Knowledge Key:
Postoperative
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PROSPECT Recommendations
- Postoperative gabapentinoids cannot be recommended (Grade D, LoE 4) because there is no procedure-specific evidence and because the benefit:risk ratio is not sufficiently favourable for this ambulatory procedure, despite analgesic efficacy in other procedures (transferable evidence, LoE 1)
Clinical Practice
- None cited
Transferable Evidence
- Three 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 (
Haemorrhoid surgery-specific evidence
- None cited
PROSPECT Recommendations
- Postoperative systemic conventional NSAIDs are recommended (Grade B) based on transferable evidence showing analgesic efficacy (LoE 1)
- There is not enough evidence at this time to recommend the use of one NSAID over another
- The use of conventional NSAIDs should depend upon assessment of individual patient risks (Grade B), including bleeding complications, actual or recent gastroduodenal ulcer history (transferable evidence, LoE 1), cardiovascular morbidity (LoE 4), aspirin-sensitive asthma, renal function and hepatic function (transferable evidence, LoE 3)
Clinical Practice
- Conventional NSAIDs should be administered at the appropriate time to provide sufficient analgesia when the patient wakes
Transferable Evidence
- Conventional NSAIDs have proven analgesic efficacy in a variety of surgical procedures (
- One randomized study in patients undergoing colorectal resection demonstrated that patients receiving IV PCA morphine plus ketorolac required significantly less rescue analgesic than patients receiving IV PCA morphine alone (with comparable pain scores), although recovery of bowel function was not significantly different between the two groups
- A meta-analysis of randomised controlled trials that was 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 (
- Randomised endoscopic trials in healthy elderly 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 (
- 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 (
- 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 (
- A randomised trial in healthy volunteers showed that three conventional NSAIDs (diclofenac, ketorolac and ketoprofen) caused a reversible platelet dysfunction
- 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
- Aspirin and conventional NSAIDs can induce asthma attacks in patients with aspirin-exacerbated respiratory disease (
- 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 (with lumiracoxib;
- 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 (
- Chronic administration of conventional NSAIDs and COX-2-selective inhibitors may elevate blood pressure, particularly in hypertensive patients receiving antihypertensive medication (
Haemorrhoid surgery-specific evidence
- The time to first bowel movement was significantly shorter in a group receiving diflunisal compared with a group receiving oral paracetamol + weak opioid (p<0.05;
- Pain scores (rated on a scale from 0–3) were not significantly different in groups receiving either diflunisal or oral paracetamol + weak opioid, at any time point assessed (i.e. at 4 h intervals from 16–72 h) (
- There were no significant differences between groups treated with either nimesulide or naproxen in VAS pain scores at any time point recorded (i.e. twice per day on POD 1, 2, 3, 4, 11, and 20) (
- Pain scores (assessed using a verbal categorical scale, where 0=no pain, 1=mild pain, 2=moderate pain, and 3=severe pain) were higher with diclofenac compared with betamethasone, but no statistics were reported (
- The proportion of patients requiring additional IM pethidine injections as rescue analgesia was similar with diflunisal and oral paracetamol + weak opioid (
- A significantly higher proportion of patients required rescue analgesia (parenteral pethidine 50 mg) in a diclofenac group versus a betamethasone group (p<0.05;
- More patients receiving betamethasone (75%) were discharged from hospital on the day of surgery compared with patients receiving diclofenac (0%), although no statistics were reported (
- Global efficacy as assessed by patients and doctors was similar with nimesulide and naproxen (
- Length of hospital stay was comparable with diflunisal and oral paracetamol + weak opioid (
- Study details Madsen 1987 Click here for more information
PROSPECT Recommendations
- Postoperative COX-2-selective inhibitors are recommended (Grade B) based on transferable evidence showing analgesic efficacy (LoE 1)
- 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)
Clinical Practice
