Pre-Operative - ESRA
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Laparoscopic Cholecystectomy 2005

Pre-Operative

LAPAROSCOPIC CHOLECYSTECTOMY-SPECIFIC EVIDENCE

Arguments for…

  • Pre-operative clonidine significantly reduced opioid use compared with placebo Sung et al 2000 Click here for more information
  • Pre-operative clonidine significantly reduced the incidence of nausea compared with placebo (p<0.05), but there was no significant difference between groups for the incidence of vomiting Sung et al 2000

Arguments against…

 

LAPAROSCOPIC CHOLECYSTECTOMY-SPECIFIC EVIDENCE

Arguments for..

  • Gabapentin significantly reduced VAS pain scores at rest over the first 24 h following surgery compared with placebo (p<0.05)  Pandey et al 2004
  • Gabapentin significantly reduced opioid consumption compared with placebo (p<0.05; 2 µg/kg IV fentanyl was given on request) Pandey et al 2004
  • Gabapentin significantly reduced VAS pain scores at rest compared with tramadol at 6–24 h postoperatively (p<0.05), but not at 0–6 h Pandey et al 2004
  • Gabapentin significantly decreased opioid consumption compared with tramadol in the first 24 h postoperatively (p<0.05; 2 µg/kg IV fentanyl was given on request) Pandey et al 2004
  • Gabapentin was associated with a lower incidence of respiratory depression than tramadol (p<0.05) Pandey et al 2004

Arguments against…

 

LAPAROSCOPIC CHOLECYSTECTOMY-SPECIFIC EVIDENCE

Arguments for…

  • Eight studies out of ten showed a significant benefit of conventional NSAIDs over placebo or no treatment for reducing VAS pain scores; in most cases the benefit was limited to the very early postoperative period Munro et al 1998 Click here for more information
  • Five studies out of ten showed a significant benefit of conventional NSAIDs compared with placebo or no treatment for reducing supplemental analgesic use Forse et al 1996 Click here for more information
  • One study out of one showed that IM ketorolac (60 mg), administered intra-operatively pre-procedure (n=31), significantly increased the time to first analgesic request (p<0.05) compared with placebo (n=23) and IM ketorolac, administered intra-operatively post-procedure (n=20)  Lane et al 1996
  • One study measured parameters of pulmonary function and found that the values of FEV1 and FEF25–75 were significantly higher at 4 h after surgery in the ketorolac group compared with the placebo group (p<0.05) Liu et al 1993
  • One study out of one showed that tenoxicam (20 mg) + ondansetron (4 mg), administered in 20 ml saline before induction of anaesthesia, significantly reduced the time to first flatus compared with ondansetron alone (p<0.05) Elhakim et al 1995
  • Pre-operative ketoprofen significantly reduced VAS pain scores compared with postoperative ketoprofen during the first 12 h following surgery (p<0.05), with the effect being most evident during the first 3 h (p=0.001), although there was no significant difference between the two groups at 24 h Boccara et al 2005
  • Pre-operative ketoprofen significantly increased the time to first analgesic demand compared with postoperative ketoprofen (p<0.05) Boccara et al 2005
  • Pre-operative ketoprofen significantly reduced VAS pain scores compared with pre-operative propacetamol in one study, but two studies showed no significant difference for VAS pain scores between postoperative NSAIDs and postoperative propacetamol/paracetamol Boccara et al 2005 Click here for more information
  • One study showed that pre-operative ketoprofen significantly increased the time to first analgesic demand compared with pre-operative propacetamol, but there was no significant difference between the agents given postoperatively  Boccara et al 2005
  • Pre-operative ketoprofen significantly reduced opioid use compared with pre-operative propacetamol, but there was no significant difference between these agents given postoperatively Boccara et al 2005 Click here for more information
  • One study showed that pre-operative administration of IV tenoxicam + IM dextromethorphan was associated with significantly lower VAS pain scores than IV saline + IM dextromethorphan at 1 and 2 h at rest and at 1, 2 and 4 h on coughing (p<0.05 in each case), but not at other time points (data was collected at 1, 2, 4, 12, 24 and 48 h) Yeh et al 2004
  • The time to first analgesic request was significantly longer in the IV tenoxicam + IM dextromethorphan group compared with IV saline + IM dextromethorphan (p<0.001) Yeh et al 2004
  • One study showed that supplemental analgesia use and the number of patients requiring supplemental analgesia were significantly lower in the IV tenoxicam + IM dextromethorphan group compared with IV saline + IM dextromethorphan (p<0.05; p<0.001, respectively) (supplemental analgesia was IM pethidine 1 mg/kg on request) Yeh et al 2004
  • Compared with placebo, a regimen of conventional NSAID plus strong opioid, followed by LA infiltration, was associated with significantly lower VAS pain scores at 0, 0.5, 1, 2, 3 and 4 h after arrival in PACU, then at discharge and at 10 h (p<0.05 in each case) but not at 24 or 48 h; and also reduced VRS pain scores at all time points, except at 24 h (p<0.05) Michaloliakou et al 1996
  • Compared with placebo, a regimen of conventional NSAID plus strong opioid, followed by LA infiltration, was associated with a significantly greater proportion of patients without pain on arrival in PACU and with only mild pain at discharge (p<0.001 in each case)  Michaloliakou et al 1996
  • Compared with placebo, a regimen of conventional NSAID plus strong opioid, followed by LA infiltration, was associated with a significantly longer time to first analgesic request (p<0.001) Michaloliakou et al 1996
  • Compared with placebo, a regimen of conventional NSAID plus strong opioid, followed by LA infiltration, was associated with a significantly reduced proportion of patients requiring postoperative analgesia (p<0.001; postoperative analgesia was 10–20 mg IV pethidine every 10 minutes, until pain relief established, followed by oral or IM ketorolac 10–30 mg) Michaloliakou et al 1996
  • Compared with placebo, a regimen of conventional NSAID plus strong opioid, followed by LA infiltration, was associated with a significantly shorter time to discharge from PACU (p<0.05), although the time to the first bowel movement was similar in both groups Michaloliakou et al 1996
  • Compared with placebo, a regimen of conventional NSAID plus strong opioid, followed by LA infiltration, was associated with significantly reduced nausea scores in PACU (p<0.05), but there was no significant difference at any other time Michaloliakou et al 1996

