Knowledge Key:
Arguments against Arguments againste
Arguments for Arguments for
Prospect Recommendation Prospect Recommendation
Clinical Practice Clinical Practice
Transferable Evidence Transferable Evidence
Procedure Specific Evidence Procedure Specific Evidence

Pre-Operative

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In this section, data are available from studies that assessed pre-operative analgesia versus pre-operative placebo...

In this section, data are available from studies that assessed pre-operative analgesia versus pre-operative placebo, as well as those that examine the concept of pre-emptive – or preventive – analgesia, assessed pre-operative analgesia versus the same analgesia given postoperatively.

A previous systematic review of pre-emptive analgesia for postoperative pain relief in a variety of surgical procedures – such as orthopaedic, dental, gynaecological and abdominal – concluded that there is no benefit of pre-emptive over postoperative administration (Møiniche 2002). More recently, a meta-analysis of studies comparing pre-operative interventions with similar postoperative interventions in various procedures, found that pre-operative epidural analgesia was effective in reducing postoperative pain scores, but that pre-operative NSAIDs, local anaesthetic wound infiltration, NMDA antagonists and opioids did not improve postoperative analgesia (Ong 2005b).

 Despite these findings, it is considered that analgesic medication needs to be initiated in time to ensure an adequate analgesic effect in the immediate postoperative period. This may necessitate administration prior to the postoperative period.

Systemic Analgesia

PROSPECT Recommendations

  • Clonidine is not recommended (Grade D), despite limited procedure-specific evidence for analgesic efficacy, because it is associated with an increased risk of hypotension and bradycardia (LoE 4)

Clinical Practice

  • The risk:benefit ratio for clonidine is unclear. Recognised side-effects include hypotension, sedation, dizziness and bradycardia
  • There is no consensus among clinicians on the optimum dose of clonidine that should be used

Transferable Evidence from Other Procedures

Open Colonic Resection-Specific Evidence - Study information

PROSPECT Recommendations

  • Pre-operative COX-2-selective inhibitors are recommended (Grade B) for colonic resection based on procedure-specific evidence that they have an analgesic effect postoperatively (LoE 2), only for patients who do not receive epidural analgesia (LoE 4)
  • It is recommended that the use of COX-2-selective inhibitors should depend upon assessment of individual patient risks (Grade B): cardiovascular morbidity (transferable evidence, LoE 1), renal function and hepatic function (transferable evidence, LoE 3), or actual or recent gastroduodenal ulcer history (LoE 4). In addition, the potential risk of anastomotic leakage needs to be considered (transferable evidence, LoE 3). Further observations are required regarding the potential risk of N

Clinical Practice

  • Rofecoxib has been withdrawn from the market, and marketing of valdecoxib has been suspended in most countries
  • There is no procedure-specific evidence that pre-operative administration of COX-2-selective inhibitors is more effective than postoperative administration

