scores in two out of three studies Click here for more information
  • Continuous epidural morphine was superior to control for reducing supplementary analgesic consumption in one study (p<0.01; n=30)
  • Daily bolus epidural morphine was superior to IM oxycodone for reducing postoperative pain scores at 3 h (n=30) Click here for more information
  • Daily bolus epidural morphine was superior to IM oxycodone for reducing supplementary analgesic consumption (p<0.01; n=30)
  • The addition of opioid to epidural LA conferred a benefit over epidural LA alone in reducing postoperative pain scores in two studies Click here for more information
  • Continuous epidural bupivacaine was similar to continuous epidural morphine for reducing postoperative pain scores (n=45) Click here for more information
  • Continuous epidural bupivacaine was associated with similar supplementary analgesic consumption compared with epidural morphine (bolus or continuous) (n=45)
  • Continuous epidural bupivacaine was superior to epidural morphine (bolus or continuous) in reducing the time to first bowel movement (p<0.05; n=45)
  • Epidural clonidine was superior to control for reducing the amount of fentanyl administered postoperatively for 12–24 and 24–36 h (all p<0.05; n=25)
  • Pre-/postoperative epidural clonidine was superior to control for the reduction of postoperative pain scores Click here for more information
  • Pre-/postoperative epidural clonidine was superior to the control for reducing postoperative analgesic requirement Click here for more information
  • Pre-/postoperative epidural clonidine significantly reduced the time to return of normal bowel function compared with control (p<0.001; n=40)
  • The incidence of morphine-associated nausea, vomiting, and itching was significantly lower with pre-/postoperative epidural clonidine, compared with control (p<0.001; n=40)
  • Intra-/postoperative epidural bupivacaine-sufentanil-clonidine + intra-operative IV ketamine was superior to intra-operative IV lidocaine-sufentanil-clonidine + intra-operative IV ketamine + postoperative IV lidocaine-morphine-clonidine for reducing postoperative pain Click here for more information
  • Cumulative number of satisfied analgesic requests was significantly lower with intra-/postoperative epidural bupivacaine-sufentanil-clonidine + intra-operative IV ketamine, compared with intra-operative IV lidocaine-sufentanil-clonidine + intra-operative IV ketamine + postoperative IV lidocaine-morphine-clonidine, from 24–72 h after surgery
  • Mean summary area under the curve (AUC) of VRS pain scores at rest for 0–72 h postoperatively was significantly lower with PCEA, compared with continuous epidural analgesia (p<0.001; n=205), and median summary VRS pain scores on movement for 24–72 h postoperatively were significantly lower in the PCEA group compared with the continuous epidural group (p<0.001; n=205)
  • PCEA was superior to continuous epidural infusion for reducing postoperative analgesic consumption Click here for more information
  • A significantly higher proportion of patients in the PCEA group were 'very satisfied' with the treatment compared with the continuous epidural infusion group at 72 h postoperatively and at discharge (both p<0.0001; n=205)
  • Epidural LA plus strong opioid showed no difference in the incidence of nausea and vomiting compared with GA plus systemic analgesia in four studies Click here for more information
  • A meta-analysis of randomised studies performed to compare the effect of local anaesthetic epidural analgesia with parenteral opioid analgesia in patients undergoing colorectal surgery, found no significant difference in the incidence of PONV (5 studies analysed; n=189), anastomotic leakage (7 studies analysed; n=459), or length of hospital stay (n=716)
  • Postoperative thoracic epidural analgesia conferred no significant benefit over postoperative PCA for reducing the time to first bowel movement (n=34 analysed)
  • There was no significant difference in patient quality of life or satisfaction with hospital stay scores between the groups receiving postoperative thoracic epidural analgesia and postoperative PCA (n=59)
  • There was no significant difference between the postoperative thoracic epidural analgesia group and postoperative PCA group for a return to normal levels of activities at discharge, 10 days and 30 days postoperatively ((n=59)
  • Postoperative thoracic epidural analgesia conferred no significant benefit over postoperative PCA for reducing the length of hospital stay (n=59)
  • Epidural morphine (bolus or continuous) was similar to IM baralgine or IM oxycodone for the time to first bowel movement in two studies (n=21, n=30)
  • Epidural morphine was associated with a similar incidence of nausea and orthostatic hypotension compared with GA and IV plus postoperative PCA morphine (n=24)
  • Epidural bupivacaine was associated with an increased incidence of orthostatic hypotension compared with GA and IV plus postoperative PCA morphine (p<0.05) (n=26)
  • Epidural bupivacaine had a similar incidence of nausea compared with GA and IV plus postoperative PCA morphine (n=26)
  • Continuous epidural morphine was similar to systemic analgesia for the length of postoperative hospital stay in two studies (n=21, n=24)
  • High dose continuous epidural infusion of bupivacaine plus fentanyl provided no significant benefit over a lower dose regimen for improving various postoperative outcomes (n=100) Click here for more information
  • Epidural clonidine provided no significant benefit for postoperative pain scores 0–72 h (n=25)
  • Epidural clonidine provided no significant benefit for sedation scores compared with control at 12–24 h and 24–36 h postoperatively (p<0.05; n=25)
  • Pre-/postoperative epidural clonidine provided no significant benefit for reducing the length of hospital stay compared with control (n=40)
  • Intra-/postoperative epidural bupivacaine-sufentanil-clonidine + intra-operative IV ketamine was associated with a higher incidence of orthostatic hypotension at first mobilisation, compared with intra-operative IV lidocaine-sufentanil-clonidine + intra-operative IV ketamine + postoperative IV lidocaine-morphine-clonidine (p=0.05; n=40)

