Abdominal Hysterectomy 2006

ABDOMINAL HYSTERECTOMY-SPECIFIC EVIDENCE – STUDY INFORMATION

Arguments for…

• Three out of five studies demonstrated that pre- and postoperative oral gabapentin was superior compared with placebo for reducing pain scores Gilron et al 2005 Click here for more information
• Two studies out of two showed a significant reduction in pain scores following pre- and postoperative oral gabapentin + rofecoxib administration compared with placebo following abdominal hysterectomy Gilron et al 2005 Click here for more information
• Four out of five studies demonstrated a decrease in supplementary postoperative analgesic use following pre- and postoperative oral gabapentin administration compared with placebo Dierking et al 2004 Click here for more information
• Two out of two studies demonstrated a decrease in supplementary postoperative analgesic use following pre- and postoperative oral gabapentin + rofecoxib administration compared with placebo Gilron et al 2005 Click here for more information
• Qualitative analysis of three out of four studies demonstrated that there was no significant difference in the incidence of adverse effects following pre- and postoperative oral gabapentin administration compared with placebo Dierking et al 2004
• Quantitative analysis showed that there was a significantly lower incidence of nausea in gabapentin group compared with the placebo group Click here for more information
• The incidence of side effects following pre- and postoperative oral gabapentin + rofecoxib was significantly lower in two studies out of two when compared with placebo Gilron et al 2005 Click here for more information
• Patient satisfaction with postoperative pain management was significantly higher at 24 h following pre- and postoperative oral gabapentin compared with placebo (p<0.001) Turan et al 2006
• Patient satisfaction with postoperative pain management was significantly higher in the pre- and postoperative oral gabapentin + rofecoxib group compared with placebo at 24 (p<0.01), 48 (p<0.01) and 72 h (p value not stated) postoperatively Turan et al 2006
• There was a significant inverse association between plasma levels of gabapentin at 2 h postoperatively, and morphine usage from 0–4 h postoperatively (R² =0.30, p=0.003, and R² =0.24, p=0.008, respectively), compared with placebo Dierking et al 2004
• Peak expiratory flow was higher in the pre- and postoperative oral gabapentin group compared with the placebo group throughout postoperative days 1 and 2 (p=0.002-0.0032) Gilron et al 2005
• Peak expiratory flow was higher in the pre- and postoperative oral gabapentin + rofecoxib group compared with the placebo group throughout postoperative days 1 and 2 (p<0.001) Gilron et al 2005

TRANSFERABLE EVIDENCE FROM OTHER PROCEDURES

Arguments for…

• Two systematic reviews and a meta-analysis evaluated the use of gabapentin for postoperative analgesia and demonstrated significant reductions in postoperative pain and supplementary analgesic requirements compared with inactive controls Dahl et al 2004

Arguments for…

• One systematic review Ho et al 2006
• One systematic review Ho et al 2006

PROSPECT RECOMMENDATIONS

• Pre- and postoperative gabapentin is recommended (Grade A) for its procedure-specific effects in reducing postoperative opioid use and postoperative nausea
• Further studies are required before it is possible to recommend a specific dose or regimen for administration (single or repeated doses)
• Procedure-specific and transferable evidence suggests that gabapentin may be associated with sedation, and it is recommended (Grade B) that this side effect should be considered when determining the dose that will be administered