Transferable Evidence from Other Procedures - Study information

  • A pre-operative single bolus of parecoxib was superior to placebo for postoperative pain scores on sitting-up over 24 h (p=0.02), providing a mean decrease of 14 mm in VAS scores on a 100 mm scale in patients undergoing abdominal hysterectomy (n=36)
  • A retrospective cohort study showed that the COX-2-selective inhibitors rofecoxib and celecoxib were associated with a lower risk of acute kidney infection than less-selective NSAIDs
  • A meta-analysis that included data from 17 parecoxib and 15 valdecoxib placebo-controlled trials in non-cardiac surgery showed that there was no significant association between short-term treatment with parecoxib and/or valdecoxib and an increase in cardiovascular thromboembolic adverse events, compared with placebo (n=8511 overall)
  • A review concluded that COX-2-selective inhibitors were as effective as conventional NSAIDs for treatment of postoperative pain in various surgical models, and offer a number of other advantages including: reduced incidence of gastrointestinal ulceration, no inhibitory effect on platelet function (and thereby a reduced risk of blood loss) and no induction of bronchospasm in patients with aspirin-sensitive asthma
  • 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)
  • 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
  • A randomised clinical trial showed that the COX-2-selective inhibitor rofecoxib was associated with significantly less intra-operative blood loss than the conventional NSAID diclofenac in patients undergoing abdominal or vaginal hysterectomy or breast surgery
  • Studies in healthy volunteers demonstrated that COX-2-selective inhibitors had no effect on platelet aggregation
  • 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
  • Pre-operative oral rofecoxib compared with placebo had significantly lower pain scores at rest and after spirometry at 12 h postoperatively in patients undergoing abdominal surgery (rofecoxib 25 mg and 50 mg versus placebo p<0.05; n=48)
  • COX-2-selective inhibitors are similarly effective compared with conventional NSAIDs for reducing postoperative opioid consumption in patients undergoing abdominal hysterectomy Celik et al 2003 Click here for more information
  • Pre-operative oral COX-2-selective inhibitors were as effective as oral conventional NSAIDs for reducing postoperative pain scores in two studies of patients undergoing abdominal hysterectomy (n=25; n=40)
  • Pre-operative oral rofecoxib was associated with a lower incidence of PONV compared with placebo in one study (p<0.05; n=40)
  • One study found that pre-operative oral etoricoxib was superior to placebo for reducing mean postoperative morphine consumption after 24 h (120 and 180 mg etoricoxib versus placebo, p=0.012) (n=49)
  • A pre-operative single bolus of IV parecoxib or oral rofecoxib reduced morphine consumption over 24 h compared with placebo in patients undergoing abdominal hysterectomy Ng et al 2003 Click here for more information
  • Pre-operative oral etoricoxib was superior to placebo for reducing pain scores at rest and on coughing at a minority of timepoints Chau-in et al 2008 Click here for more information
  • COX-2-selective inhibitors provide similar postoperative analgesia to conventional NSAIDs
  • Pre-operative oral rofecoxib reduced morphine consumption at 24 h postoperatively compared with placebo in patients undergoing abdominal surgery (rofecoxib 25 mg versus placebo p<0.01; n=48)
  • One study in patients undergoing fast-track colonic surgery found that postoperative analgesia with the COX-2-selective inhibitor celecoxib was associated with a higher risk of anastomotic leakage, compared with when celecoxib was not used
  • Although there is some concern COX-2-selective inhibitors may impair wound healing, evidence from animal and clinical studies is conflicting (
  • COX-2-selective inhibitors and conventional NSAIDs may elevate blood pressure, particularly in hypertensive patients receiving antihypertensive medication
  • 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
  • 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
  • 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
  • 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
  • Two meta-analyses comparing pre-incisional and post-incisional NSAIDs/COX-2-selective inhibitors have found no significant benefit of pre-incisional administration for reducing pain scores
  • A pre-operative single bolus of COX-2-selective inhibitor did not significantly reduce postoperative pain scores at rest compared with placebo within 0–24 h in two studies of patients undergoing abdominal hysterectomy (n=40; n=36)

Open Colonic Resection-Specific Evidence – Study information

  • Pre-operative + postoperative oral valdecoxib was superior to placebo for reducing postoperative pain scores Sim et al 2007 Click here for more information
  • Pre-operative parecoxib was superior to placebo for reducing postoperative morphine consumption at a minority of timepoints Lee et al 2008 Click here for more information
  • Pre-operative + postoperative oral valdecoxib was superior to placebo for reducing postoperative morphine consumption Sim et al 2007 Click here for more information
  • The time until first flatus and first bowel movement was significantly shorter with pre-operative + postoperative oral valdecoxib, compared with placebo (p=0.003 and p=0.041, respectively; n=79)
  • The time taken to tolerate a solid diet was significantly shorter with pre-operative + postoperative oral valdecoxib versus placebo (p=0.029; n=79)
  • The length of hospital stay was significantly shorter for patients in the pre-operative + postoperative oral valdecoxib group, compared with the placebo group (p=0.009; n=79)
  • Pre-operative + postoperative administration of 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
  • Pre-operative IV parecoxib did not confer any significant benefit over intra-operative IV parecoxib or placebo for the reduction of postoperative pain scores Lee et al 2008 Click here for more information
  • There was no significant difference in postoperative morphine consumption between the pre-operative IV parecoxib and intra-operative IV parecoxib groups from 0–48 h postoperatively (n=40)
  • The incidence of postoperative nausea and vomiting, dizziness and pruritus was similar between the pre-operative IV parecoxib, intra-operative IV parecoxib and placebo groups (n=60)
  • The incidence of postoperative sedation and nausea was similar with pre-operative + 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 (n=79)
  • The hospital re-admission rate was similar in both the pre-operative + postoperative oral valdecoxib, and placebo groups (n=79)
  • The incidence of postoperative nausea and vomiting, dizziness and pruritus was similar in the pre-operative IV parecoxib and intra-operative IV parecoxib groups

PROSPECT Recommendations

  • Pre-operative conventional NSAIDs are not recommended (Grade B) despite their analgesic efficacy, because pre-operative administration of these agents can increase the risk of intra- and postoperative bleeding (transferable evidence, LoE 1)
  • In addition, pre-operative conventional NSAIDs are not recommended, because there is evidence from other procedures that pre-operative administration of conventional NSAIDs is no more effective than postincisional administration for reducing pain scores (Grade B) (transferable evidence, LoE 1). In addition, the potential risk of anastomotic leakage needs to be considered (transferable evidence, LoE 3)