PROSPECT Recommendations

  • Continuous postoperative wound infusion with LA is not recommended (Grade D, LoE 4) as procedure-specific evidence is limited and inconsistent
  • Pre-closure wound infiltration with local anaesthetic is not recommended for open colonic resection (Grade D, LoE 4), due to lack of procedure-specific evidence and inconclusive transferable evidence from other large abdominal surgeries

Clinical Practice

  • Continuous pre-peritoneal infusion of LA may be considered as an alternative when epidural analgesia is not feasible or contraindicated based on limited procedure-specific evidence for analgesic benefit (LoE 2)
  • Intra-operative wound infiltration is a well-established method of analgesia with a favourable safety profile. However, methods of postoperative wound infusion are not well established

Transferable Evidence from Other Procedures - Study information

  • A qualitative and quantitative systematic review compared continuous postoperative wound infusion with LA versus control in multiple surgical procedures (cardiothoracic, general, gynaecology-urology, orthopaedics). Meta-analysis of 44 randomised studies showed that continuous wound infusion with LA was superior to control for reduction of postoperative pain scores and postoperative morphine consumption (n=1814)
  • Five of eight studies showed no significant benefit of intra-operative wound infiltration over placebo for reducing postoperative pain scores following abdominal hysterectomy Click here for more information
  • Postoperative PCA wound infiltration with LA following hysterectomy provided limited benefit over placebo for reducing postoperative pain scores, but significantly reduced postoperative analgesic consumption Click here for more information
  • A systematic review of incisional local anaesthesia showed that evidence of analgesic efficacy in hysterectomy (4 studies), open cholecystectomy (8 studies) and a variety of other surgical procedures (9 studies) was inconclusive Click here for more information
  • Three randomised trials in patients undergoing abdominal hysterectomy showed that single-shot postoperative LA wound infiltration conferred no significant benefit over placebo/no treatment for reducing postoperative pain scores