- COX-2-selective inhibitors should be administered at the appropriate time to provide sufficient analgesia when the patient wakes
- Rofecoxib has been withdrawn from the market, and marketing of valdecoxib has been suspended in most countries
Transferable Evidence
- Rofecoxib 50 mg and parecoxib 40 mg have an equipotent analgesic efficacy relative to traditional NSAIDs in postoperative pain after minor and major surgical procedures (
- A systematic review to quantify the efficacy of single-dose oral valdecoxib and IV parecoxib demonstrated that both are effective treatments for acute postoperative pain, and show similar incidences of adverse effects
- Randomised endoscopic trials in healthy elderly 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 (
- Studies in healthy volunteers demonstrated that COX-2-selective inhibitors had no effect on platelet aggregation or bleeding time compared with placebo Greenberg et al 2000 Click here for more information
- 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 study to assess the safety of the COX-2-selective inhibitors parecoxib and valdecoxib following non-cardiac 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) (
- 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 (
- 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 (
- 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 (with lumiracoxib;
- 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 (
- Chronic administration of COX-2-selective inhibitors and conventional NSAIDs may elevate blood pressure, particularly in hypertensive patients receiving antihypertensive medication (
Haemorrhoid surgery-specific evidence
- None cited
PROSPECT Recommendations
- Ketamine cannot be recommended (Grade D, LoE 4) because there is no procedure-specific evidence at this time and because the benefit:risk ratio is not sufficiently favourable for this ambulatory procedure, despite analgesic efficacy in other procedures (transferable evidence, LoE 1)
- Dextromethorphan is not recommended (Grade D, LoE 4) based on inconclusive procedure-specific and transferable evidence
Clinical Practice
- Administration of IM dextromethorphan is not widely used in clinical practice
Transferable Evidence
- Studies of ketamine in a variety of surgeries, including abdominal, gynaecological, orthopaedic, gastric, hepatic, and genitourinary surgery, showed a reduction in postoperative pain or opioid use when used as an adjunct to morphine (
- 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
Haemorrhoid surgery-specific evidence
- In a group receiving IM dextromethorphan + CPM, the total pethidine consumption was significantly lower compared with a group receiving CPM alone (p<0.001). The proportion of patients who required pethidine injection was significantly fewer with IM dextromethorphan + CPM versus CPM alone (p<0.005;
- The time to first pethidine injection was significantly longer with IM dextromethorphan + CPM compared with CPM alone (p=0.006;
- The incidence of pethidine-related side-effects (such as nausea, vomiting, dizziness and headache) was significantly lower with IM dextromethorphan + CPM compared with CPM alone (p<0.025;
- Worst pain scores in patients requesting pethidine were not significantly different with IM dextromethorphan + CPM compared with CPM alone (
- Study details Chang 1999 Click here for more information
PROSPECT Recommendations
- Strong opioids are recommended for moderate-to-high intensity postoperative pain (VAS>/= 30 mm) (Grade B), to supplement oral paracetamol and conventional NSAIDs/COX-2-selective inhibitors, based on transferable evidence for analgesic efficacy (LoE 1)
Clinical Practice
- Strong opioids cause constipation, which may hinder recovery
- Where possible, non-opioid analgesics should be used instead of opioids to avoid the risk of constipation
Transferable Evidence
- Strong opioids are effective for reducing high- and moderate-intensity postoperative pain (
- A systematic review comparing intravenous PCA opioids with intravenous, intramuscular or subcutaneous opioids by injection showed that PCA opioids were associated with greater pain relief, reduced supplemental analgesic requirements (analysis of eleven studies, total n=691), and more patients preferred PCA opioids (analysis of four trials, total n=352) compared with traditional opioid analgesia (
- A quantitative systematic review showed that opioid by PCA provided better pain control and greater patient satisfaction than conventional opioid parenteral analgesia in a variety of surgical procedures (37/56 trials used IM analgesia in the control group) (