Arguments against…

  • The time to first analgesic request was similar between tenoxicam and placebo in two comparison arms of one study (arm 1: pre-operative IV tenoxicam + IM chlorpheniramine maleate (20 mg) versus IV saline + IM chlorpheniramine maleate (20 mg); arm 2: pre-operative IV tenoxicam + IM dextromethorphan + IM chlorpheniramine maleate (20 mg) versus IV saline + IM dextromethorphan + IM chlorpheniramine maleate (20 mg)) Yeh et al 2005
  • Only two studies out of seven that recorded the incidence of nausea and/or vomiting showed that conventional NSAIDs significantly reduced the incidence of nausea and/or vomiting compared with placebo or no treatment Elhakim et al 1995Click here for more information
  • Pre-operative ketoprofen did not significantly reduce opioid use compared with postoperative ketoprofen Boccara et al 2005
  • There was no significant difference in the incidence of nausea or vomiting between pre-operative and postoperative administration of ketoprofen Boccara et al 2005
  • There were no significant differences between ketoprofen and propacetamol for the incidence of nausea or vomiting, administered pre- or post-operatively Boccara et al 2005
  • One study out of one found no significant differences for the duration of hospital stay between IM ketorolac, administered intra-operatively pre- and post-procedure, and placebo Lane et al 1996
  • One study out of one found no significant difference for the time to hospital discharge between IM diclofenac, administered after induction of anaesthesia (n=26), and placebo (n=23) Wilson et al 1994
  • One study out of one found that VAS pain scores in the IV tenoxicam + IM chlorpheniramine group were significantly higher than those in the IV saline + IM dextromethorphan + IM chlorpheniramine group at 1 h at rest and at 2 and 4 h on coughing (p<0.05 in each case), but not at other time points (VAS pain scores were recorded at 1, 2, 4, 12, 24 and 48 h) Yeh et al 2004
  • One study out of one found that the time to first analgesic request, pethidine use and the incidence of pethidine-related side-effects were not significantly different between the IV tenoxicam + IM chlorpheniramine and the IM dextromethorphan groups + IM chlorpheniramine Yeh et al 2004
  • One study that compared IM ketorolac + glycerin suppository, administered after the induction of anaesthesia, with IM saline + indomethacin suppository, showed no significant difference in pain scores, opioid use and incidence of nausea/vomiting Forse et al 1996
  • One study out of one found that the incidence of pethidine-related side-effects, such as nausea and vomiting, was similar in both the IV tenoxicam + IM dextromethorphan and the IV saline + IM dextromethorphan groups Yeh et al 2004
  • Study details Boccara et al 2005 Click here for more information
  • Table 1. Systemic conventional NSAIDs versus placebo or no treatment: Study details Elhakim et al 1995 Click here for more information