Open Colonic Resection-Specific Evidence - Study information

  • Continuous wound infusion with Lidocaine and bupivacaine was similar to an intermittent IV morphine infusion for postoperative pain scores Click here for more information
  • Continuous wound infusion with Lidocaine and bupivacaine was superior to IV morphine infusion for the total amount of morphine used (p<0.001; n=70)
  • Continous wound infusion with ropivacaine was superior to placebo for reducing postoperative pain scores during movement at a minority of timepoints Click here for more information
  • Continuous pre-peritoneal infusion with ropivacaine was superior to placebo for reducing postoperative pain scores Click here for more information
  • Continuous pre-peritoneal infusion with 0.2% ropivacaine significantly reduced postoperative consumption of PCA morphine compared with placebo during the first 3 postoperative days (p=0.0004) (n=42)
  • Continuous pre-peritoneal infusion with ropivacaine was superior to placebo for reducing the time to hospital discharge (p=0.02) (n=42)
  • Continuous wound infusion with lidocaine and bupivacaine conferred no benefit over intermittent IV morphine infusion for reducing time to first bowel movement, time to first flatus and timing of postoperative mobilisation (n=70)
  • Continuous wound infusion with lidocaine and bupivacaine was associated with a similar incidence of vomiting compared with intermittent IV PCA morphine infusion (n=70)
  • Continuous wound infusion with 0.54% ropivacaine conferred no significant benefit over placebo for reducing PCA morphine use on postoperative Days 1, 2 and 3 (n=310 analysed)
  • Continuous wound infusion with ropivacaine conferred no significant benefit over placebo for reducing the length of hospital stay (n=310)
  • Continuous wound infusion with ropivacaine had no significant effect on the incidence of postoperative nausea and vomiting, compared with placebo (n=42)
  • Pre-peritoneal continuous infusion with ropivacaine had no significant effect on the incidence of postoperative nausea and vomiting, compared with placebo (n=310)
  • Continuous wound infusion with 0.54% ropivacaine conferred no significant benefit over placebo for the reduction of VAS mobility scores on postoperative Days 1,2, and 3 (n=310)

PROSPECT Recommendations

  • Care protocols (which include controlled rehabilitation with early ambulation and diet, or multi-modal optimisation programmes) following colonic resection are recommended (Grade A) based on factors other than the management of postoperative pain (e.g. postoperative ileus (procedure specific LoE 1) and length of hospital stay (procedure specifc LoE 1)), as postoperative pain benefits are inconsistent (LoE 4). Controlled studies are necessary to define the influence of the various components
  • The 'anti-inflammatory regimen' (GA combined with spinal, epidural, IV corticosteroid and NSAID) is not recommended over GA + IV opioid analgesia (Grade D, LoE 4) because of limited evidence in colonic resection. Moreover, it introduces an increased level of complexity

Clinical Practice

  • Epidural anaesthesia combined with general anaesthesia is used routinely for colonic resection, except in patients with contra-indications to epidurals, where general anaesthesia alone is used.
  • Nasogastric tubes should be removed as early as possible to avoid gastroparesis.

Transferable Evidence from Other Procedures - Study information

  • Multimodal rehabilitation protocols (the fast-track methodology, enhanced recovery programmes, etc.) have been assessed in large prospective cohort studies, randomised trials and systematic reviews. These concluded that integration of optimised pain relief together with early oral nutrition, anti-ileus treatment, mobilisation, appropriate fluid therapy and revision of perioperative care principles hasten recovery, thereby decreasing duration of postoperative hospitalisation as well as reducing m
  • Studies integrating continuous epidural LA with enforced early nutrition and mobilisation uniformly suggest an improved recovery, and decreased hospital stay and convalescence Click here for more information
  • A meta-analysis showed that omitting nasogastric tubes conferred a significant benefit over their use for reducing the time to first oral intake, pulmonary complications, fever, atelectasis and pneumonia
  • A meta-analysis showed that patients managed without nasogastric tubes had significantly greater abdominal distension and vomiting