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures - Study information

  • Conventional NSAIDs have proven analgesic efficacy in a variety of surgical procedures
  • A meta-analysis of randomised controlled trials performed to evaluate the risk of morphine-related adverse effects in patients treated with NSAIDs, demonstrated that NSAIDs decreased the incidence of nausea, vomiting and sedation, but not pruritus, urinary retention or respiratory depression
  • One randomised trial in patients undergoing transurethral prostatectomy showed that diclofenac did not affect total blood loss compared with placebo
  • Pre-operative naproxen was equally as effective as the COX-2-selective inhibitor rofecoxib for reducing postoperative pain scores at rest over 24 h, in patients undergoing abdominal hysterectomy (n=40)
  • A restrospective, case-control study showed that postoperative analgesia with the conventional NSAID diclofenac (150 mg daily) was associated with a significantly higher number of anastomotic leakages than postoperative opioid analgesia in patients undergoing laparoscopic colorectal surgery
  • Conventional NSAIDs and COX-2-selective inhibitors may elevate blood pressure, particularly in hypertensive patients receiving antihypertensive medication
  • 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
  • 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
  • Aspirin and conventional NSAIDs can induce asthma attacks in patients with aspirin-exacerbated respiratory disease
  • A randomised clinical trial showed that the conventional NSAID diclofenac was associated with significantly greater intra-operative blood loss than the COX-2-selective inhibitor rofecoxib in patients undergoing abdominal or vaginal hysterectomy or breast surgery
  • 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
  • A randomised trial in healthy volunteers showed that three conventional NSAIDs (diclofenac, ketorolac and ketoprofen) caused a reversible platelet dysfunction
  • 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
  • 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
  • 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
  • Pre-incisional administration of conventional NSAIDs conferred no significant benefit over post-incisional administration for reducing the incidence of PONV in two studies of patients undergoing abdominal hysterectomy (n=65, n=30)
  • Post-incisional NSAID was superior to pre-incisional NSAID for extending the time to first analgesic request in one study (n=30)
  • Of three studies in abdominal hysterectomy, all showed no significant difference between pre-incisional and post-incisional conventional NSAIDs for supplementary analgesic consumption (n=65; n=30; n=77)
  • Two of three studies showed no significant difference between single bolus conventional NSAIDs administered before or after incision for postoperative pain scores in patients undergoing abdominal hysterectomy Nakayama et al 2001a Click here for more information
  • Two meta-analyses comparing pre-incisional and post-incisional NSAIDs/COX-2-selective inhibitors have found no significant benefit of pre-incisional administration for reducing pain scores
  • Pre-operative rofecoxib was superior to naproxen for reducing the use of postoperative supplementary analgesics within 12–18 h (p<0.05), but there was no significant difference within 0–24 h in patients undergoing abdominal hysterectomy

Open Colonic Resection-Specific Evidence

  • Pre-operative + postoperative IV flurbiprofen was superior to placebo for reducing postoperative pain scores Xu et al 2008 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)
  • The incidence of postoperative nausea and vomiting was similar in the pre-operative + postoperative flurbiprofen axetil and placebo groups (n=40)

PROSPECT Recommendations

  • Pre-operative corticosteroids are not recommended for analgesia (Grade A) because of procedure-specific evidence showing no significant benefit in reducing VAS pain scores (LoE 1) and concerns that they could affect anastomotic and wound integrity (LoE 4). However, they may be used for reduction of PONV (transferable evidence, LoE 1)

Clinical Practice

  • Nausea and vomiting are frequent in abdominal surgeries, and corticosteroids may be used for their anti-emetic effects in patients at risk
  • A single pre-operative high-dose bolus of corticosteroid may be considered in high-risk pulmonary patients
  • Corticosteroids are not used in routine clinical practice because of the concerns that they could affect anastomotic and wound integrity

Transferable Evidence from Other Procedures - Study information

  • A single prophylactic dose of corticosteroid is effective for preventing PONV in surgery associated with high emetic effects
  • A review of major abdominal surgery, a randomised study of patients at high-risk of nausea and vomiting undergoing surgery, and a systematic review of drugs that prevent PONV, all showed that corticosteroids decrease PONV
  • IV methylprednisolone significantly improved postoperative recovery outcomes compared with placebo in abdominal surgery Krantz et al 1990 Click here for more information
  • A meta-analysis showed that a single pre-operative dose of IV methylprednisolone (15–30 mg/kg) was associated with significantly fewer pulmonary complications compared with placebo or no treatment, but data on postoperative pain could not be meta-analysed Sauerland et al 2000 Click here for more information
  • IV methylprednisolone (30 mg/kg) significantly decreased pulmonary complications compared with placebo in one study identified in a review of major abdominal surgery
  • Corticosteroids did not significantly decrease pain compared with placebo in two studies identified in a review of major abdominal surgery

