Pre-operative

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Pre-operative analgesia

Data are available from studies that assessed pre-operative analgesia versus pre-operative placebo, as well as those that, to examine the concept of pre-emptive — or preventive — analgesia, assessed pre-operative analgesia versus the same analgesia given postoperatively. However, a previous systematic review of pre-emptive analgesia for acute or chronic postoperative pain relief in a variety of surgical procedures — such as orthopaedic, dental, gynaecological and abdominal — has concluded that there is no benefit of pre-emptive over postoperative administration (Møiniche 2002). Nevertheless, it is considered that analgesic medication needs to be initiated in time to ensure an adequate analgesic effect in the immediate postoperative period. This may necessitate administration prior to the postoperative period.

PROSPECT Recommendations

  • There is no procedure-specific evidence that pre-operative administration of COX-2-selective inhibitors is more effective than postoperative administration
  • As with all analgesics it is recommended that COX-2-selective inhibitors should be administered in enough time to provide sufficient analgesia when the patient wakes (grade D)
  • It is recommended that the use of COX-2-selective inhibitors should depend upon assessment of individual patient risks (cardiovascular morbidity, actual or recent gastroduodenal ulcer history, bone healing, renal function and hepatic function [grade B] or aspirin-sensitive asthma [grade D])
  • Although there is concern about impairment of bone-healing with COX-2-selective inhibitors, there are no conclusive clinical studies to show that they have detrimental effects

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

  • COX-2-selective inhibitors given pre-operatively significantly reduced postoperative pain scores compared with placebo following spinal fusion Reuben et al 2000 Click here for more information
  • COX-2-selective inhibitors given pre-operatively had a significant postoperative opioid-sparing effect compared with placebo following spinal fusion Reuben et al 2000 Click here for more information
  • Pre-operative administration of oral rofecoxib 25 mg once daily, oral rofecoxib 50 mg or oral celecoxib 200 mg, did not increase intra- or postoperative blood loss when compared with placebo, in patients undergoing total knee arthroplasty or spinal fusion Reuben et al 2000
  • Randomised endoscopic trials in healthy volunteers have shown that COX-2-selective inhibitors are associated with a lower incidence of upper gastrointestinal ulceration compared with conventional NSAIDs for short-term use Harris et al 2001
  • Studies in healthy volunteers demonstrated that COX-2-selective inhibitors had no effect on platelet aggregation Greenberg et al 2000
  • A randomised clinical trial showed that the COX-2-selective inhibitor rofecoxib was associated with significantly less intra-operative blood loss than the conventional NSAID diclofenac in patients undergoing abdominal or vaginal hysterectomy or breast surgery Hegi et al 2004
  • Clinical studies investigating the response to oral challenge with COX-2-selective inhibitors in patients with aspirin-induced asthma have demonstrated that COX-2-selective inhibitors do not have an effect on respiratory function Bavbek et al 2004
  • A study to assess the safety of the COX-2-selective inhibitors parecoxib and valdecoxib following non-cardiac general surgery (including gastrointestinal, orthopaedic, gynaecological, urological, and thoracic surgeries) showed no difference in the incidence of cardiovascular thromboembolic events, renal dysfunction/failure, gastrointestinal ulcer complications, and surgical wound-healing complications, compared with placebo (n=1062) (in press, Anesthesiology)
  • Two clinical trials showed that in patients who had undergone CABG surgery, COX-2-selective inhibitors (valdecoxib and parecoxib) were associated with a higher rate of serious cardiovascular thromboembolic events (including myocardial infarction) compared with placebo Nussmeier et al 2005
  • Hypersensitivity reactions and serious skin reactions (e.g. toxic epidermal necrolysis, Stevens-Johnson syndrome, and erythema multiforme) can occur with all COX-2-selective inhibitors. Serious skin reactions have been reported in association with valdecoxib at a higher rate than with other COX-2-selective agents EMEA 2004a
  • Conventional NSAIDs and COX-2-selective inhibitors have been associated with an increased risk of transient hepatotoxicity. Cases of acute hepatic failure have also been reported. Elderly females, with autoimmune disease, and taking other potentially hepatotoxic drugs, may be most susceptible O'Connor et al 2003
  • Short-term use of COX-2-selective inhibitors or conventional NSAIDs can increase the risk of transient renal impairment, especially in patients with existing renal dysfunction, and both types of agent have been associated with cases of acute renal failure in high-risk patients Cheng et al 2004
  • COX-2-selective inhibitors and conventional NSAIDs may elevate blood pressure, particularly in hypertensive patients receiving antihypertensive medication Cheng et al 2004
  • Although there is some concern that COX-2-selective inhibitors may impair wound healing, evidence from animal and clinical studies is conflicting Blomme et al 2003
  • Conventional NSAIDs and COX-2-selective inhibitors have been associated with impaired bone healing in various animal models and in vitro studies Gajraj 2003

Total Hip Arthroplasty-Specific Evidence

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

PROSPECT Recommendations

  • Pre-operative conventional NSAIDs are not recommended, despite their analgesic efficacy, because they are associated with an increased risk of intra- and postoperative bleeding (grade A)
  • There is no procedure-specific evidence that pre-operative administration of conventional NSAIDs is more effective than postoperative administration