- A meta-analysis of randomised controlled trials that was performed to evaluate the risk of morphine-related adverse effects in patients treated with NSAIDs demonstrated that combination of morphine plus NSAIDs decreased the incidence of nausea, vomiting and sedation, but not pruritus, urinary retention or respiratory depression, compared with morphine alone (
- A systematic review showed that patients using PCA consumed a greater quantity of opioids than those treated using conventional opioid parenteral analgesia, and had a higher incidence of pruritus, but a similar incidence of other side-effects, in a variety of surgical procedures. There was no difference between groups in the length of hospital stay (
- Pethidine induced significantly higher sedation and respiratory depression compared with tramadol (both 100 mg intravenously) (n=48;
- Strong opioids are associated with adverse effects, including nausea, vomiting, sedation, confusion, paralytic ileus and urinary retention (
- One study comparing PCA with conventional pain therapy (CPT; IV piritramide or oral/IM tramadol) demonstrated an increased consumption of postoperative analgesic in the PCA group compared with the CPT group (p<0.01), although the PCA group reported a significantly greater satisfaction with pain therapy compared with the CPT group (p<0.01; n=42 patients)
Haemorrhoid surgery-specific evidence
- None cited
PROSPECT Recommendations
- Weak opioids are recommended for low-to-moderate intensity postoperative pain (VAS<50 mm) (Grade B), to supplement oral paracetamol and conventional NSAIDs/COX-2-selective inhibitors, based on transferable evidence for analgesic efficacy (LoE 1)
Clinical Practice
- Weak opioids cause constipation, which may hinder recovery
- Non-opioid analgesics should be used instead of opioids to avoid the risk of constipation
- Tramadol causes less constipation than conventional opioids
Transferable Evidence
- Tramadol was more effective than placebo for pain relief in a meta-analysis of post-surgical patients
- The combination of tramadol and paracetamol enhances analgesic efficacy compared with either agent alone
- A systematic review found that the combination of dextropropoxyphene 65 mg with paracetamol 650 mg showed similar efficacy to tramadol 100 mg
- A systematic review found that the combination of codeine with paracetamol provided additional pain relief compared with paracetamol alone
- A meta-analysis of randomised controlled trials found that the combination of codeine with ibuprofen caused an enhanced analgesic effect compared with ibuprofen alone, although the incidence of adverse effects was increased
- Two studies found that codeine 30 mg + paracetamol 300 mg was associated with a higher incidence of constipation and vomiting than tramadol 37.5 mg + paracetamol 325 mg following arthroscopy
- Adverse effects associated with tramadol include headache, nausea, vomiting, dizziness, and somnolence. A meta-analysis of individual patient data from randomised controlled trials found a dose-response of adverse effects with tramadol; postsurgical patients had fewer side-effects than dental patients
- A systematic review found that the combination of codeine with paracetamol was associated with an increase in drowsiness and dizziness compared with paracetamol alone
- A systematic review found an increased incidence of central nervous system adverse effects with paracetamol 650 mg plus dextropropoxyphene 65 mg compared with placebo, but the incidence of other adverse effects was reduced compared with tramadol 100 mg
Haemorrhoid surgery-specific evidence
- None cited
PROSPECT Recommendations
- Postoperative paracetamol is recommended (Grade B), based on transferable evidence (LoE 1) showing efficacy for low-moderate pain (VAS <50 mm)
- Paracetamol alone is not recommended for high-intensity pain (VAS >/=50 mm) (Grade B), based on transferable evidence (LoE 1) showing a lack of analgesic efficacy
Clinical Practice
- It is considered that paracetamol is ineffective as a single therapy for treatment of high-intensity pain (VAS>50 mm)
Transferable Evidence
- Paracetamol is an effective analgesic for the treatment of postoperative pain of moderate intensity (
- There is evidence that concurrent use of paracetamol and conventional NSAIDs improves pain relief compared with paracetamol alone, but there is no evidence for a superior analgesic effect of the combination compared with conventional NSAIDs alone
Haemorrhoid surgery-specific evidence
- None cited
PROSPECT Recommendations
- Injection of botulinum toxin is not recommended (Grade D, LoE 4), due to inconsistent procedure-specific evidence for analgesic benefit in the postoperative period