Open Colonic Resection-Specific Evidence - Study information

  • IV methylprednisolone sodium succinate (30 mg/kg) given 90 min before induction of anaesthesia significantly improved mobilisation and recovery compared with IV placebo (p<0.05) Schulze et al 1997 Click here for more information
  • IV methylprednisolone sodium succinate (30 mg/kg) given 90 min before induction of anaesthesia significantly improved pulmonary function (as measured by peak flow, forced vital capacity, and forced expiratory volume) compared with IV placebo 6 hours postoperatively (p<0.05; n=24)
  • IV methylprednisolone sodium succinate (30 mg/kg) given 90 min before induction of anaesthesia and epidural analgesia did not confer a significant benefit over IV placebo for cumulative VAS pain scores Schulze et al 1997 Click here for more information
  • Pre-operative IV dexamethasone did not confer a significant benefit over placebo for reduction of VAS pain scores at rest at any time point assessed (4 and 8 h, Days 1, 2 and 3) (n=27)
  • Pre-operative IV dexamethasone had no signficant effect on postoperative IM morphine (10 mg) requirements, compared with placebo (n=27)
  • Incidence of postoperative nausea and vomiting was similar in the pre-operative IV dexamethasone and placebo groups (n=27)
  • There were no significant differences in the time to first flatus, first bowel sound or first bowel movement with pre-operative IV dexamethasone versus placebo (n=27)
  • The length of hospital stay was similar for patients in the pre-operative IV dexamethasone and placebo groups (n=27)

PROSPECT Recommendations

  • Gabapentin/pregabalin cannot be recommended at this time (Grade D, LoE 4) due to a lack of procedure-specific evidence, although analgesic data from other procedures are promising

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

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

Open Colonic Resection-Specific Evidence

  • [No data found within the parameters of the systematic review]

PROSPECT Recommendations

  • Continuous administration of IV lidocaine limited to the pre-/intra-operative period is not recommended (Grade D, LoE 4) because of inconsistent and insufficient procedure-specific evidence (LoE 1)
  • Continuous administration of pre/intra-operative IV lidocaine is recommended if continued during the immediate postoperative period, when epidural analgesia is not feasible or contra-indicated (Grade B), based on transferable evidence (LoE 1) and limited procedure-specific evidence (LoE 2) for recovery benefits, compared with control (see Intra-operative and Postoperative IV lidocaine sections)

Clinical Practice

  • IV lidocaine can be considered as an alternative when there are contra-indications to epidural analgesia techniques
  • Further evidence is needed to precisely define the role of IV lidocaine in this setting, including direct comparisons with epidural analgesia
  • IV lidocaine may induce hypotension
  • If IV lidocaine is used it is recommended that safety data are taken into account

Transferable Evidence from Other Procedures

  • [None cited]

Open Colonic Resection-Specific Evidence - Study information

  • Pre-/intra-operative IV lidocaine reduced postoperative pain scores at rest and on coughing at a minority of time points compared with control Kuo et al 2006 Click here for more information
  • Pre-/intra-operative IV lidocaine significantly reduced postoperative morphine requirement compared with control Kuo et al 2006 Click here for more information
  • Pre-/intra-operative IV lidocaine significantly reduced intra-operative fentanyl requirement compared with control Kuo et al 2006 Click here for more information
  • Pre-/intra-operative IV lidocaine was associated with a lower incidence of morphine-related nausea or vomiting compared with control (p<0.01; n=40)
  • Pre-/intra-operative IV lidocaine significantly reduced the time to first flatus, compared with the control group (p<0.01; n=40)
  • 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 the control (p=0.004; n=60)
  • Pre-/intra-operative IV lidocaine conferred no significant benefit over control for reducing the length of hospital stay (n=40)
  • 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 minutes) (n= 60)

PROSPECT Recommendations

  • Pre-operative NMDA receptor antagonists are not recommended (Grade D, LoE 4) because of limited procedure-specific evidence of analgesic efficacy

Clinical Practice

  • There is a lack of clinical experience with NMDA receptor antagonists. Moreover, NMDA receptor antagonists are associated with adverse events, e.g. ketamine is known for its increased risk of CNS side effects

