Postoperative Interventions

Systemic non-opioid analgesics

Arguments for…

Paracetamol was associated with a lower cumulative 24-hour dose of rescue oxycodone in a 3-arm study comparing paracetamol/ondansetron, paracetamol/placebo or placebo/placebo. Ondansetron did not influence the cumulative 24-hour dose of rescue oxycodone. Pain scores and opioid side effects were not different between groups (n=120) (Jokela 2010; LoE 1)
The combination of bupivacaine port site infiltration and ketorolac resulted in lower pain scores during the first six hours following surgery than placebo or either technique alone in one small 4-arm study (n=83) (Kim 2005; LoE 1)
Ketorolac had a sparing effect on remifentanil consumption, and decreased sedation score by, on average, approximately 0.5 points, in a study comparing IV-PCA using remifentanil, two combinations of remifentanil and ketorolac, and fentanyl combined with ketorolac (n=79) (Kim 2011; LoE 1)
Fentanyl PCA with nefopam reduced cumulative on-demand fentanyl consumption during the first 48 postoperative hours (107 ± 105 mcg [2 mg nefopam per PCA bolus] and 120.7 ± 91.1 mcg [4 mg nefopam per PCA bolus]) compared with fentanyl PCA only (236 ± 128 mcg). Pain scores, side effects and patient satisfaction were not different between groups (n=81) (Moon 2016; LoE 1)

A combination of paracetamol and NSAID/COX-2-selective inhibitor is recommended unless there are contraindications (Grade A), based on the origin and the type and duration of pain after laparoscopic hysterectomy as well as the available evidence of an opioid-sparing effect from procedure-specific RCTs (LoE 1)

Studies compared:
- IV-PCA morphine versus oxycodone (Lenz 2009; LoE 1)
- IV-PCA fentanyl versus oxycodone (Kim 2015, LoE 1; Kim 2017, LoE 1; Park 2015, LoE 1)
- Brief infusions of remifentanil (Lee 2010; LoE 1) or sufentanil (Lee 2012; LoE 1) before extubation

Opioids are recommended as rescue analgesia, postoperatively (Grade C)
- Observational studies suggest that most patients after laparoscopic hysterectomy require opioids as rescue drugs for a median of 4 days (As-Sanie 2017) (LoE 3)
- There is insufficient evidence to specifically recommend one opioid over another