Preoperative Parenteral Parecoxib and Follow-Up Oral Valdecoxib Reduce Length of Stay and Improve Quality of Patient Recovery After Laparoscopic Cholecystectomy Surgery

A comparison of regional versus general anesthesia for ambulatory anesthesia: a meta-analysis of randomized controlled trials

Both regional anesthesia and general anesthesia have been proposed to provide optimal ambulatory anesthesia. We searched MEDLINE and other databases for randomized controlled trials comparing regional anesthesia and general anesthesia in ambulatory surgery patients for meta-analysis. Only major conduction blocks were considered to be regional anesthesia. Regional anesthesia was further separated into central neuraxial block and peripheral nerve block. Fifteen (1003 patients) and 7 (359 patients) trials for central neuraxial block and peripheral nerve block were included in the meta-analysis. Both central neuraxial block and peripheral nerve block were associated with increased induction time, reduced pain scores, and decreased need for postanesthesia care unit analgesics. However, central neuraxial block was not associated with decreased postanesthesia care unit bypass or time or reduced nausea despite reduced analgesics, and it was associated with a 35-min increase in total ambulatory surgery unit time. In contrast, peripheral nerve block was associated with decreased postanesthesia care unit need and decreased nausea but, again, not with decreased ambulatory surgery unit time. This meta-analysis indicates potential advantages for regional anesthesia, such as decreased postanesthesia care unit use, nausea, and postoperative pain. Although these factors have been proposed to reduce ambulatory surgery unit stay, neither central neuraxial block nor peripheral nerve block were associated with reduced ambulatory surgery unit time. Other factors, such as unsuitable discharge criteria and limitations of meta-analysis, may explain this discrepancy.

A procedure-specific systematic review and consensus recommendations for postoperative analgesia following laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy has advantages over the open procedure for postoperative pain. However, a systematic review of postoperative pain management in this procedure has not been conducted.

METHODS

A systematic review was conducted according to the guidelines of the Cochrane Collaboration. Randomized studies examining the effect of medical or surgical interventions on linear pain scores in patients undergoing laparoscopic cholecystectomy were included. Qualitative and quantitative analyses were performed. Recommendations for patient care were derived from review of these data, evidence from other relevant procedures, and clinical practice observations collated by the Delphi method among the authors.

RESULTS

Sixty-nine randomized trials were included and 77 reports were excluded. Recommendations are provided for preoperative analgesia, anesthetic and operative techniques, and intraoperative and postoperative analgesia.

CONCLUSIONS

A step-up approach to the management of postoperative pain following laparoscopic cholecystectomy is recommended. This approach has been designed to provide adequate analgesia while minimizing exposure to adverse events.

Effect of preoperative Cox-II-selective NSAIDs (coxibs) on postoperative outcomes: a systematic review of randomized studies

BACKGROUND

Preoperative use of coxibs has been claimed to reduce postoperative pain and analgesic consumption, and to affect other postoperative outcomes.

METHODS

Systematic review of randomized trials comparing preoperative coxib with preoperative placebo, or active comparator. Searching of PubMed and Cochrane Library to August 2004. A qualitative and a quantitative analysis.

RESULTS

Twenty-two included trials with 2246 patients had high reporting quality and validity scores, though treatment group sizes were small, with a median size of 30 patients. Most trials used oral preoperative rofecoxib (mainly 50 mg) or celecoxib (mainly 200 mg). Preoperative coxibs significantly reduced both postoperative pain and analgesic consumption compared with preoperative placebo in 15/20 trials. In one further trial postoperative pain was reduced and in one analgesic consumption. There was no significant difference in the incidence of postoperative nausea and vomiting in 13/17 studies or when data were pooled. Postoperative antiemetic use was significantly reduced in all five trials reporting it; the NNT to prevent one patient using postoperative antiemetic was 10 (5.5 to 66). No trial reported any significant difference in intraoperative blood loss or recovery from anaesthesia. Patient satisfaction was significantly increased with preoperative coxib use. No conclusions could be drawn from the three trials comparing preoperative coxib with preoperative NSAID. One study reported significantly improved cost-efficacy with rofecoxib.