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

  • Intravenous diclofenac 75 mg or ketorolac 60 mg given pre-operatively significantly reduced pain scores compared with pre-operative placebo in the immediate postoperative period and at 8 h after total hip or knee arthroplasty Alexander et al 2002
  • Intravenous diclofenac 75 mg or ketorolac 60 mg given pre-operatively had a significant opioid-sparing effect compared with pre-operative placebo after hip or knee arthroplasty (for both drugs versus placebo: time 0, p = 0.009 and 8 h, p = 0.026; n =1 02) Alexander et al 2002
  • One randomised trial in patients undergoing transurethral prostatectomy showed that diclofenac did not affect total blood loss compared with placebo Bricker et al 1987
  • Randomised endoscopic trials in healthy volunteers have shown that COX-2-selective inhibitors are associated with a lower incidence of upper gastrointestinal ulceration compared with conventional NSAIDs for short-term use Harris et al 2001
  • Randomised trials in healthy volunteers showed that conventional NSAIDs (ketorolac, naproxen or diclofenac) reduced the platelet aggregation response compared with placebo; ketorolac and naproxen also prolonged bleeding time compared with placebo Greer et al 1999
  • Meta-analyses of randomised controlled trials showed that peri-operative conventional NSAIDs increased the risk of postoperative bleeding requiring treatment and/or the risk of re-operation for haemostasis after tonsillectomy compared with controls Marret et al 2003
  • A randomised trial in healthy volunteers showed that three conventional NSAIDs (diclofenac, ketorolac and ketoprofen) caused a reversible platelet dysfunction Niemi et al 1997
  • A randomised controlled trial showed that three conventional NSAIDs (diclofenac, ketorolac and ketoprofen) were associated with a similar incidence of surgical site bleeding after elective surgery Forrest et al 2002
  • A randomised clinical trial showed that the conventional NSAID diclofenac was associated with significantly greater intra-operative blood loss than the COX-2-selective inhibitor rofecoxib in patients undergoing abdominal or vaginal hysterectomy or breast surgery Hegi et al 2004
  • Aspirin and conventional NSAIDs can induce asthma attacks in patients with aspirin-exacerbated respiratory disease Stevenson 2004
  • Conventional NSAIDs and COX-2-selective inhibitors have been associated with an increased risk of transient hepatotoxicity. Cases of acute hepatic failure have also been reported. Elderly females, with autoimmune disease, and taking other potentially hepatotoxic drugs, may be most susceptible O'Connor et al 2003
  • Short-term use of conventional NSAIDs or COX-2-selective inhibitors can increase the risk of transient renal impairment, especially in patients with existing renal dysfunction, and both types of agent have been associated with cases of acute renal failure in high-risk patients Cheng et al 2004
  • Conventional NSAIDs and COX-2-selective inhibitors may elevate blood pressure, particularly in hypertensive patients receiving antihypertensive medication Cheng et al 2004
  • Conventional NSAIDs and COX-2-selective inhibitors have been associated with impaired bone healing in various animal models and in vitro studies Gajraj 2003

Total Hip Arthroplasty-Specific Evidence

  • Pre-operative administration of ketorolac 60 mg intravenously was superior to administration of ketorolac at closure for pain scores in the immediate postoperative period (p=0.03 at rest, p=0.0002 on movement), but the effect was not significant at all other times (6–48 h) Fletcher et al 1995
  • Pre-operative administration of ketorolac was superior to administration of ketorolac at closure for reducing the requirement for supplementary analgesia up to 6 h postoperatively (p<0.01), but not from 6–48 h Fletcher et al 1995
  • Pre-operative ibuprofen, 600 mg orally three times per day two weeks before surgery, showed no significant benefit in reducing postoperative pain scores or morphine consumption and produced a similar incidence of PONV compared with placebo, for 0–24 h (n=50) Bugter et al 2003
  • Pre-operative ibuprofen, 600 mg orally three times per day two weeks before surgery, significantly increased the median total peri-operative blood loss compared with placebo (1161 ml versus 796 ml; p<0.01; n=50) Bugter et al 2003
  • Pre-operative conventional NSAIDs significantly increased peri-operative blood loss in patients undergoing total hip arthroplasty compared with other analgesic agents in four out of five studies An et al 1991 Click here for more information
 

PROSPECT Recommendations

  • Gabapentin cannot be recommended at this time 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

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

 Total Hip Arthroplasty-Specific Evidence

  • [None cited]

PROSPECT Recommendations

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

Clinical Practice

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

Transferable Evidence from Other Procedures

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

Total Hip Arthroplasty-Specific Evidence

  • [None cited]

PROSPECT Recommendations

  • Pre-operative strong opioids are not recommended because of inconsistent evidence of their postoperative analgesic efficacy (grade A)
  • As with all analgesia, strong opioids should be administered in time to provide sufficient analgesia in the early postoperative recovery period (grade D)

Clinical Practice

  • As with all types of analgesia for postoperative pain, strong opioids should be instituted in time to secure sufficient analgesia when the patient wakes

Transferable Evidence from Other Procedures

  • Pre-operative oral administration of morphine sulphate 20 mg reduced supplementary analgesia requirements compared with pre-operative placebo, in a group of patients undergoing total hip or knee arthroplasty (p<0.05; n=98) Reiter et al 2003
  • Pre-operative oral administration of morphine sulphate 20 mg did not reduce postoperative pain scores compared with pre-operative placebo, in a group of patients undergoing total hip or knee arthroplasty (n=98) Reiter et al 2003

Total Hip Arthroplasty-Specific Evidence

  • Pre-operative morphine or pre-operative buprenorphine were not significantly different from placebo for the incidence of nausea or vomiting O'Sullivan et al 1983
  • Pre-operative morphine or pre-operative buprenorphine were not significantly different from placebo for postoperative pain scores O'Sullivan et al 1983
  • Oral sustained-release morphine 20 mg every 12 h, starting at premedication, did not significantly decrease VAS scores compared with IM morphine 10 mg every 6 h postoperatively Bourke et al 2000
  • Study details O'Sullivan et al 1983 Click here for more information