Postoperative Interventions

Systemic non-opioid analgesics

Arguments for…

Pre- and postoperative (for 24 h) IV paracetamol infusions reduced pain scores compared with IV dexmedetomidine over the ﬁrst 24 h after operation (p<0.05; n=78) (Swaika 2013; LoE 2). Both groups had adequate analgesia, but IV paracetamol was associated with signiﬁcantly less sedation when compared with dexmedetomidine infusions
Postoperative IV paracetamol was associated with reduced pain scores during the ﬁrst 12 h when compared with IV tramadol alone (Bandey 2016, LoE 2, n=60). The tramadol group did not receive routine postoperative paracetamol
When pre- and postoperative IV paracetamol was compared with oral paracetamol, there was no signiﬁcant difference in pain scores or opioid consumption (n=60) (Plunkett 2017, LoE 1)

Arguments against…

Postoperative paracetamol did not reduce pain scores or rescue analgesic use compared with placebo in a four-arm study comparing metamizol or parecoxib or paracetamol with placebo (n=120) (Abdulla 2012; LoE 1)

Paracetamol is recommended for routine use, continued postoperatively (Grade A), based on evidence of analgesic benefit (LoE 2)
The previous review recommended only postoperative paracetamol, but this review extends this recommendation to the pre-/intra-operative period

Arguments for…

Addition of dexketoprofen to tramadol PCA was associated with reduced pain scores and opioid consumption (n=40) (Ekmekçi 2012; LoE 2)
NSAID (metamizol) was associated with lower rescue analgesic use compared with placebo, but no change in pain scores, in a four-arm study comparing metamizol or parecoxib or paracetamol with placebo (n=120) (Abdulla 2012; LoE 1)
Two studies examined a combination of pre- and postoperative COX-2-selective inhibitors. One found reduced pain scores with lornoxicam quick-release 8 mg PO or parecoxib 40 mg IV compared with placebo (n=108) (Kouroukli 2013; LoE 1), but the effect was not seen at small doses (20 mg) of parecoxib IV (n=70) (Akaraviputh 2009; LoE 1)

Arguments against…

A single dose of parecoxib (80 mg or 40 mg) given at the end of anaesthesia showed no difference in pain scores or analgesic requirement compared with placebo (n=81) (Puolakka 2006; LoE 1)

NSAIDs/COX-2-selective inhibitors are recommended for routine use, continued postoperatively (Grade A), based on evidence of analgesic benefit (LoE 1 and 2)
The previous review recommended only postoperative NSAID, but this review extends this recommendation to the pre-/intra-operative period

Fentanyl versus oxycodone PCA did not demonstrate any difference in pain scores in one study (Hwang 2014, LoE 2, n=81)
Oxycodone given immediately after the operation was more effective than fentanyl for reducing pain scores, but tended to have more side-effects (Koch 2008, LoE 1, n=73)
The studies have shown side effects of opioids, which are to be avoided if possible.

Opioid analgesia should be reserved for rescue analgesia only (Grade B) to avoid potential side effects where possible (LoE 1 and 2)
The previous review recommended opioids for rescue analgesia (Grade D) but not for routine analgesia (Grade B) due to side effects during recovery