Transferable Evidence from Other Procedures

  • Studies of intravenous or neuraxial ketamine in a variety of surgeries, including abdominal, gynaecological, orthopaedic, gastric, hepatic, and genitourinary surgery, showed a reduction in postoperative pain and opioid use when used as an adjunct to morphine
  • In patients undergoing laparoscopic cholecystectomy, dextromethorphan (pre- incisional and post gallbladder removal) was superior to control for reducing VAS scores, reducing the use of supplementary analgesics, and increasing the time to first analgesic request
  • Low-dose ketamine was associated with few and mild adverse effects, especially when administered in conjunction with general anaesthesia
  • A systematic review found that dextromethorphan did not reduce postoperative pain scores with a clinically significant magnitude, and although significant decreases in supplemental opioid consumption were observed, these were of questionable clinical importance in most cases
  • Two meta-analyses comparing pre-incisional and postincisional treatments found no significant analgesic benefit of pre-incisional administration of NMDA receptor antagonists
  • Two systematic reviews of randomised controlled trials comparing magnesium with placebo demonstrated inconclusive results overall with regards to pain scores and supplemental analgesic use

Open Colonic Resection-Specific Evidence - Study information

  • IM dextromethorphan was superior to control for reducing postoperative pain scores during coughing at 1, 2, 4, 8 and 24 h (p<0.001; n=60), although there were no significant differences in resting pain scores between the groups at any time point assessed
  • IM dextromethorphan was more effective than control for reducing postoperative opioid requirements Yeh et al 2005 Click here for more information
  • IM dextromethorphan significantly reduced the time to passage of first flatus, compared with the control (p<0.0001; n=60)
  • 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)
  • The incidence of morphine-related side-effects (drowsiness, dizziness, nausea, vomiting and pruritus) was similar in both the IM dextromethorphan and control groups (n=60)
  • Dextromethorphan conferred no significant benefit over control for reducing the length of hospital stay (n=60)

PROSPECT Recommendations

  • Pre-operative administration of strong opioids is not recommended (Grade B) for colonic resection as they are significantly less effective than postoperative strong opioids for reducing postoperative pain (transferable evidence, LoE 1)

Clinical Practice

  • [None Cited]

Transferable Evidence from Other Procedures - Study information

  • Pre-incisional strong opioids showed no significant benefit over post-incisional strong opioids for reducing postoperative pain scores (LoE 1) Fassoulaki et al 1995 Click here for more information
  • Pre-incisional strong opioids did not confer a significant benefit over post-incisional strong opioids for reducing supplementary analgesic consumption in patients undergoing abdominal hysterectomy (LoE 1) Kilickan et al 2001 Click here for more information
  • Pre-incisional strong opioids provided no significant benefit over post-incisional strong opioids for increasing the time to first analgesic request in three studies of patients undergoing abdominal hysterectomy reporting this parameter (n=34, n=85, n=39)
  • A meta-analysis of studies comparing pre-operative interventions with similar postoperative interventions in various procedures found that pre-operative NSAIDs and local anaesthetic wound infiltration improved analgesic consumption and time to first rescue analgesic request, but not pain scores. Evidence did not support an improvement in postoperative analgesia following administration of pre-operative NMDA antagonists and opioids
  • Pre-incisional strong opioids were associated with a similar incidence of PONV to post-incisional strong opioids in patients undergoing abdominal hysterectomy (n=34, n=40, n=60)

Open Colonic Resection-Specific Evidence

  • [No data found within the parameters of the systematic review]

PROSPECT Recommendations

  • Pre-operative administration of weak opioids is not recommended (Grade B) based on procedure-specific evidence that it has limited postoperative analgesic benefit compared with postoperative administration (LoE 2)

Clinical Practice

  • Tramadol 300 mg is considered to be a clinically effective dose, and therefore the 100 mg dose used in the study by Wordliczek et al. is probably too low to provide sufficient pain relief

Transferable Evidence from Other Procedures

  • A systematic review of pre-emptive analgesia for postoperative pain relief in a variety of surgical procedures – such as orthopaedic, dental, gynaecological and abdominal – has concluded that there is no benefit of pre-emptive over postoperative administration
  • A meta-analysis of studies comparing pre-operative interventions with similar postoperative interventions in various procedures found that pre-operative NSAIDs and local anaesthetic wound infiltration improved analgesic consumption and time to first rescue analgesic request, but not pain scores. Evidence did not support an improvement in postoperative analgesia following administration of pre-operative NMDA antagonists and opioids

Open Colonic Resection-Specific Evidence - Study information

  • 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)
  • Pre-, or intra-operative IV tramadol 100 mg did not confer any benefit for reducing postoperative pain scores compared with postoperative IV tramadol 100 mg Wordliczek et al 2002 Click here for more information
  • Pre-operative administration of IV tramadol resulted in a significantly shorter time to first analgesic request compared with administration immediately after peritoneal closure, or immediately following surgery (p<0.01; n=90)
  • Tramadol 100 mg administered pre- or intra-operatively, did not confer any benefit for reducing the incidence of PONV compared with postoperative IV tramadol 100 mg (n=90)