Clinical Practice
- The injection of botulinum toxin for pain after haemorrhoid surgery is not performed routinely in clinical practice
Transferable Evidence
- None cited
Haemorrhoid surgery-specific evidence
- Overall pain at rest was significantly lower with Botox versus glyceryl trinitrate (GTN) ointment (p<0.01), although overall pain during defecation was similar between groups (
- Significantly fewer nimesulide tablets (100 mg) were consumed by patients receiving Botox compared with those treated with GTN ointment (p<0.05;
- The incidence of adverse events potentially related to drug treatment was significantly lower with Botox compared with GTN (p<0.03; 5 patients receiving GTN reported transient moderate-to-severe headaches) (
- The time to complete healing of perianal wounds was similar with Botox and GTN ointment (
- The time to first defecation was similar in groups treated with either Botox injection or GTN ointment (
- The incidence of anal incontinence was comparable between groups receiving either Botox injection or GTN ointment (
- The incidence of urinary retention was not significantly different between groups treated with either Botox injection or GTN ointment (
- The time to return to work was similar with Botox and GTN (
- There was no significant difference in the length of hospital stay in a Botox group versus a GTN group (
- Study details Patti 2006 Click here for more information
PROSPECT Recommendations
- Flavonoids are not recommended (Grade D, LoE 4) because of limited and inconclusive procedure-specific evidence
Clinical Practice
- None cited
Transferable Evidence
- None cited
Haemorrhoid surgery-specific evidence
- Two out of three studies showed a significant reduction in pain scores with flavonoids compared with no treatment Click here for more information
- One out of two studies reported a significant reduction in rescue analgesic use with flavonoids compared with no treatment Click here for more information
- Study details Click here for more information
PROSPECT Recommendations
- Laxatives are recommended (Grade A) in the days prior to surgery, as an adjunct to analgesic therapy, based on procedure-specific evidence (LoE 1 and 2)
Clinical Practice
- Stool softeners are an alternative to laxatives in clinical practice
Transferable Evidence
- None cited
Haemorrhoid surgery-specific evidence
- Two studies out of two demonstrated that laxatives caused a significant reduction in pain scores on defecation compared with placebo/control London 1987 Click here for more information
- There was a significant reduction in VAS pain scores on day 10 with Plantago ovata compared with control (p<0.01), but not on day 20 (
- In one study, oral paracetamol requirements after defecation were significantly lower with lactulose compared with placebo (p<0.01), although IM papaveretum consumption was not significantly different between groups, and analgesic requirements before defecation (papaveretum and paracetamol) were similar (
- Two studies out of two demonstrated a shorter length of hospital stay with laxatives compared with placebo/control (
- The tenesmus rate in patients in a Plantago ovata group was significantly lower than in patients in a control group (p<0.01;
- The time to first bowel action was significantly shorter in patients receiving lactulose compared with patients receiving placebo (p=0.01), although the number of bowel actions in the first week was not significantly different between groups (p=0.05;
- There were no significant differences between groups treated with lactulose and placebo in VAS or VRS pain scores in the 24 h preceding defecation on POD 1–3 (
- Study details London 1987 Click here for more information
PROSPECT Recommendations
- Oral metronidazole is recommended (Grade A) as an adjunct to analgesic therapy based on procedure-specific evidence (LoE 1)
Clinical Practice
- None cited
Transferable Evidence
- None cited
Haemorrhoid surgery-specific evidence
- Three out of four studies demonstrated a reduction in pain scores with metronidazole compared with placebo/no treatment Click here for more information
- In two out of three studies, the time to return to work or normal activities was significantly shorter with metronidazole compared with placebo/no treatment Click here for more information
- In one study out of two, wound healing occurred significantly faster with metronidazole compared with placebo/no treatment; the second study also showed faster wound healing with metronidazole, but no statistics were reported Click here for more information