ABDOMINAL HYSTERECTOMY-SPECIFIC EVIDENCE – STUDY INFORMATION

Arguments for…

• Six out of eight studies showed a significant benefit of postoperative conventional NSAIDs compared with placebo for postoperative pain scores Ng et al 2002a Click here for more information
• Conventional NSAIDs conferred a significant benefit over placebo for reducing supplementary analgesia requirements over 24 h or more Blackburn et al 1995 Click here for more information
• One study showed a marginal but significant benefit of rectal diclofenac over rectal paracetamol for reducing mean pain scores over 24 h (p=0.008; n=44): mean reduction in VAS of 0 mm at 8 h, 8 mm at 16 h and 21 mm for 0–24 h on a 100-mm scale Cobby et al 1999
• Ketorolac combined with morphine was not significantly different from a higher dose of morphine alone for reducing postoperative pain scores in one study (n=22) Kim et al 2001
• Ketorolac combined with morphine was superior to a higher dose of morphine alone for significantly reducing postoperative morphine consumption at 4 h (p=0.037) and 24 h (p=0.015) in one study (n=22) Kim et al 2001
• There was no significant difference between postoperative ketorolac and morphine each given by IM PCA for reducing postoperative pain scores at the doses studied (both study groups were allowed rescue morphine) (n=29) Black et al 1990
• Four studies and two arms of a fifth study showed no significant difference between conventional NSAIDs and weak opioids for VAS pain scores at rest over 24 h Rodriguez et al 1993 Click here for more information
• There was no significant difference between conventional NSAIDs and weak opioids for time to first analgesic request in one study reporting this parameter (n=58) Ilias et al 1996
• There is evidence that diclofenac is superior to paracetamol for reducing mean 24-h postoperative pain scores Cobby et al 1999 Click here for more information

Arguments against…

• Results were mixed for conventional NSAIDs compared with placebo for the time to first analgesic request Ilias et al 1996 Click here for more information
• Conventional NSAIDs and placebo were not significantly different for the incidence of PONV (all groups received background strong opioid) Blackburn et al 1995 Click here for more information
• There is evidence that weak opioids are superior to conventional NSAIDs for reducing supplementary analgesic consumption Rodriguez et al 1993 Click here for more information
• There was no significant difference between conventional NSAIDs and paracetamol for the requirement of postoperative supplementary analgesics Cobby et al 1999 Click here for more information
• Conventional NSAIDs and paracetamol were not significantly different for the incidence of vomiting Cobby et al 1999Click here for more information
• There is limited evidence of a reduction in the incidence of PONV with a conventional NSAID compared with a weak opioid Torres et al 2001 Click here for more information

TRANSFERABLE EVIDENCE FROM OTHER PROCEDURES

Arguments for…

• One randomised trial in patients undergoing transurethral prostatectomy showed that diclofenac did not affect total blood loss compared with placebo Bricker et al 1987

Arguments against…

• Piroxicam plus thoracic epidural analgesia using bupivacaine and morphine provided no significant benefit over epidural analgesia alone for reducing postoperative pain scores and supplementary analgesic consumption, in major upper abdominal surgery (n=44) Mogensen et al 1992b
• 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
• 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

PROSPECT RECOMMENDATIONS

• Conventional NSAIDs are recommended for their analgesic and opioid-sparing effects (grade A). 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)
• In patients receiving epidural analgesia, it is recommended that conventional NSAIDs are used only if analgesia is inadequate (grade B)
• 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)
• The use of conventional NSAIDs should depend upon assessment of individual patient risks (bleeding complications including epidural haematoma, cardiovascular morbidity, actual or recent gastroduodenal ulcer history, aspirin-sensitive asthma, renal function and hepatic function) (grade B)

