Postoperative

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PROSPECT Recommendations

  • Post-delivery NSAIDs are recommended (GoR A) based on procedure-specific evidence (LoE 1), even in breastfeeding women (LoE 3)
  • Consensus agreement 100% (9/9)

C-Section-Specific Evidence

  • Rectal naproxen followed by oral naproxen compared with placebo reduced postoperative pain scores, especially on the first day after surgery, reduced the need for additional analgesics and prolonged the time to first analgesic request Angle et al 2002
  • For patients receiving IT morphine, the addition of diclofenac IM every 8 h compared to diclofenac IM only on request significantly reduced pain scores at 24 h, independent of the doses of IT morphine (0.1 mg, 0.05 mg, 0.025 mg) Cardoso et al 1998
  • Rectal diclofenac 100 mg every 12 h led to less morphine consumption compared with placebo. However, pain scores were similar between the two groups Dahl et al 2002
  • The use of diclofenac suppository 100 mg compared to no suppository reduced the need for ropivacaine and fentanyl given via PCEA from 6 to 18 h, but not from 0 to 6 h and not from 18 to 24 h. There was no significant difference between the two group in pain scores on movement Lim et al 2001
  • The postoperative administration of paracetamol and diclofenac was not superior to diclofenac alone and to paracetamol alone in pain scores at rest and on movement. However, patients receiving the combination of paracetamol and diclofenac needed significantly less morphine given via iPCA compared with paracetamol alone, but not compared with diclofenac. The groups did not differ in time to first independent ambulation Munishankar et al 2008
  • Administration of rectal diclofenac (3x 50 mg) was superior to placebo for reducing the need for supplemental analgesia. Postoperative pain was lower in patients receiving diclofenac during the first 3 h, but not afterwards Olofsson et al 2000
  • Rectal indomethacin significantly reduced pain scores and prolonged the time to first analgesic request compared with placebo Pavy et al 1995
  • The administration of intravenous ketorolac (</=120 mg/day) compared with placebo reduced the consumption of meperidine for 24 h, but not afterwards. The pain relief was similar between the two groups Pavy et al 2001
  • Diclofenac rectally plus propacetamol IV or diclofenac rectally provided more effective analgesia compared with placebo or propacetamol IV alone Siddik et al 2001 Click here for more information
  • Diclofenac suppository 100 mg after surgery followed by 3 additional doses at 8 h intervals was superior to pethidine 1 mg/kg IM after surgery followed by three additional doses at 8 h intervals for pain relief at 10 h, 18 h and 26 h, but not at 2 h. The incidence of PONV was similar between the two groups, but patients receiving pethidine reported dizziness significantly more frequently Soroori et al 2006
  • The combination of epidural morphine 2 mg plus diclofenac sodium 75 mg IM was superior to epidural morphine 2 mg plus saline solution IM and to epidural saline plus diclofenac 75 mg IM for pain relief. However, patients receiving epidural morphine experienced PONV and pruritus significantly more often Sun et al 1992
  • The administration of diclofenac 75 mg IM every 12 h for 2 doses compared to no intervention reduced the need for rescue analgesia and produced significantly lower pain scores Surakarn and Tannirandorn 2009
  • Postoperative ketorolac 30 mg IM and postoperative pethidine 75 mg IM showed similar analgesic efficacy and time to first analgesic request, although more side-effects were noted in the pethidine group Gin et al 1993
  • There were no significant differences in postoperative pain scores and supplemental analgesic use between the intravenous paracetamol group versus oral ibuprofen group Alhashemi et al 2006
  • The administration of oral valdecoxib 20 mg every 12 h for 72 h compared with placebo was not superior in pain relief, need for supplemental analgesics and time to first analgesic request Carvalho et al 2006
  • Spinal morphine 0.1 mg combined with IV ketorolac was not superior to different doses of spinal morphine (0.1 mg or 0.2 mg) or IV ketorolac alone in terms of pain relief and time to first analgesic request Cohen et al 1996
  • The administration of subcutaneous pethidine 1 mg/kg followed by subcutaneous pethidine 1 mg/kg with metoclopramide 10 mg IM every 8 h for three days was superior to oral diclofenac sodium 75 mg twice daily in terms of the need for rescue analgesia. However, both groups were not different in pain scores and incidence of PONV Marzida 2009
  • NSAIDs study details Click here for more information