- VAS pain scores were significantly lower with metronidazole + glyceryl trinitrate (GTN) + lactulose compared with placebo on days 2, 3 (both p<0.05), 6 and 7 (both p<0.01), but not at 24 h, or on days 4 and 5. Pain after defecation was significantly lower with metronidazole + GTN + lactulose compared with placebo after the 1st and 2nd defecations (both p<0.05), but not after the 3rd, 4th or 5th (
- Time to return to work or normal activities was significantly shorter in patients receiving metronidazole + GTN + lactulose compared with those receiving placebo (p<0.05;
- In four studies out of four, rescue analgesic requirements were not significantly different in groups receiving metronidazole or placebo/no treatment Click here for more information
- Analgesic requirements (IV diclofenac 100 mg, then nimesulide 100 mg tablets as needed) were not significantly different between patients receiving metronidazole + GTN + lactulose compared with those receiving placebo (
- Time to healing was not significantly different between patients receiving metronidazole + GTN + lactulose and those receiving placebo (
- Metronidazole versus placebo/no treatment
- Study details Click here for more information
- Metronidazole + glyceryl trinitrate (GTN) + lactulose versus placebo
- Study details Di Vita 2003 Click here for more information
PROSPECT Recommendations
- The use of an anal sphincter relaxant is not recommended (Grade D, LoE 4) for analgesia based on limited procedure-specific evidence
Clinical Practice
- Anal sphincter relaxants are not commonly used in clinical practice
Transferable Evidence
- None cited
Haemorrhoid surgery-specific evidence
- Pain scores at 4 h, maximum pain during the first 24 h after surgery, and pain scores on POD 2 were similar in patients receiving a trimebutine suppository and those receiving no suppository (
- There were no significant differences in rescue analgesic requirements (number of ketoprofen tablets required and number of patients requiring IM pethidine injection) with or without a trimebutine suppository (
- Study details Ho 1997a Click here for more information
PROSPECT Recommendations
- Topical glyceryl trinitrate is not recommended (Grade D, LoE 4) due to inconsistent procedure-specific data
- Topical calcium channel blocker is not recommended (Grade D, LoE 4) due to limited procedure-specific evidence
- Calcium alginate dressings are not recommended (Grade D, LoE 4) due to limited procedure-specific evidence
Clinical Practice
- Two studies involving the use of topical glyceryl trinitrate (GTN) showed an improvement in wound healing
- Any effort to decrease postoperative oedema can be beneficial for postoperative analgesia
Transferable Evidence
- None cited
Haemorrhoid surgery-specific evidence
- Topical ointments
- Haemostatic dressings
PROSPECT Recommendations
- No recommendation can be made regarding postoperative local perianal infiltration, due to limited and inconsistent procedure-specific evidence (LoE 4)
Clinical Practice
- Haemorrhoid surgery is a short procedure, and therefore the effects of LA infiltration may be most beneficial when administered pre-operatively
- Epinephrine is commonly used for LA infiltration, as it is often combined in a preparation with lidocaine and some other LAs
Transferable Evidence
- None cited
Haemorrhoid surgery-specific evidence
- In one study out of one, the time to the first demand for IM opiate analgesia was significantly longer with perianal bupivacaine infiltration compared with placebo (p<0.01;
- In one study out of one, complete wound healing at 6 weeks was observed in all patients treated with both perianal bupivacaine infiltration and placebo (
- In one study out of two, there was no significant difference in pain scores between groups receiving perianal bupivacaine infiltration or placebo on POD 1 and 2 ( Marsh 1993 Click here for more information
- In two out of two studies, there were no significant differences in rescue analgesic requirements in patients treated with either perianal bupivacaine infiltration or placebo Chester 1990 Click here for more information
- In one study out of one, the time to first bowel movement was similar with perianal bupivacaine infiltration and placebo (
- A similar incidence of urinary retention was reported with both perianal bupivacaine infiltration and placebo (
- The length of hospital stay was not significantly different between groups undergoing perianal bupivacaine infiltration or placebo infiltration (
- Patient satisfaction with analgesia was similar with perianal bupivacaine infiltration and placebo (
- Study details Chester 1990 Click here for more information