ABDOMINAL HYSTERECTOMY-SPECIFIC EVIDENCE – STUDY INFORMATION

Arguments for…

• Strong opioids administered pre-, intra- and postoperatively were superior to placebo for reducing postoperative pain scores Broome et al 1995 Click here for more information
• Three studies showed that strong opioids administered pre-, intra- and postoperatively were superior to placebo for reducing supplementary analgesic consumption Broome et al 1995 Click here for more information
• Strong opioid administered as a single postoperative bolus provided a significant benefit over placebo for reducing postoperative pain scores at 24 h Collis et al 1995 Click here for more information
• The incidence of PONV was not significantly different between strong opioid and placebo plus rescue strong opioid in four out of five studies reporting this parameter Broome et al 1995 Click here for more information
• Sufentanil provided a significant benefit over morphine for reducing postoperative pain scores at rest and on movement for the first 2 h following initiation of PCA, but there was no significant difference for the remaining 24 h Ginsberg et al 2000 Click here for more information
• Sufentanil provided a significant benefit over morphine for reducing the supplementary analgesic consumption from 0–24 h (p<0.05), in one study reporting this parameter (n=40) Ginsberg et al 2000
• Three out of five studies showed a significant benefit of IV PCA over IM regular/on-request administration of strong opioids for reducing postoperative pain scores D’Haese et al 1998 Click here for more information
• There is mixed evidence for the benefit of PCA compared with regular/on-request IM administration of strong opioids for reducing overall opioid consumption, although one study suggests that they produced different patterns of dosing Thomas et al 1995 Click here for more information
• The incidence of PONV was not significantly different between PCA and IM morphine, in two studies reporting this parameter (n=126, n=22) Choiniere et al 1998
• Bolus plus infusion IV PCA morphine conferred a significant benefit over bolus IV PCA morphine alone for reducing postoperative pain scores with no significant difference in overall analgesic consumption El-Falaki et al 2000 Click here for more information
• IV pethidine was superior to intranasal pethidine for reducing postoperative pain scores at 5–80 min (p<0.05) and for reducing the total amount of pethidine consumed (p<0.05), in one study (n=60) Striebel et al 1993
• Oral slow-release and IM morphine were similar for postoperative pain scores, supplementary analgesic consumption and the incidence of PONV in two studies (n=38; n=30) Fell et al 1982
• Strong opioids gave numerically lower postoperative pain scores than weak opioids in three studies Coetzee et al 1998
• Morphine gave a numerically longer time to first analgesic request than tramadol in one study reporting this parameter, although the result did not reach statistical significance Coetzee et al 1998
• Different strong opioids were not significantly different from each other, for reducing postoperative pain scores, supplementary analgesia and PONV, in the majority of studies assessing different strong opioid regimens Chui et al 1992 Click here for more information

Arguments against…

• Bolus IV PCA plus background infusion of morphine was associated with a consistently greater consumption of morphine than IV PCA alone but the results did not reach statistical significance, in two studies (n=20, n=20) El-Falaki et al 2000
• Three studies showed no significant benefit of a postoperative bolus of strong opioid over placebo for reducing supplementary analgesic consumption Collis et al 1995
• Strong opioids provided no significant benefit over NMDA-receptor antagonists for postoperative pain scores or supplementary analgesic consumption in two studies Knoche et al 1983 Click here for more information

TRANSFERABLE EVIDENCE FROM OTHER PROCEDURES

• Opioids administered by PCA decreased the risk of pulmonary complications and patients preferred them compared with regular IM, IV or subcutaneous opioid treatment, although there was no significant difference for pain scores, as determined in a quantitative systematic review of randomised trials in various surgical procedures Walder et al 2001

CLINICAL PRACTICE

Arguments for…

• Strong opioids are considered to be an effective analgesic for postoperative pain following abdominal hysterectomy, but, because of their adverse effects, they are generally used in combination with non-opioid analgesics to minimise the opioid
• Regular administration, titrated for pain intensity, is generally accepted as an effective method of administering strong opioids

Arguments against…

• IM administration of strong opioids is considered to be more painful than IV administration. However, the dose and rapidity of IV administration should be assessed to minimise the risk of respiratory depression
• Transdermal patches are not approved for routine use because of the risk of opioid accumulation
• Continuous infusions of strong opioids by PCA, on top of PCA bolus doses, are being used less frequently as a precaution against opioid accumulation

PROSPECT RECOMMENDATIONS

• Strong opioids are recommended based on their analgesic efficacy in reducing high-intensity pain (VAS=50) in the early postoperative period (grade A)
• At clinical doses, different strong opioids are equally effective (grade A)
• IV PCA administration of strong opioids is recommended based on its greater analgesic efficacy, lower opioid load and greater patient satisfaction compared with regular (fixed-interval) or on-request dosing in hysterectomy and other procedures (grade A); however, fixed-interval IV administration titrated to pain intensity is also recognised as an effective mode of administration (grade D)
• Continuous infusion of strong opioid during PCA bolus dosing is not recommended, despite its analgesic efficacy over PCA bolus doses alone (grade A), because of potential opioid accumulation (grade D)
• IM administration of strong opioids is not recommended based on the pain associated with these injections (grade D)
• To minimise the dose of strong opioids, and associated side-effects, it is recommended that strong opioids are combined with COX-2-selective inhibitors or conventional NSAIDs, plus paracetamol (grade B) (see respective sections)
• There are not currently enough data to make a recommendation for other modes of administration of strong opioids, such as intra-nasal or slow-release tablets
• Transdermal patches are not recommended: they are not approved for routine use due to the risk of opioid accumulation (grade D)