PROSPECT Recommendations

  • Ketamine cannot be recommended at this time (GoR D) based on inconsistent procedure-specific evidence
  • Consensus agreement 100% (9/9)

C-Section-Specific Evidence

  • The administration of IV low-dose ketamine as an adjuvant to bupivacaine for spinal anaesthesia was associated with longer postoperative analgesia and a reduced need for analgesia consumption than bupivacaine alone Menkiti et al 2012
  • IV low-dose ketamine combined with IT bupivacaine provided better pain relief and lower postoperative analgesic consumption than bupivacaine alone Sen et al 2005
  • The administration of IV ketamine 0.2 mg/kg before the induction of anaesthesia decreased postoperative pain scores, the need for supplemental analgesia and prolonged the time to first analgesic request Ghazi-Saidi and Hajipour 2002
  • Women receiving IM S-ketamine 0.5 mg/kg followed by a 2 µg/kg/min IV continuous infusion over 12 h had a prolonged time to first analgesic request and a reduced cumulative morphine consumption compared with placebo. However, ketamine was associated with a significantly increased incidence of drowsiness, diplopia, nystagmus, dizziness, light-headness, positive dysphoria and vomiting Suppa et al 2012
  • The addition of IV ketamine compared to placebo for postoperative analgesia showed no benefit in time to first analgesic request, incidence of breakthrough pain and supplemental analgesics Bauchat et al 2011
  • The IV use of different doses of ketamine (0.25 mg/kg, 0.5 mg/kg, 1 mg/kg) compared with placebo produced similar postoperative pain scores and need for supplemental analgesia Bilgen et al 2012
  • Intraoperative IV ketamine (0.5 mg/kg) compared with placebo had no effect on pain relief and morphine consumption between 2 and 24 h Reza et al 2010
  • The administration of IV ketamine 0.5 mg/kg before the skin incision and infused continually at 0.25 mg/kg/h until the end of surgery was not superior to placebo in postoperative pain relief and supplemental fentanyl consumption Han et al 2013
  • Ketamine study details Click here for more information

PROSPECT Recommendations

  • Systemic opioids provide effective analgesia (GoR A, LoE 1), but are only recommended as rescue analgesics due to side effects (GoR D)
  • Consensus agreement 100% (9/9)

C-Section-Specific Evidence

  • Oral opioid vs IT opioid Click here for more information
  • The administration of subcutaneous pethidine 1 mg/kg followed by subcutaneous pethidine 1 mg/kg with metoclopramide 10 mg IM every 8 h for three days was superior to oral diclofenac sodium 75 mg twice daily for the need for rescue analgesia. However, both groups were not different in pain scores and incidence of PONV Marzida 2009
  • Oral oxycodone and IT morphine were similar for postoperative pain scores, but fewer patients receiving IT morphine requested supplemental analgesia McDonnell et al 2010 Click here for more information
  • Postoperative ketorolac 30 mg IM and postoperative pethidine 75 mg IM showed similar analgesic efficacy and time to first analgesic request, although more side-effects were noted in the pethidine group Gin et al 1993
  • Diclofenac suppository 100 mg after surgery followed by another three doses at 8 h intervals was superior to pethidine 1 mg/kg IM after surgery followed by another three doses at 8 h intervals for pain relief at 10 h, 18 h and 26 h, but not at 2 h. The incidence of PONV was similar between the two groups, but patients receiving pethidine experienced dizziness significantly more frequently Soroori et al 2006
  • Oral opioid versus IT opioid study details Click here for more information
  • Systemic opioid versus conventional NSAID study details Click here for more information
  • Systemic opioid: route of administration study details Click here for more information
  • Systemic opioid vs NSAID
  • Systemic opioid: route of administration
  • Transnasal butorphanol was superior to butorphanol IV in terms of quality and duration of analgesia Abboud et al 1991 Click here for more information
  • Pain relief was significantly greater in the group receiving oral oxycodone-paracetamol compared with the group receiving morphine via iPCA for 12 h and oral oxycodone-paracetamol after 12 h Davis et al 2006
  • The administration of piritramide via iPCA versus oral oxycodone was similar in terms of pain scores, need for supplemental anagesics and in the incidence of PONV Dieterich et al 2012
  • Subcutaneous and IM morphine produced a similar incidence of side effects and pain scores at rest, but pain scores on movement were reduced in the subcutaneous morphine group at 12, 16 and 20 h Safavi and Honarmand 2007