 

LAPAROSCOPIC CHOLECYSTECTOMY-SPECIFIC EVIDENCE

Arguments for…

Arguments against…

  • Pre-operative injection of dexamethasone (± ondansetron) did not reduce the duration of hospital stay compared with placebo or ondansetron alone Elhakim et al 2002
  • Pre-operative injection of dexamethasone (8 and 16 mg) + ondansetron did not significantly reduce antiemetic use compared with ondansetron alone Elhakim et al 2002
  • Pre-operative dexamethasone did not significantly affect pulmonary function (FVC, FEV1, PEF) compared with placebo Bisgaard et al 2003
  • There was no significant difference between the four doses of dexamethasone (2, 4, 8, 16 mg) for VAS pain scores at rest or with activity (each group received ondansetron 4 mg) Elhakim et al 2002
  • There was no significant difference between the four doses of dexamethasone (2, 4, 8, 16 mg) for opioid use at 12 and 24 h after surgery (each group received ondansetron 4 mg)  Elhakim et al 2002
  • There were no significant differences between the four doses of dexamethasone (2, 4, 8, 16 mg) for the incidence of PONV, antiemetic use and duration of hospital stay (each group received ondansetron 4 mg) Elhakim et al 2002
  • Study details Bisgaard et al 2003 Click here for more information

 

LAPAROSCOPIC CHOLECYSTECTOMY-SPECIFIC EVIDENCE

Arguments for…

Arguments against…

  • One study showed that pre-operative celecoxib and placebo were similar for abdominal and trocar entry site VAS pain scores at rest and during coughing at 0–6 h, and 12 and 24 h; both groups were similar for shoulder pain VRS Cheng et al 2004
  • There was no significant difference between celecoxib and placebo for the cumulative morphine consumption over the first 24 h following surgery Cheng et al 2004
  • One study showed that patients in both celecoxib and placebo groups took a similar length of time for analgesic request and had a similar severity of nausea and vomiting Cheng et al 2004
  • Parecoxib/valdecoxib was associated with reduced incidence of vomiting at 24 h post-discharge (p<0.05) compared with placebo, but overall incidence of PONV throughout the study period was not reduced Gan et al 2004 Click here for more information
  • There was no significant difference for bleeding tendency between celecoxib and placebo Cheng et al 2004
  • Study details Cheng et al 2004 Click here for more information

 

LAPAROSCOPIC CHOLECYSTECTOMY-SPECIFIC EVIDENCE

Arguments for…

  • IV lidocaine infusion significantly reduced VAS pain scores on coughing compared with placebo for 12 h following surgery (p<0.05), but not at 24 or 48 h, and only for 2 h at rest  Wu CT et al 2005
  • Compared with placebo, IV lidocaine infusion + IM dextromethorphan significantly reduced VAS pain scores at rest for the first 12 h postoperatively (p<0.05), but not at 24 and 48 h, and on coughing for the first 24 h (p<0.05), but not at 48 h  Wu CT et al 2005
  • IV lidocaine infusion + IM dextromethorphan significantly reduced VAS pain scores at rest at 1 and 4 h (p<0.05), and on coughing for the first 24 h (p<0.05), compared with either agent alone, but not at other time points (VAS measured at 1, 4, 12, 24 and 48 h)  Wu CT et al 2005
  • Total pethidine consumption was significantly lower in the IV lidocaine infusion group compared with the placebo group (p<0.001), as was the proportion of patients requiring pethidine (p<0.01) Wu CT et al 2005
  • IV lidocaine infusion + IM dextromethorphan significantly increased the time to first pethidine request compared with placebo (p<0.001) Wu CT et al 2005
  • IV lidocaine infusion + IM dextromethorphan significantly increased the time to first pethidine request compared with lidocaine alone (p<0.05) but not compared with dextromethorphan alone Wu CT et al 2005
  • IV lidocaine infusion + IM dextromethorphan was associated with significantly reduced pethidine requirements compared with placebo or either agent alone Wu CT et al 2005 Click here for more information
  • The incidence of nausea and vomiting was significantly lower in the IV lidocaine infusion + IM dextromethorphan group compared with the placebo group (p<0.001) Wu CT et al 2005
  • IV lidocaine infusion + IM dextromethorphan was associated with a significantly reduced incidence of nausea and vomiting compared with lidocaine alone (p<0.05), but not compared with dextromethorphan alone Wu CT et al 2005
  • IV lidocaine infusion + IM dextromethorphan significantly reduced the time to first passage of flatus compared with placebo (p<0.001)  Wu CT et al 2005
  • IV lidocaine infusion + IM dextromethorphan significantly reduced the time to first passage of flatus compared with either agent alone (p<0.05 Wu CT et al 2005

