Postoperative - ESRA
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Colonic Resection "2009"

Postoperative

OPEN COLONIC RESECTION-SPECIFIC EVIDENCE

Arguments for…

  • 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)

Arguments against…

  • 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

 

OPEN COLONIC RESECTION-SPECIFIC EVIDENCE – STUDY INFORMATION

Arguments for…

  • 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)

Arguments against…

  • 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)

 

OPEN COLONIC RESECTION-SPECIFIC EVIDENCE – STUDY INFORMATION

Arguments for…

  • 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)

Arguments against…

  • 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)

 

OPEN COLONIC RESECTION-SPECIFIC EVIDENCE – STUDY INFORMATION

Arguments against…

  • 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)

OPEN COLONIC RESECTION-SPECIFIC EVIDENCE – STUDY INFORMATION

Arguments for…

  • 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)

Arguments against…

  • 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)

OPEN COLONIC RESECTION-SPECIFIC EVIDENCE – STUDY INFORMATION

Arguments for…

  • 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)

Arguments against…

  • 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)

OPEN COLONIC RESECTION-SPECIFIC EVIDENCE – STUDY INFORMATION]

Arguments for…

  • 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)

Arguments against…

  • 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)

 

OPEN COLONIC RESECTION-SPECIFIC EVIDENCE – STUDY INFORMATION

Arguments for…

  • 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)

Arguments for…

  • 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)

 

OPEN COLONIC RESECTION-SPECIFIC EVIDENCE – STUDY INFORMATION

Arguments for…

  • 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

Arguments for…

  • 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)