Epidural Analgesia

PROSPECT Recommendations

  • Continuous thoracic epidural anaesthesia and analgesia at a level appropriate to the site of incision are recommended for routine use (Grade A), based on superior postoperative analgesic and safety benefits compared with systemic techniques (procedure-specific evidence, LoE 1, also see Intra-operative and Postoperative Epidural Analgesia sections), except in a minority of patients with a contra-indication to epidural administration
  • Pre-operative administration of a single-shot epidural analgesia produces a similar postoperative analgesic efficacy to postoperative administration
  • Where epidural techniques are used, it is recommended that a combination of strong opioid and local anaesthetic is used (Grade A) because of the increased analgesic efficacy of the combination compared with strong opioids alone and to reduce the dose of strong opioid and its associated side-effects (procedure-specific evidence, LoE 1, see Intra-operative and Postoperative Epidural Analgesia sections)
  • Where epidural techniques are used, it is recommended that the epidural catheter is inserted pre-operatively because this is the most practical timing for insertion (Grade D, LoE 4)

Clinical Practice

  • In colonic surgery, the analgesic and recovery benefits of an epidural outweigh the risks of rare major complications and warrant the use of this more labour-intensive treatment
  • Where epidural techniques are used, the most practical timing for insertion of the epidural catheter is pre-operatively
  • 1 mg epidural morphine is considered inadequate to block visceral pain; however, larger doses are likely to cause bladder dysfunction. Therefore, pre-operative epidural administration of local anaesthetic with opioids is preferred to opioids alone

Transferable Evidence from Other Procedures - Study information

  • Pre-operative epidural morphine bolus was superior to epidural saline placebo for reducing postoperative pain scores at rest and on movement at 1 and 6 h (p<0.05 for all comparisons; n=36) in patients undergoing abdominal hysterectomy
  • Pre-operative epidural morphine bolus was superior to epidural saline placebo for reducing postoperative supplementary analgesic consumption at 6 and 12 h (p<0.05 for both times; n=36) in patients undergoing abdominal hysterectomy
  • Pre-operative epidural morphine bolus was superior to epidural saline placebo for extending the time to first analgesic request (p<0.05; n=36) in patients undergoing abdominal hysterectomy
  • Pre-operative epidural morphine and placebo were not different for the incidence of postoperative nausea in patients undergoing abdominal hysterectomy (n=36)
  • Pre- plus intra-operative epidural ropivacaine was superior to placebo for reducing intra-operative sufentanil in major abdominal tumour surgery (p<0.001; n=30)
  • Pre- plus intra-operative epidural ropivacaine provided no significant benefit over placebo for reducing postoperative pain scores for 0–96 h following major abdominal tumour surgery (both groups received postoperative epidural) (n=30)
  • Pre- plus intra-operative epidural ropivacaine provided no significant benefit over placebo for reducing supplementary analgesic consumption for 0–96 h following major abdominal tumour surgery (both groups received postoperative epidural) (n=30)
  • Pre- plus intra-operative epidural ropivacaine provided no significant benefit over placebo for reducing side-effects for 0–96 h following major abdominal tumour surgery (both groups received postoperative epidural) (n=30)
  • Pre-incisional epidural analgesia provided no significant benefit for reducing postoperative pain scores compared with post-incisional administration in a variety of abdominal procedures (LoE 1) Abdel-Ghaffar et al 1998 Click here for more information
  • Evidence for the benefit of pre-incisional compared with post-incisional epidural analgesia for reducing supplementary analgesic consumption in abdominal procedures is inconsistent (LoE 4) Espinet et al 1996 Click here for more information

Open Colonic Resection-Specific Evidence - Study information

  • Pre-operative bolus epidural morphine 1 mg plus postoperative parenteral analgesia was superior to postoperative parenteral analgesia alone on the day of surgery for VAS scores Simpson et al 1993 Click here for more information
  • Adding pre-operative bolus epidural morphine reduced parenteral opioid consumption on the first and second postoperative day compared with parenteral analgesia alone (p=0.002 and p=0.07, respectively; n=13)
  • Adding pre-operative bolus epidural morphine increased the time to first request of analgesia compared with parenteral analgesia alone (p=0.03; n=13)
  • Pre-operative + postoperative epidural clonidine was superior to control for the reduction of postoperative pain scores Wu et al 2004 Click here for more information
  • Pre-operative + postoperative epidural clonidine was superior to control for reducing postoperative analgesic requirement Wu et al 2004 Click here for more information
  • Pre-operative + 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-operative + postoperative epidural clonidine, compared with control (p<0.001; n=40)
  • Epidural LA plus morphine 40 min before surgical incision conferred no significant benefit over administration at wound closure for reducing postoperative VAS pain scores Dahl et al 1992 Click here for more information
  • Epidural LA plus morphine given 40 min before surgical incision was similar to that given at closure for level of sensory block to pinprick for 0–72 h (n=32)
  • The length of hospital stay was similar for patients in the pre-operative + postoperative epidural clonidine and control groups (n=40)