PROSPECT Recommendations

  • Post-delivery paracetamol is recommended (GoR A) based on procedure-specific evidence (LoE 1)
  • Consensus agreement 100% (9/9)

C-Section-Specific Evidence

  • There were no significant differences in postoperative pain scores and supplemental analgesic use between the IV paracetamol group and the oral ibuprofen group
  • The administration of IV paracetamol at the end of surgery and every 6 h for 24 h was superior to placebo for pain scores at 6, 12 and 24 h and for consumption of rescue analgesia Omar and Issa 2011
  • The postoperative administration of paracetamol and diclofenac was not superior to diclofenac alone and to paracetamol alone in pain scores at rest and on movement. However, patients receiving the combination of paracetamol and diclofenac needed significantly less morphine given via iPCA compared with paracetamol alone, but not compared with diclofenac. The groups did not differ in time to first independent ambulation Munishankar et al 2008
  • Paracetamol study details Click here for more information

PROSPECT Recommendations

  • Bilateral iliohypogastric and ilioinguinal blocks are recommended (GoR A) based on procedure-specific evidence for postoperative analgesia (LoE 1)
  • Consensus agreement 100% (9/9)

C-Section-Specific Evidence

  • In a systematic review, abdominal nerve blocks were found to reduce pain scores and postoperative opioid requirements vs placebo/no block Bamigboye and Hofmeyr 2009
  • An iliohypogastric-ilioinguinal peripheral nerve block using 0.5% bupivacaine 24 mL compared to saline decreased pain scores and delayed the first request for analgesia Wolfson et al 2012
  • Ilioinguinal and iliohypogastric nerve block with 0.5% ropivacaine was superior to nerve block with saline for pain scores at rest at 6, 8, 12, and 24 h and with movement at 6 and 8 h and led to a decreased supplemental analgesia need without increasing side effects Sakalli et al 2010
  • Ilioinguinal nerve block with 0.5% bupivacaine was superior to no nerve block for pain scores at 0, 4, 8 and 24 h while consumption of supplemental analgesia was decreased Bunting and McConachie 1988
  • Ilioinguinal and iliohypogastric nerve block under ultrasound guidance compared with placebo did not improve postoperative analgesia or decrease postoperative analgesic requirements Vallejo et al 2012
  • Iliohypogastric and ilioinguinal blocks study details Click here for more information

PROSPECT Recommendations

  • Bilateral TAP blocks are recommended (GoR A) based on procedure-specific evidence for postoperative analgesia (LoE 1)
  • Consensus agreement 100% (9/9)

C-Section-Specific Evidence

  • US-guided TAP block compared with no block significantly reduced postoperative morphine consumption. There were no differences between the groups in pain scores at rest and on moving, sedation level and PONV Tan et al 2012
  • TAP block compared with no block significantly reduced postoperative tramadol consumption, postoperative pain scores at rest and on coughing Eslamian et al 2012
  • A systematic review comparing TAP block with placebo showed inconsistent results concerning time to first analgesic request, postoperative opioid consumption and postoperative pain scores Fusco et al 2014
  • Spinal morphine 100 µg, but not TAP block, improved postoperative pain relief. The additional use of bilateral TAP block with bupivacaine 2 mg/kg combined with spinal morphine did not further improve postoperative pain relief McMorrow et al 2011
  • TAP block study details Click here for more information