CONCLUSIONS

Preoperative coxibs had clear benefits in terms of reduced postoperative pain, analgesic consumption and patient satisfaction compared with placebo. Effects on postoperative nausea and vomiting remain uncertain, as do those on recovery from surgery or economic benefit. Future trials should be larger and more pragmatic in nature.

A Randomized, Double-Blind Comparison Between Parecoxib Sodium and Propacetamol for Parenteral Postoperative Analgesia After Inguinal Hernia Repair in Adult Patients

The newly injectable cyclooxygenase-2 selective nonsteroidal antiinflammatory drug, parecoxib, has never been compared with propacetamol, a parenteral formulation of acetaminophen. In this prospective, randomized, double-blind, double-dummy study, we randomly assigned 182 patients scheduled for initial inguinal hernia repair under general anesthesia to receive a single injection of 40 mg parecoxib or 2 injections of 2 g propacetamol within the first 12 h after surgery. The study variables were morphine consumption, pain at rest and while coughing, and patient satisfaction throughout the first 12 h postoperatively. For statistical analysis, we used the Student's t-test, chi(2), and covariance analysis. Total morphine consumption did not differ between the two groups. Pain was less intense in the parecoxib group at rest (P = 0.035) but did not differ for pain while coughing. The incidence of side effects was similar. Significantly more patients in the parecoxib group rated their pain management as good or excellent (87% versus 70% in the propacetamol group, P = 0.001). Within the first 12 h after inguinal hernia repair in adult patients, a single injection of parecoxib 40 mg compares favorably with 2 injections of propacetamol 2 g.

Multimodal Analgesia Techniques and Postoperative Rehabilitation

The concept of multimodal analgesia involves the use of different classes of analgesics and different sites of analgesic administration to provide superior dynamic pain relief with reduced analgesic-related side effects. Although multimodal analgesia techniques have assumed increasing importance in the management of perioperative pain, it has become increasingly apparent that postoperative outcome may not be improved. Nevertheless, the integration of multimodal analgesia techniques with a multimodal and multidisciplinary rehabilitation program may enhance recovery, reduce hospital stay, and facilitate early convalescence.

Reduction of opioid-related adverse events using opioid-sparing analgesia with COX-2 inhibitors lacks documentation: a systematic review

BACKGROUND

We have reviewed opioid-related adverse events in studies of opioid sparing with cyclooxygenase-2 (COX-2) inhibitors compared with placebo in postoperative pain.

METHODS

Randomized, controlled trials were evaluated. Outcome measures were significant reduction in consumption of supplementary opioids with the COX-2 inhibitors and reported opioid-related adverse events (nausea, vomiting, constipation, dizziness, sedation, pruritus and/or urinary retention) 0-24 h after surgery.

RESULTS

Nineteen studies including 26 comparisons of four COX-2 inhibitors (rofecoxib, celecoxib, parecoxib and valdecoxib) were evaluated, in which significant opioid-sparing averaging about 35% with COX-2 inhibitors and opioid-related adverse events were reported. The trials were in general of high quality (median Oxford quality score 4) but the reporting quality of adverse events was poor. Opioid-related adverse events, i.e. vomiting, constipation and pruritus, were only significantly reduced with COX-2 inhibitors in four of the 26 comparisons. Quantitative analysis of combined data revealed a significantly reduced risk for only dizziness; the clinical relevance was minor as the number needed to treat (NNT) was about 33.

CONCLUSION

The limitation of this review is the lack of quality of data of adverse events from the original trials. Although supplementary opioid consumption in all trials was significantly reduced by on average 35% with the COX-2 inhibitors, it was only sporadically possible to demonstrate a clinically important reduction in opioid-related adverse events. Data did not support the common opinion that opioid-sparing with COX-2 inhibitors provides much clinical beneficial effect with respect to opioid-related adverse events. Future studies have to increase the awareness and proper reporting of adverse events in the postoperative period.