ABDOMINAL HYSTERECTOMY-SPECIFIC EVIDENCE – STUDY INFORMATION

Arguments for…

• Four studies and two arms of a fifth study showed that weak opioids and conventional NSAIDs had a similar effect of reducing VAS pain scores at rest over 24 h Rodriguez et al 1993 Click here for more information
• Weak opioids and conventional NSAIDs had a similar effect of reducing supplementary analgesic consumption in one study reporting this parameter (n=130) Torres et al 2001
• Conventional NSAIDs and weak opioids have a similar effect for prolonging the time to first analgesic request in one study reporting this parameter (n=58) Ilias et al 1996

Arguments against…

• Tramadol 50 mg IV administered postoperatively on request gave numerically lower postoperative pain scores than placebo, but this was not statistically significant, in one study (n=40) Ilias et al 1996
• Tramadol 50 mg IV administered postoperatively on request gave a numerically longer time to first analgesic request than placebo but this was not statistically significant in one study (n=80) Ilias et al 1996
• Strong opioids gave numerically lower postoperative pain scores than weak opioids in three studies Coetzee et al 1998
• Morphine gave a numerically longer time to first analgesic request than tramadol in one study reporting this parameter, although the result did not reach statistical significance Coetzee et al 1998

ABDOMINAL HYSTERECTOMY-SPECIFIC EVIDENCE – STUDY INFORMATION

Arguments for…

• Paracetamol was superior to placebo for reducing postoperative pain scores, producing reductions in VAS scores of £13 mm Cobby et al 1999 Click here for more information
• Paracetamol was superior to placebo for reducing supplementary analgesic consumption within 0–24 h Cobby et al 1999 Click here for more information
• One study showed that IV paracetamol was as effective as IV ketorolac for reducing postoperative pain scores (n=176) Varrassi et al 1999

Arguments against…

• One study showed a marginal but significant benefit of rectal diclofenac compared with rectal paracetamol for reducing mean pain scores over 24 h, giving a mean difference in VAS of 0 mm at 8 h, 8 mm at 16 h and 21 mm for 0–24 h, on a 100-mm scale (p=0.008; n=44) Cobby et al 1999

TRANSFERABLE EVIDENCE FROM OTHER PROCEDURES

Arguments for…

• Paracetamol 1 g plus diclofenac 100 mg was superior to diclofenac 100 mg alone given once postoperatively, for reducing postoperative pain in dental surgery (p<0.05; n=46) Breivik et al 1999

Arguments against…

• There was no benefit of paracetamol with NSAID compared with NSAID alone for reducing pain scores in a meta-analysis of results from a variety of surgical procedures including dental, orthopaedic and gynaecological operations Rømsing et al 2002
• 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 (n=39) Montgomery et al 1996

PROSPECT RECOMMENDATIONS

• Paracetamol is recommended for moderate- (VAS<50>30 mm) or low-intensity (VAS £30 mm) pain, in combination with COX-2-inhibitors or conventional NSAIDs, based on its mild analgesic and opioid-sparing effect following hysterectomy (grade A)
• However, paracetamol is not recommended for high-intensity pain (VAS³ 50 mm) because it has no additional analgesic benefit over that conferred by NSAIDs following abdominal gynaecological procedures (grade B)