PROSPECT Recommendations

  • TENS is not recommended (GoR D) based on limited procedure-specific evidence
  • Consensus agreement 78% (7/9)

C-Section-Specific Evidence

  • IV morphine-PCA combined with Hi-TENS significantly reduced the consumption of morphine compared with IV morphine-PCA alone. However, there were no significant differences in pain scores between the two groups Binder et al 2011
  • TENS versus placebo-TENS was superior for pain relief at rest and on movement. There was no difference in the request for additional analgesics Smith et al 1986
  • TENS was superior to placebo-TENS for pain relief at 8 h after delivery and associated with a reduced need for supplemental analgesia Kayman-Kose et al 2014
  • TENS study details Click here for more information

PROSPECT Recommendations

  • Wound infiltration with local anaesthetics is recommended (GoR A) based on procedure-specific evidence (LoE 1)
  • Consensus agreement 100% (9/9)
  • Wound infiltration with NSAIDs is not recommended at this time (GoR D) due to limited comparative data with systemic administration
  • Consensus agreement 89% (8/9)
  • Continuous wound infusion with local anaesthetics is recommended (GoR A) based on procedure-specific evidence (LoE 1)
  • Consensus agreement 100% (9/9)
  • Continuous wound infusion with NSAIDs is not recommended (GoR D) based on limited procedure-specific evidence
  • Consensus agreement 100% (9/9)

C-Section-Specific Evidence

  • In a systematic review, wound infiltration with LA reduced opioid use compared with control Bamigboye and Hofmeyr 2009
  • Combined pre- plus post-incisional local wound infiltration with lidocaine was superior to either pre-incisional or post-incisional local wound infiltration alone in postoperative pain scores Fouladi et al 2013
  • The addition of ketorolac to subcutaneous wound instillation of bupivacaine compared with bupivacaine resulted in lower pain scores on movement, but not at rest. However, the addition of hydromorphone to LA wound instillation did not significantly decrease postoperative pain scores at all. The use of supplemental analgesics was significantly lower in the group with additional ketorolac compared to the only bupivacaine group Carvalho et al 2013
  • Ropivacaine wound instillation via an elastometric pump was superior to sterile water in the reduction of postoperative morphine consumption. Pain scores at rest did not differ between the groups during the first 6 h. However, patients receiving ropivacaine had lower pain scores during coughing and leg raising between 3 and 6 h, but not before Fredman et al 2000
  • Continuous wound infusion with ropivacaine for 48 h was superior to epidural morphine for postoperative pain at rest and on movement. Patients receiving epidural morphine experienced significantly more PONV, pruritus and urinary retention O'Neill et al 2012
  • Wound infiltration with tramadol or levobupivacaine was superior to saline for the consumption of supplemental analgesia and for pain relief at 15 min, but not between 2 and 24 h Demiraran et al 2013
  • Continuous wound infusion for 48 h with 0.5% ropivacaine and ketoprofen through a multiholed wound catheter inserted below the fascia resulted in a reduced need for supplemental morphine compared with administration above the fascia. The groups did not differ in pain scores at movement. However, patients receiving administration below the fascia reported lower pain scores at 3, 6, 12, 24 and 36 h, but not at 48 h Rackelboom et al 2010
  • Subcutaneous surgical wound infiltration with bupivacaine 5 mg/mL compared with saline at 2 mL/h for 24 h resulted in similar postoperative pain scores and need for supplemental and rescue analgesia Carvalho et al 2010
  • IT morphine was superior to wound infiltration with ropivacaine or placebo for reducing the consumption of supplemental analgesics Kainu et al 2012 Click here for more information
  • Epidural levobupivacaine was superior to levobupivacaine administered via subfascial catheter in reducing pain scores at rest during the first 4 hours, but not afterwards. However, pain scores at walking and consumption for opioids were similar between the groups Ranta et al 2006
  • The IV system with morphine 10 mg and ketorolac 120 mg was more effective than continuous infusion of 0.2% levobupivacaine in reducing the need for supplemental analgesic and in reducing pain scores Magnani et al 2006
  • Wound infiltration or infusion study details Click here for more information