Spinal Analgesia

PROSPECT Recommendations

  • Spinal morphine is not recommended (Grade D) because of the risk of side-effects (LoE 4)
  • Spinal clonidine is not recommended (Grade B) because of limited analgesic effect (procedure-specific evidence LoE 2) and the risk of side-effects (LoE 4)

Clinical Practice

  • Spinal morphine may produce some postoperative pain relief but also produces risk of PONV and prolongation of postoperative ileus, and limited duration of analgesic effect

Transferable Evidence from Other Procedures

  • [None Cited]

Open Colonic Resection-Specific Evidence - Study information

  • The incidence of postoperative nausea or vomiting was similar with pre-operative spinal morphine + IV PCA morphine, compared with PCA morphine alone (n=52)
  • Spinal bupivacaine was superior to placebo for reducing postoperative PCA morphine consumption Click here for more information
  • Spinal bupivacaine significantly reduced the area of hyperalgesia around the incision site, compared with placebo, at 24, 48, and 72 h postoperatively (p<0.05; n=40)
  • Pre-operative spinal bupivacaine significantly reduced the incidence of postoperative residual pain, compared with placebo, at 2 weeks, and after 1 month (p<0.05; n=40)
  • Spinal clonidine was superior to placebo for reducing postoperative morphine requirements Click here for more information
  • Spinal clonidine was superior to placebo for reducing postoperative pain at a minority of time points Click here for more information
  • Pre-operative spinal morphine + IV PCA morphine was superior to IV PCA morphine alone for reducing postoperative pain scores Click here for more information
  • Intra-operative IV sufentanil requirements were similar in the spinal morphine and spinal morphine + sufentanil groups (n=77)
  • There was no significant difference in patient satisfaction (VAS scale 1–100) with pre-operative spinal morphine versus spinal morphine + sufentanil (n=77)
  • Incidence of postoperative nausea and vomiting was similar between the pre-operative spinal morphine group and the pre-operative spinal morphine + sufentanil group (n=77)
  • There was no significant difference in postoperative PCA morphine consumption with spinal morphine versus spinal morphine + sufentanil in the PACU, or at 24 or 48 h postoperatively (n=77)
  • There were no significant differences between the spinal morphine and spinal morphine + sufentanil groups for VAS pain scores at rest and coughing during the first 48 h postoperatively (n=77)
  • Spinal bupivacaine conferred no significant benefit over placebo for reducing VAS pain scores at rest, mobilisation or during coughing at any of the time points assessed (2, 6 and 12 h, Days 1, 2 and 3) (n=40)
  • Spinal clonidine conferred no significant benefit over spinal bupivacaine for reducing VAS pain scores at rest, mobilisation or during coughing at any of the time points assessed (2, 6 and 12 h, Days 1, 2 and 3) (n=40)
  • The incidence of intra-operative adverse haemodynamic events was significantly greater with pre-operative spinal clonidine compared with pre-operative spinal bupivacaine or placebo (p<0.05) (n=20/group)
  • Spinal clonidine versus placebo
  • Spinal bupivacaine versus placebo
  • Spinal morphine versus spinal morphine + sufentanil
  • Pre-operative spinal morphine + IV PCA morphine versus IV PCA morphine alone
  • Spinal clonidine versus spinal bupivacaine

LA for Analgesia

PROSPECT Recommendations

  • Bilateral TAP block is not recommended at the current time (Grade D, LoE 4) because of limited procedure-specific evidence, despite some positive transferable evidence (LoE 1)

Clinical Practice

  • The single-shot TAP block technique may provide effective postoperative analgesia but the duration is limited. Despite this, further study evidence is expected which may support the use of this technique

Transferable Evidence from Other Procedures

  • Unilateral TAP block significantly reduced postoperative VAS pain scores and postoperative morphine consumption compared with control, in patients undergoing open appendicectomy (n=52)
  • Bilateral TAP block with ropivacaine significantly reduced postoperative VAS pain scores, postoperative morphine consumption and the incidence of postoperative sedation, compared with placebo, in patients undergoing abdominal hysterectomy (n=50)