Open Colonic Resection-Specific Evidence - Study information

  • Care by CREAD numerically, but not statistically, lowered morphine consumption compared with patients undergoing TRAD care (137 ± 109 versus 187 ± 125 mg; p=0.08; n=64)
  • Care by CREAD was superior to TRAD care for reducing the time to discharge and length of hospital stay (5.4 versus 7.1 days, p=0.02; n=64)
  • Care by CREAD numerically but not statistically reduced the number of patients with postoperative ileus or small-bowel obstruction compared with patients undergoing TRAD care (3 versus 4 patients; n=64)
  • A multi-modal optimisation programme conferred a significant benefit over traditional care for reducing postoperative pain scores Click here for more information
  • A multi-modal optimisation programme conferred a significant benefit over traditional care for reducing postoperative fatigue scores on Day 7 (p=0.008; n=25)
  • A multi-modal optimisation programme conferred a significant benefit over traditional care for tolerating a regular hospital diet earlier (48 versus 76 h; p<0.001), and reduced the median length of hospital stay (3 versus 7 days; p<0.002; n=25)
  • Gastrostomy tubes were superior to nasogastric tubes for reducing patient discomfort levels (p<0.01; n=107)
  • Patients receiving gastrostomy tubes reported significantly less tube-related inconvenience than patients receiving nasogastric tubes on postoperative Day 2, at discharge and at 4 weeks postoperatively (all p<0.02; n=107)
  • Mechanical massage with aspiration of abdominal wall was superior to mechanical massage without aspiration for reducing mean postoperative pain scores from Days 2–5 (p<0.001; n=50)
  • Mechanical massage with aspiration of abdominal wall was superior to mechanical massage without aspiration for reducing supplementary analgesic consumption Days 1–3 (p<0.05; n=50)
  • Mechanical massage with aspiration of abdominal wall was superior to mechanical massage without aspiration for reducing the time to first flatus (p<0.01; n=50)
  • The 'anti-inflammatory' regimen (GA, spinal, epidural, IV corticosteroid and NSAID) reduced VAS pain scores at rest and during coughing for 0–8 days postoperatively compared with GA and IV opioid analgesia (p<0.001; n=20)
  • The 'anti-inflammatory' regimen (GA, spinal, epidural, IV corticosteroid and NSAID) significantly reduced fatigue compared with GA and IV opioid analgesia (p<0.05; n=20) Schulze et al 1992
  • The 'anti-inflammatory' regimen (GA, spinal, epidural, IV corticosteroid and NSAID) significantly enhanced ambulatory function (i.e. washing and mobility) compared with GA and IV opioid analgesia (p<0.05; n=20) Schulze et al 1992
  • Care by CREAD did not confer a benefit over TRAD care for reducing postoperative pain scores on Days 2, 10 or 30 (n=64)
  • Care by CREAD showed that pain scores evaluated by the McGill pain questionnaire were higher at discharge but were equal on postoperative Day 10 compared with care by TRAD (p<0.02; n=64)
  • Mechanical massage with aspiration of abdominal wall and mechanical massage without aspiration groups both demonstrated similar Hamilton anxiety scores at the end of the study (n=50)
  • Mechanical massage with aspiration of abdominal wall and mechanical massage without aspiration groups had a similar time to discharge from hospital (n=50)
  • Gastrostomy and nasogastric tubes were associated with similar postoperative pain scores (n=107)
  • Postoperative restriction of IV fluids did not confer any benefit over the standard IV fluid regimen for reducing VAS pain scores at rest or during movement during the hospital stay (n=80)
  • Postoperative restriction of IV fluids did not confer any benefit over the standard IV fluid regimen for reducing the consumption of postoperative supplementary analgesics (n=80) Click here for more information
  • Postoperative restriction of IV fluids did not confer any benefit over the standard IV fluid regimen for reducing the incidence of postoperative nausea and vomiting (n=80)
  • Time to passage of first flatus was similar for patients allocated to the restricted postoperative IV fluid and standard postoperative IV fluid regimens (n=80)
  • Postoperative restriction of IV fluids conferred no significant benefit over the standard postoperative fluid regimen for reducing the time to medical discharge or hospital discharge (n=80)
  • Peri-operative IV glucose + amino acids conferred no signficant benefit over peri-operative IV glucose alone, for the reduction of VAS pain scores at rest or during movement at 12, 24, 36 or 48 h postoperatively (n=16)