Arguments against…

 

LAPAROSCOPIC CHOLECYSTECTOMY-SPECIFIC EVIDENCE

Arguments for…

  • In two out of two studies, pre-operative IM dextromethorphan + IM chlorpheniramine maleate was associated with significantly reduced VAS pain scores compared with IM chlorpheniramine maleate alone Wu CT et al 2005 Click here for more information
  • Pre-operative, but not intra-operative, IM dextromethorphan + IM chlorpheniramine maleate significantly reduced the ‘worst pain’ score compared with IM chlorpheniramine maleate alone (p<0.000001) Wu et al 1999
  • One study out of one found that VAS pain scores in the IM dextromethorphan + IM chlorpheniramine maleate + IV saline group were significantly lower than those in the IV tenoxicam + IM chlorpheniramine maleate group at 1 h at rest and at 2 and 4 h on coughing (p<0.05, in each case), but not at other time points (VAS pain scores were recorded at 1, 2, 4, 12, 24 and 48 h) Yeh et al 2004
  • One study showed that pre-operative administration of IV tenoxicam + IM dextromethorphan + IM chlorpheniramine maleate was associated with significantly lower VAS pain scores than IV saline + IM chlorpheniramine maleate at 1 and 2 h at rest and at 1, 2 and 4 h on coughing (p<0.05 in each case), but not at other time points recorded (i.e. at 1, 2, 4, 12, 24 or 48 h) Yeh et al 2004
  • IM dextromethorphan + IV lidocaine significantly reduced postoperative pain compared with either dextromethorphan or IV lidocaine alone Wu CT et al 2005 Click here for more information
  • Compared with placebo, IM dextromethorphan + IV lidocaine significantly reduced VAS pain scores at rest for the first 12 h postoperatively (p<0.05), but not at 24 or 48 h, and on coughing for the first 24 h (p<0.05), but not at 48 h (each group received IM chlorpheniramine maleate) Wu CT et al 2005
  • In one study Wu CT et al 2005 Click here for more information
  • One study showed that supplemental analgesia use and the number of patients requiring supplemental analgesia were significantly lower in the IV tenoxicam + IM dextromethorphan + IM chlorpheniramine maleate group compared with IV saline + IM chlorpheniramine maleate (p<0.05; p<0.001, respectively) (supplemental analgesia was IM pethidine 1 mg/kg on request) Yeh et al 2004
  • Pre-operative Wu et al 1999 Click here for more information
  • The time to first analgesic request was significantly longer in the IV tenoxicam + IM dextromethorphan + IM chlorpheniramine maleate group compared with IV saline + IM chlorpheniramine maleate (p<0.001) Yeh et al 2004
  • IM dextromethorphan + IV lidocaine + IM chlorpheniramine maleate significantly reduced total pethidine use, the number of patients requiring morphine, and the time to first request, compared with IM chlorpheniramine maleate alone (p<0.001) (1 mg/kg IM pethidine was given if requested Wu CT et al 2005
  • IM dextromethorphan + IV lidocaine significantly reduced supplementary analgesic requirements compared with either agent alone Wu CT et al 2005 Click here for more information
  • IM dextromethorphan + IV lidocaine significantly reduced the time to first pethidine request compared with lidocaine alone (p<0.05), but not compared with dextromethorphan alone (all groups received IM chlorpheniramine maleate) Wu CT et al 2005
  • IM dextromethorphan + IV lidocaine were associated with significantly reduced incidence of nausea and vomiting compared with placebo (p<0.001), and compared with lidocaine alone (p<0.05), but not compared with dextromethorphan alone (all groups received IM chlorpheniramine maleate) Wu CT et al 2005
  • IM dextromethorphan + IV lidocaine were associated with significantly reduced time to first passage of flatus compared with placebo (p<0.001), and compared with either agent alone (p<0.05) (all groups received IM chlorpheniramine maleate) Wu CT et al 2005
  • Pre-operative IM dextromethophan significantly reduced the bed rest time compared with placebo and intra-operative IM dextromethorphan (p<0.001) Wu et al 1999
  • Pre-operative IM dextromethorphan significantly reduced the ‘worst pain’ score compared with intra-operative IM dextromethorphan Wu et al 1999
  • Pre-operative IM dextromethorphan significantly increased the time to first pethidine request compared with intra-operative IM dextromethorphan Wu et al 1999
  • Total pethidine consumption (1 mg/kg IM pethidine was given if requested) was significantly lower in the pre-operative IM dextromethorphan group compared with the intra-operative IM dextromethorphan group (p<0.0001) Wu et al 1999
  • IV ketamine infusion significantly reduced pain compared with placebo: VAS pain scores at rest at 2–4 h (p<0.05 in each case), but not at 0, 1, 8 or 20 h; VRS pain scores at 2 and 3 h (p<0.05 in each case), but not at other time points Ayoglu et al 2005
  • IV ketamine infusion significantly reduced cumulative opioid use compared with placebo at 2 and 3 h (p<0.05 in both cases), but not at 4 or 20 h (postoperative opioid was PCA bolus of 1 mg morphine, 10-minute lockout, maximum 4 h dose 20 mg) Ayoglu et al 2005
  • Pre-incisional IV ketamine + ropivacaine infiltration significantly reduced VAS pain scores compared with placebo at 0, 3 and 24 h (p<0.01 in each case), at 6 and 12 h (p<0.05 in both cases), but not at 48 h Papaziogas et al 2001
  • Pre-incisional IV ketamine + ropivacaine infiltration was associated with a significantly longer time to first request compared with placebo (p<0.05) Papaziogas et al 2001
  • Pre-incisional IV ketamine + ropivacaine infiltration significantly reduced the use of postoperative analgesics compared with placebo (p<0.05, postoperative analgesia: 50–100 mg diclofenac was given rectally, or 75 mg parenteral dextropropexyphene, if required; 50 mg IM pethidine was given if dextropropoxyphene was insufficient) Papaziogas et al 2001
  • IV ketamine infusion significantly reduced VAS pain scores at rest compared with magnesium at 4 and 20 h (p<0.05 in both cases), but not at 0–4 h or at 8 h; ketamine also significantly reduced VRS pain scores compared with magnesium at 4 h ( p<0.05), but not at other time points Ayoglu et al 2005