ABDOMINAL HYSTERECTOMY-SPECIFIC EVIDENCE

Arguments for…

• A regimen of ketamine plus midazolam was superior to pethidine for reducing postoperative pain scores, and was associated with a lower incidence of PONV compared with pethidine Jahangir et al 1993 Click here for more information
• Piritramide was superior to pentazocine, which was superior to ketamine for reducing postoperative pain scores Knoche et al 1983 Click here for more information
• Buprenorphine 0.4 mg SL on request was superior to papaveretum 20 IM on request for reducing postoperative pain scores (p<0.01) and supplementary analgesic consumption (p<0.001; n=60) Fry 1979

Arguments against…

• NMDA-receptor antagonists provided no significant benefit over placebo in reducing postoperative pain scores, supplementary analgesic consumption or PONV in the majority of studies, but the results were mixed and were independent of the timing of administration Burstal et al 2001 Click here for more information
• Postoperative midazolam provided no significant benefit in reducing postoperative pain scores or supplementary analgesic consumption for 0–24 h in one study Egan et al 1992 Click here for more information
• Clomipramine 50 mg IM and pentazocine 30 mg IM, each administered 30 min postoperatively, were similar for postoperative pain scores within 0–7 h (n=40) Tiengo et al 1987
• Delta-9-tetrahydrocannabinol 5 mg, administered as a single dose orally 24 h after surgery, did not provide a significant benefit over placebo for reducing postoperative pain scores at 0–6 h after administration (n=40) Buggy et al 2003
• Naloxone 0.25 µg/kg/h or 1 µg/kg/h conferred no benefit over placebo for reducing postoperative pain scores within 0–24 h and high-dose naloxone increased analgesic consumption over 0–24 h (p<0.05) (although low-dose naloxone decreased analgesic consumption, p<0.05) (n=60) Gan et al 1997

CLINICAL PRACTICE

Arguments against…

• NMDA-receptor antagonists are not used routinely because of the current lack of understanding of their optimum dose, rate and route of administration as well as their cost-benefit relationship. In addition, they are associated with adverse side-effects, e.g. ketamine is known for its toxicity and for causing dysphoria
• There is limited clinical experience of using pentazocine, clomipramine, delta-9-tetrahydrocannabinol and naloxone for analgesic purposes

PROSPECT RECOMMENDATIONS

• NMDA-receptor antagonists are not recommended based on inconsistent evidence of their analgesic efficacy (grade A), lack of clinical understanding of these agents, and the risk of side-effects (grade D)
• Benzodiazepines are not recommended based on their lack of analgesic efficacy (grade A)
• Other agents, such as pentazocine, clomipramine, delta-9-tetrahydrocannabinol and naloxone cannot be recommended for postoperative analgesia based on limited evidence for their analgesic efficacy (grade A) and a lack of clinical experience with these agents (grade D)

TRANSFERABLE EVIDENCE FROM OTHER PROCEDURES

Arguments for…

• Parecoxib 20 or 40 mg IV every 12 h reduced supplementary analgesic consumption compared with placebo in patients undergoing major gynaecological surgery (n=60) (p<0.05) Tang et al 2002
• 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
• 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 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) (in press, Anesthesiology)

Arguments against…

• 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 (n=60) (p<0.05) Tang et al 2002
• 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

CLINICAL PRACTICE

• Rofecoxib has been withdrawn from the market, and marketing of valdecoxib has been suspended in most countries

PROSPECT RECOMMENDATIONS

• COX-2-selective inhibitors are recommended for their effect in reducing supplementary analgesic use (grade B). 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)
• In patients receiving postoperative epidural analgesia, it is recommended that COX-2-selective inhibitors are used only if analgesia is inadequate (grade B) (see Postoperative, Conventional NSAIDs section)
• 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)
• The use of COX-2-selective inhibitors should depend upon assessment of individual patient risks (cardiovascular morbidity, actual or recent gastroduodenal ulcer history, renal function and hepatic function [grade B] or aspirin-sensitive asthma [grade D])