Open Colonic Resection-Specific Evidence - Study information

  • Pre-operative bilateral TAP block was superior to control for reducing postoperative pain scores Click here for more information
  • Pre-operative bilateral TAP block was superior to control for reducing postoperative morphine requirements Click here for more information
  • Pre-operative bilateral TAP block significantly reduced postoperative sedation scores, compared with control, at 4 and 6 h postoperatively (p=0.01), although there was no significant difference between the groups at 2 and 24 h, or in the PACU
  • Pre-operative bilateral TAP block was associated with a significantly higher incidence of PONV, compared with control (p<0.05)

Non-pharmacological Therapy

PROSPECT Recommendations

  • Pre-operative use of guided imagery is not recommended (Grade D, LoE 4) because of limited procedure-specific evidence, despite some evidence of analgesic effect (LoE 1)

Clinical Practice

  • [None Cited]

Transferable Evidence from Other Procedures

  • Pre-operative use of guided imagery was significantly more effective for reducing postoperative pain intensity (p<0.05), distress from pain (p<0.01) and the ability to cope with pain (p<0.01) compared with routine postoperative care, in patients undergoing abdominal surgery (n=51)
  • Pre-operative use of guided imagery resulted in significantly lower supplementary analgesic consumption over 0–48 h compared with routine postoperative care (p<0.05; n=51)

Open Colonic Resection-Specific Evidence - Study information

  • One of two studies showed that care by guided imagery was more effective than standard care for reducing postoperative pain scores Click here for more information
  • One of two studies found that care by guided imagery was more effective than routine postoperative care for reducing postoperative analgesic requirements Click here for more information
  • One of two studies showed that care by guided imagery was more effective than routine postoperative care for reducing time to first bowel movement Click here for more information
  • Guided imagery tapes provided no significant benefit over relaxation tapes for reducing VAS pain scores at rest or coughing during postoperative Days 1–4 (n=38)
  • Relaxation tapes provided no significant benefit over routine postoperative care for the reduction of VAS pain scores at rest or coughing during postoperative Days 1–4 (n=40)
  • There was no significant difference in the total analgesic consumption or the number of analgesic requests between patients in the relaxation and guided imagery groups (n=42)
  • Time to first flatus and first bowel movement was similar for patients in the guided imagery and relaxation groups (n=42)
  • Time to first flatus and first bowel movement was similar for patients in the relaxation and routine care groups (n=42)
  • One study found that care by guided imagery provided no benefit over routine postoperative care for reducing the median length of hospital stay, postoperative ileus or the incidence of nausea or vomiting (n=130)

Alternative Interventions

PROSPECT Recommendations

  • Laxatives are not recommended for analgesia (Grade B) because limited procedure-specifc evidence shows no analgesic benefit (LoE 2), but they may be used for reasons other than pain relief (LoE 4)

Clinical Practice

  • [None Cited]

Transferable Evidence from Other Procedures

  • Time until first defecation and GI recovery were significantly shorter with biscodyl versus placebo (p=0.001 and p=0.007, respectively; n=169)
  • Pre-operative + postoperative administration of biscodyl provided no significant benefit over placebo for the reduction of VAS pain scores (n=169)
  • There was no significant difference in the level of opioid consumption between patients who received bisacodyl or placebo during the first 8 postoperative days (n=169)
  • The incidence of postoperative cramping and nausea was similar in the biscodyl and placebo groups (n=169)
  • Biscodyl conferred no significant benefit over placebo for reducing the length of hospital stay (n=169)

Open Colonic Resection-Specific Evidence - Study information

  • [None Cited]

PROSPECT Recommendations

  • Pre-operative pentoxifylline is not recommended (Grade D, LoE 4) due to limited procedure-specific evidence of its analgesic effect

Clinical Practice

  • Further studies are needed to recommend the use of pentoxifylline in clinical practice

Transferable Evidence from Other Procedures

  • [None Cited]

Open Colonic Resection-Specific Evidence - Study information

  • Pre-operative IV pentoxifylline was superior to placebo for the reduction of VAS pain scores during coughing after 1, 2, and 4 h, and on Days 1 and 2 (p<0.05; n=40), however, there was no siginificant difference between the groups for resting pain scores at each of the time points assessed (1, 2, 4 h and Days 1, 2 and 3)
  • Pre-operative IV pentoxifylline was superior to placebo for reducing morphine consumption during Days 1–3 (p<0.0001; n=40)
  • Pre-operative IV pentoxifylline was superior to placebo for extending the time until first PCA morphine trigger (p<0.0001; n=40)
  • Pre-operative IV pentoxifylline was superior to placebo for reducing the time until first flatus
  • Pre-operative IV pentoxifylline was superior to placebo for reducing inflammatory cytokines related to postoperative pain
  • The incidence of morphine-related adverse effects (drowsiness, dizziness, nausea, and vomiting) was similar in both the pre-operative IV pentoxifylline and placebo groups