Arguments against…

  • One study out of one found that the time to first analgesic request, pethidine use and the incidence of pethidine-related side-effects were not significantly different between the IV tenoxicam + IM chlorpheniramine maleate and the IM dextromethorphan + IM chlorpheniramine maleate + IV saline groups Yeh et al 2004
  • One study out of one found that the incidence of pethidine-related side-effects, such as nausea and vomiting, was similar in both the IV tenoxicam + IM dextromethorphan + IM chlorpheniramine maleate and the IM chlorpheniramine maleate + IV saline groups Yeh et al 2004
  • In two out of three studies, the incidence of adverse effects, such as nausea and vomiting, was similar in the IM dextromethorphan + IM chlorpheniramine maleate + IV saline and the IM chlorpheniramine maleate + IV saline groups Wu et al 1999 Click here for more information
  • There were no significant differences between pre-operative and intra-operative IM dextromethorphan treatment groups for the incidence of nausea or vomiting Wu et al 1999
  • IV magnesium infusion did not significantly reduce VAS or VRS pain scores compared with placebo at any time during 0–20 h Ayoglu et al 2005
  • Postoperative, but not pre-operative, IV ketamine (bolus dose) reduced postoperative pain compared with placeboMathisen et al 1999 Click here for more information
  • IV magnesium infusion did not significantly reduce cumulative opioid use compared with placebo at any time during 0–20 h (postoperative opioid was PCA bolus of 1 mg morphine, 10-minute lockout, maximum 4 h dose 20 mg) Ayoglu et al 2005
  • Pre-operative and postoperative (R)-ketamine (bolus dose) were similar to placebo for pethidine use in the first 4 h, and for use of paracetamol + codeine at 24 h and 7 days postoperatively (postoperative analgesia: bolus doses of 0.1 mg/kg pethidine, 5-minute lockout, for 4 h, and after discharge, 500 mg paracetamol + 30 mg codeine) Mathisen et al 1999
  • IV ketamine and IV magnesium infusion were associated with similar cumulative opioid use during 0–20 h (postoperative opioid was PCA bolus of 1 mg morphine, 10-minute lockout, maximum 4 h dose 20 mg) Ayoglu et al 2005
  • IV ketamine and IV magnesium infusion and placebo were associated with a similar incidence of nausea and vomiting, and similar pulmonary function Ayoglu et al 2005
  • Pre-incisional IV ketamine + ropivacaine infiltration was similar to placebo for the incidence of nausea and vomiting Papaziogas et al 2001
  • Study details Wu et al 1999 Click here for more information
  • Dextromethorphan
  • Ketamine and magnesium

