Not recommended for open and laparoscopic colonic resection

Not recommended for open and laparoscopic colonic resection

















 


Pre-operative not recommended


Systemic analgesia 



  • IV clonidine (Grade D) because it is associated with an increased risk of hypotension and bradycardia
  • Conventional NSAIDs (Grade B) because pre-operative administration of these agents can increase the risk of intra- and postoperative bleeding
  • Corticosteroids for analgesia (Grade A) because of procedure-specific evidence showing no significant benefit in reducing pain scores and concerns that they could affect anastomotic and wound integrity (but they may be used for reduction of PONV)
  • Gabapentin/pregabalin (Grade D) due to a lack of procedure-specific evidence
  • Continuous administration of IV lidocaine limited to the pre-/intra-operative period (Grade D) because of inconsistent and insufficient procedure-specific evidence
  • NMDA receptor antagonists (Grade D) because of limited procedure-specifc evidence
  • Strong opioids (Grade B) as they are significantly less effective than postoperative strong opioids for reducing postoperative pain
  • Weak opioids (Grade B) based on procedure-specific evidence that they provide limited postoperative analgesic benefit compared with postoperative administration
  • Calcium channel antagonists (Grade B) based on limited procedure-specific evidence showing a lack of postoperative analgesic effect

Spinal anaesthesia



  • Spinal morphine (Grade D) because of the risk of side effects
  • Spinal clonidine (Grade B) based on procedure-specific evidence showing limited analgesic effect and the risk of side effects

Non-pharmacological therapy



  • Pre-operative use of guided imagery (Grade D) because of limited procedure-specific evidence
  • Laxatives for analgesia (Grade B) because limited procedure-specific evidence shows no analgesic benefit (but they may be used for reasons other than pain relief
  • Pentoxifylline (Grade D) due to limited procedure-specific evidence of its analgesic effect

LA for analgesia



  • Bilateral TAP block (Grade D) because of limited procedure-specific evidence

 


Intra-operative not not recommended


Systemic analgesia



  • IV clonidine (Grade D) because it associated with an increased risk of hypotension, sedation and bradycardia
  • Calcium channel antagonists (Grade B), based on limited procedure-specific evidence showing a lack of postoperative analgesic effect
  • Gabapentin/pregabalin (Grade D) due to a lack of procedure-specific evidence
  • Continuous administration of IV lidocaine limited to the pre-/intra-operative period (Grade D) because of inconsistent and insufficient procedure-specific evidence
  • NMDA receptor antagonists (Grade D) because of limited procedure-specific evidence of analgesic efficacy
  • Strong opioids (Grade D), in patients receiving epidural analgesia
  • Weak opioids (Grade D), as placebo-controlled evidence for their benefit in reducing postoperative pain is limited. In patients not receiving epidural analgesia, strong opioids, not weak opioids, are recommended

Epidural analgesia



  • Addition of clonidine to the combination of epidural LA + opioid (Grade D) because of side effects

Spinal analgesia



  • Spinal analgesia in combination with epidural anaesthesia (Grade B) based on a lack of benefit in reducing postoperative pain in colonic resection

 


Postoperative


not recommended


Systemic analgesia



  • Gabapentin/pregabalin (Grade D) due to a lack of procedure-specific evidence
  • NMDA receptor antagonists (Grade D) because of limited procedure-specific evidence of analgesic efficacy
  • IM strong opioids (Grade D)
  • Weak opioids (for controlling high-intensity pain) (Grade B)

Wound infiltration or infusion



  • Continuous postoperative wound infusion with LA (Grade D) as procedure-specific evidence is limited and inconsistent
  • Pre-closure wound infiltration with local anaesthetic (Grade D) due to lack of procedure-specific evidence and inconclusive transferable evidence from other large abdominal surgeries

Multi-modal rehabilitation protocols



  • Mechanical massage with aspiration of abdominal wall (Grade D) as further supportive data are needed
  • Nasogastric tubes (Grade A) because they are associated with discomfort and inconvenience and do not decrease the duration of postoperative ileus

 


Laparoscopic colonic resection


not recommended


 


Systemic analgesia



  • Continuous intra-/postoperative IV lidocaine (Grade D) because of limited procedure-specific data, despite some postive transferable evidence

Spinal analgesia



  • Combination of spinal analgesia and general anaesthesia (Grade D) as the risk: benefit balance is not positive, and because of limited procedure-specific evidence

Epidural analgesia



  • Epidural LA + strong opioid (Grade D) due to poor risk:benefit ratio

Gasless laparoscopic colectomy



  • Gasless laparoscopy (Grade B) based on procedure-specific evidence showing lack of analgesic effect

Laxatives



  • Laxatives for analgesia (Grade B) because limited procedure-specific evidence shows no analgesic benefit (but they may be used for reasons other than pain relief)

Multi-modal rehabilitation protocols



  • Postoperative restriction of IV fluids (Grade B) due to procedure-specific evidence showing limited analgesic efficacy