ABDOMINAL HYSTERECTOMY-SPECIFIC EVIDENCE – STUDY INFORMATION

Arguments for…

• Postoperative epidural ropivacaine was superior to placebo for reducing postoperative pain scores at rest and on coughing within 0–2, 0–4 and 4–12 h, but results at 2–22 h were non-significant (n=104) Chinachoti et al 2002
• Combined epidural strong opioid and local anaesthetic was superior to epidural strong opioid alone for reducing postoperative pain scores within 12–24 h (p<0.05; n=40) Madej et al 1992
• Combined epidural strong opioid and local anaesthetic was associated with a lower incidence of PONV than epidural strong opioid alone (p<0.05; n=40) Madej et al 1992
• Addition of sufentanil to morphine, as an epidural bolus dose, gave lower postoperative pain scores than morphine alone for 0–6 h (n=30; n=120) Sinatra et al 1991
• Epidural bolus morphine alone was superior to sufentanil alone and to morphine plus sufentanil, at 240 min after administration (n=45) Sinatra et al 1991
• Bupivacaine was superior to morphine for reducing pain scores and for reducing times to recovery of bowel motility Thoren et al 1989 Click here for more information
• Postoperative epidural high-dose naloxone (0.167 µg/kg/hr) was superior to placebo for reducing postoperative pain scores at 8, 16 and 32 h (p<0.05), but results at 2, 4 and 48 h were non-significant Choi et al 2000 Click here for more information
• Clonidine or clonidine plus sumatriptan conferred a significant benefit over sumatriptan alone for reducing postoperative pain scores within 0–4 h (p<0.01) in one study Liu at al 1997b Click here for more information
• Epidural bupivacaine was superior to ropivacaine for reducing supplementary ketorolac consumption and gave a larger spread of sensory block than ropivacaine, while recovery outcomes were not significantly different Jorgensen et al 2000a Click here for more information
• Diamorphine was superior to ketamine for reducing postoperative pain scores and for extending the time to first analgesic request Peat et al 1989 Click here for more information
• Epidural analgesia had a statistically significant, and marginally clinically significant, benefit over systemic analgesia for reducing postoperative pain scores at 4 h Hindsholm et al 1993 Click here for more information
• Epidural analgesia provided a significant benefit over IV administration for reducing analgesic consumption over 24 h Eriksson-Mjoberg et al 1997b Click here for more information
• Epidural analgesia was associated with a significantly lower incidence of PONV compared with systemic analgesia Camu et al 1991 Click here for more information

Arguments against…

• There is evidence for a limited benefit of epidural clonidine over epidural morphine for reducing postoperative pain scores, but two of two studies showed that clonidine causes hypotension Lund et al 1989 Click here for more information

TRANSFERABLE EVIDENCE FROM OTHER PROCEDURES

• Epidural analgesia using local anaesthetic was superior to systemic strong opioid for reducing postoperative pain scores in six studies identified in a systematic review of abdominal surgery Jorgensen et al 2000b
• Epidural analgesia using a combination of local anaesthetic and strong opioid was superior to local anaesthetic 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 Jorgensen et al 2000b
• Epidural analgesia using local anaesthetics was superior to epidural opioids or systemic opioids for reducing the incidence of postoperative gastrointestinal paralysis, in a systematic review in abdominal surgery Jorgensen et al 2000b

PROSPECT RECOMMENDATIONS

• Continuous postoperative epidural infusion is not recommended for routine use in hysterectomy patients because its analgesic benefits compared with systemic analgesia are short-lasting and are of marginal clinical significance (up to 4 h) (grade A). Therefore, the risks of the epidural technique outweigh the analgesic benefits in low-risk patients (grade D)
• Continuous postoperative epidural analgesia with local anaesthetic plus strong opioid is recommended in high-risk patients (e.g. those at risk of organ dysfunction and some patients undergoing extensive surgery for malignancy) – and in these patients it is recommended that the epidural is also used for anaesthesia – because the benefits of the epidural technique, e.g. reduction in inhaled anaesthetics and systemic opioids as well as reduced paralytic ileus and improved pulmonary function (grade
• Despite the analgesic benefits of epidural clonidine, it is not recommended to control postoperative pain following abdominal hysterectomy because of the incidence of hypotension (grade A), sedation and bradycardia (grade D)