 

LAPAROSCOPIC CHOLECYSTECTOMY-SPECIFIC EVIDENCE

Argument for…

  • Fewer patients receiving pre-operative IV morphine requested ‘rescue’ opioid  compared with patients receiving placebo (unclear if significant for this particular comparison; 2–3 mg IV morphine was given when VAS pain 50 or greater) Munoz et al 2002
  • Immediately after surgery (i.e. at 0 h), sufentanil significantly reduced VRS pain scores compared with remifentanil (p=0.04), but there were no significant differences at all other time points (1–120 h)  Damen et al 2004
  • Compared with placebo, a regimen of strong opioid plus conventional NSAID, followed by LA infiltration, was associated with significantly lower VAS pain scores at 0, 0.5, 1, 2, 3 and 4 h after arrival in PACU, then at discharge and at 10 h (p<0.05 in each case) but not at 24 or 48 h; and also reduced VRS pain scores at all time points, except at 24 h (p<0.05) Michaloliakou et al 1996
  • Compared with placebo, a regimen of strong opioid plus conventional NSAID, followed by LA infiltration, was associated with a significantly greater proportion of patients without pain on arrival in PACU and with only mild pain at discharge (p<0.001 in each case) Michaloliakou et al 1996
  • Compared with placebo, a regimen of strong opioid plus conventional NSAID, followed by LA infiltration, was associated with a significantly longer time to first analgesic request (p<0.001) Michaloliakou et al 1996
  • Compared with placebo, a regimen of strong opioid plus conventional NSAID, followed by LA infiltration, was associated with a significantly reduced proportion of patients requiring postoperative analgesia (p<0.001; postoperative analgesia was 10–20 mg IV pethidine every 10 minutes, until pain relief established, followed by oral or IM ketorolac 10–30 mg) Michaloliakou et al 1996
  • Compared with placebo, a regimen of strong opioid plus conventional NSAID, followed by LA infiltration, was associated significantly shorter time to discharge from PACU (p<0.05), although the time to the first bowel movement was similar in both groups Michaloliakou et al 1996
  • Compared with placebo, a regimen of strong opioid plus conventional NSAID, followed by LA infiltration, was associated significantly reduced nausea scores in PACU (p<0.05), but there was no significant difference at any other time Michaloliakou et al 1996

Arguments against…

  • There were no significant differences between pre-operative IV morphine and placebo for VAS pain scores at rest or on coughing at any time point (i.e. 0–180 minutes) Munoz et al 2002
  • There were no significant differences between groups receiving pre-operative, intra-operative or postoperative IV morphine for VAS pain scores at rest or on coughing at any time point Munoz et al 2002
  • Pre-operative IV morphine and placebo groups took a similar length of time to first analgesic request Munoz et al 2002
  • There was no significant difference between pre-operative IV morphine and placebo groups for the incidence of postoperative emesis, although this was higher in the morphine group Munoz et al 2002
  • There were no significant differences between groups receiving pre-operative, intra-operative or postoperative IV morphine for opioid use (2–3 mg IV morphine was given when VAS pain 50 or greater), the incidence of emesis, or the length of time for first analgesia request  Munoz et al 2002
  • There were no significant differences between the remifentanil and sufentanil treatment groups for the use of supplementary analgesia, this being low in both groups (10 mg morphine and 100 mg diclofenac were given on demand, up to 60 mg morphine and 200 mg diclofenac/day) Damen et al 2004
  • Remifentanil and sufentanil were similar for the incidence of vomiting and VRS nausea scores at all time points and they were also similar for the time to discharge Damen et al 2004
  • Study details Munoz et al 2002 Click here for more information

 

LAPAROSCOPIC CHOLECYSTECTOMY-SPECIFIC EVIDENCE

Arguments for…

  • Oral tramadol significantly reduced VAS pain scores 0–24 h postoperatively compared with placebo (p<0.05)  Pandey et al 2004
  • Oral tramadol significantly reduced opioid use compared with placebo over the first 24 h following surgery (p<0.05; 2 µg/kg IV fentanyl was given on request)  Pandey et al 2004
  • The incidence of nausea/retching/vomiting was similar in both oral tramadol and placebo groups Pandey et al 2004
  • The incidence of nausea/retching/vomiting or sedation was similar in both oral tramadol and oral gabapentin groups Pandey et al 2004
  • The incidence of nausea and vomiting and of cardiovascular adverse events was similar in both the pre-operative IV tramadol + postoperative IV tramadol PCA group and pre-operative IV morphine + postoperative IV morphine PCA group Naguib et al 1998

Arguments against…

  • Oral tramadol was associated with significantly higher VAS pain scores at rest compared with oral gabapentin at 6–24 h postoperatively (p<0.05), but not at 0–6 h Pandey et al 2004
  • Pre- and postoperative IV tramadol were associated with significantly higher VAS pain scores at 30, 45 and 90 minutes following surgery, but not at any other time during 2–24 h, compared with pre- and postoperative IV morphine (p<0.05); pain scores recorded by an observer were similar between groups Naguib et al 1998
  • Pre-operative oral tramadol was associated with significantly greater opioid use compared with pre-operative oral gabapentin (p<0.05; 2 µg/kg fentanyl was given on request) Pandey et al 2004
  • PCA drug consumption in the early postoperative period was significantly greater in the pre-operative IV tramadol + postoperative IV tramadol group compared with the pre-operative IV morphine + postoperative IV morphine PCA group Naguib et al 1998 Click here for more information
  • There were no significant differences between pre-operative IV tramadol + postoperative IV tramadol PCA and pre-operative IV morphine and postoperative IV morphine PCA groups for the time taken to the first analgesic demand or for the proportion of patients not requesting PCA analgesia Naguib et al 1998
  • The incidence of sedation and respiratory depression was significantly higher in the oral tramadol group compared with the placebo group (p<0.05 in both cases)  Pandey et al 2004
  • The incidence of respiratory depression was significantly higher in the oral tramadol group compared with the oral gabapentin group (p<0.05) Pandey et al 2004
  • Study details Pandey et al 2004 Click here for more information

LAPAROSCOPIC CHOLECYSTECTOMY-SPECIFIC EVIDENCE

Arguments for…

  • The number of patients requiring supplemental nalbuphine, the total dose consumed and the time to first analgesic demand were similar in both pre-operative and postoperative propacetamol groups Boccara et al 2005
  • There were no significant differences between pre-operative ketoprofen and pre-operative propacetamol groups for the incidence of nausea or vomiting Boccara et al 2005
  • The incidence of nausea or vomiting was similar in both pre-operative and postoperative propacetamol groups Boccara et al 2005
  • Pre-operative propacetamol was associated with significantly higher VAS pain scores compared with pre-operative ketoprofen, but two studies showed no significant difference for VAS pain scores between postoperative NSAIDs and postoperative propacetamol/paracetamol Boccara et al 2005 Click here for more information

Arguments against…

  • Pre-operative propacetamol was associated with a significantly shorter time to first analgesic demand compared with pre-operative ketoprofen (p<0.05) (p-value given for the overall 4-group comparison) Boccara et al 2005
  • Pre-operative propacetamol was associated with significantly greater opioid use compared with pre-operative ketoprofen, but there was no significant difference between these agents given postoperatively Boccara et al 2005 Click here for more information
  • Postoperative administration of propacetamol significantly reduced VAS pain scores between 2 and 5 h postoperatively compared with pre-operative administration (p<0.05); the number of patients with severe pain (VAS 50 mm or greater) was significantly lower in the postoperative administration group compared with the pre-operative administration group (p<0.05) Boccara et al 2005
  • Study details Boccara et al 2005 Click here for more information

 

LAPAROSCOPIC CHOLECYSTECTOMY-SPECIFIC EVIDENCE

Arguments for…

  • The number of patients requiring supplemental nalbuphine, the total dose consumed and the time to first analgesic demand were similar in both pre-operative and postoperative propacetamol groups Boccara et al 2005
  • There were no significant differences between pre-operative ketoprofen and pre-operative propacetamol groups for the incidence of nausea or vomiting Boccara et al 2005

Arguments against…

  • The incidence of nausea or vomiting was similar in both pre-operative and postoperative propacetamol groups Boccara et al 2005
  • Pre-operative propacetamol was associated with significantly higher VAS pain scores compared with pre-operative ketoprofen, but two studies showed no significant difference for VAS pain scores between postoperative NSAIDs and postoperative propacetamol/paracetamol Boccara et al 2005 Click here for more information
  • Pre-operative propacetamol was associated with a significantly shorter time to first analgesic demand compared with pre-operative ketoprofen (p<0.05) (p-value given for the overall 4-group comparison) Boccara et al 2005
  • Pre-operative propacetamol was associated with significantly greater opioid use compared with pre-operative ketoprofen, but there was no significant difference between these agents given postoperatively Boccara et al 2005 Click here for more information
  • Postoperative administration of propacetamol significantly reduced VAS pain scores between 2 and 5 h postoperatively compared with pre-operative administration (p<0.05); the number of patients with severe pain (VAS 50 mm or greater) was significantly lower in the postoperative administration group compared with the pre-operative administration group (p<0.05) Boccara et al 2005
  • Study details Boccara et al 2005 Click here for more information

 

LAPAROSCOPIC CHOLECYSTECTOMY-SPECIFIC EVIDENCE

Arguments for…

  • General anaesthesia + paravertebral blockade significantly reduced VAS pain scores at rest and during activity compared with general anaesthesia alone at 6, 12, 24, 36 and 48 h (p<0.05 in each case), but not at 72 h; abdominal and shoulder VAS pain scores were significantly lower at 6 h only (p<0.05 in each case)  Naja et al 2004
  • General anaesthesia + paravertebral blockade significantly increased the proportion of patients who had VAS scores of less than 3 on movement, coughing and walking, up to 48 h postoperatively (p<0.05 in each case) Naja et al 2004
  • General anaesthesia + paravertebral blockade significantly reduced analgesic use compared with general anaesthesia alone at 0–36 h (p<0.05 in each case) (1 mg/kg IM pethidine was given in the first 12 hours if VAS 4 or greater; next 12 hours: 2 tablets oral dextropropoxyphene, every 6 hours, if VAS 4 or greater)  Naja et al 2004
  • The incidence of nausea, but not vomiting, was significantly reduced in the general anaesthesia + paravertebral blockade group compared with the general anaesthesia alone group at 6 and 12 h (p<0.05 in each case) Naja et al 2004

Arguments against…

  • General anaesthesia/bilateral paravertebral blockade was not significantly different from general anaesthesia alone for the time taken to defecation or to passing bowel gas, or for the duration of recovery room or hospital ward stay Naja et al 2004
  • Study details Naja et al 2004 Click here for more information

 

LAPAROSCOPIC CHOLECYSTECTOMY-SPECIFIC EVIDENCE

Spinal and epidural techniques 

Arguments for…

  • Pre-operative lumbar spinal LA + strong opioid was associated with significantly lower abdominal pain scores (at rest, on coughing, on first mobilisation) compared with placebo at all time points (i.e. at 2, 4, 6 and 20 h postoperatively; p<0.001 in each case) Motamed et al 2000
  • Pre-operative lumbar spinal LA + strong opioid was associated with significantly reduced cumulative IV morphine dose at 20 h after surgery compared with placebo (p<0.04), but not in the early postoperative period (postoperative IV morphine: bolus doses 1–3 mg every 5 minutes in recovery room, then PCA bolus doses 1 mg, 7-minute lockout) Motamed et al 2000

Arguments against…

 

LAPAROSCOPIC CHOLECYSTECTOMY-SPECIFIC EVIDENCE

Arguments for…

Arguments against…

  • Overall VAS pain scores (comprising of incisional, deep intra-abdominal and shoulder pain) were similar in the oral carbohydrate and placebo groups from 0–96 h in one study Bisgaard et al 2004
  • Postoperative opioid use was similar in the oral carbohydrate and placebo/no treatment groups in two of two studies  Bisgaard et al 2004
  • There were no significant differences between oral carbohydrate, placebo and no treatment groups for the duration of hospital stay Hausel et al 2005
  • Study details Bisgaard et al 2004 Click here for more information