Intravenous Acetaminophen Before Pelvic Organ Prolapse Repair: A Randomized Controlled Trial

Comparing Postoperative Pain With Laparoscopic Versus Robotic Sacrocolpopexy

STUDY OBJECTIVE

To compare postoperative pain and pain-related outcomes after laparoscopic (LS-MISC) vs robotic minimally invasive sacrocolpopexy (R-MISC).

DESIGN

A secondary analysis of an original placebo-controlled randomized controlled trial (RCT) examining preoperative intravenous (IV) acetaminophen on postoperative pain after MISC.

SETTING

Planned secondary analysis of multicenter RCT.

PATIENTS

Women undergoing MISC.

INTERVENTIONS

Coprimary outcomes at 24 hours were total opioid use in morphine milligram equivalents (MMEs) and visual analog scale (VAS) pain scores comparing LS-MISC and R-MISC. The secondary outcome was pain scores using a pain diary through 7 days after the procedure.

MEASUREMENTS AND MAIN RESULTS

The original study was a double-blind, multicenter, RCT comparing IV acetaminophen with placebo that took place between 2014 and 2017. Given that the original trial was unable to show an impact from the use of IV acetaminophen, our analysis focused on the impact of surgical modality. We included 90 subjects undergoing MISC: 65 LS-MISC and 25 R-MISC. Most were Caucasian (97.8%) and postmenopausal (88.9%) with mean age of 61.2 ± 7.2 years and body mass index of 27.6 ± 4.4 kg/m2. IV acetaminophen did not affect pain in the original study and was not different between LS-MISC and R-MISC. Concomitant hysterectomy was performed in 67% (LS-MISC) vs 60% (R-MISC, p = .49). LS-MISC underwent more perineorrhaphies (15.4% vs 0%, p = .04) and posterior repairs (18.5% vs 0%, p = .02). Operative time was longer with LS-MISC (208.5 ± 57.3 vs 143.6 ± 21.0 minutes, p <.01). Length of stay was longer with LS-MISC (0.9 ± 0.4 vs 0.7 ± 0.4 days, p = .02). Women undergoing LS-MISC consumed more opioid MMEs through 24 hours when including intraoperative opioids (48.5 ± 25.5 vs 35.1 ± 14.6 MME, p <.01). Using linear regression correcting for operative time and concomitant vaginal repairs, this difference disappeared. Likewise, when intraoperative opioids were excluded, there was no difference. There were no differences in 24-hour postoperative VAS scores, opioid use in the first week, or quality of life (Patient-Reported Outcomes Measurement Information System - Pain Interference Short Form, all p <.05).

CONCLUSION

When comparing VAS pain scores, MME opioid usage, and quality of life between LS-MISC and R-MISC, either there was no difference or differences disappeared after adjusting for confounders. Overall, opioid use, pain scores, and opioid side effects were low.

AUGS-IUGA Joint Clinical Consensus Statement on Enhanced Recovery After Urogynecologic Surgery: Developed by the Joint Writing Group of the International Urogynecological Association and the American Urogynecologic Society. Individual writing group members are noted in the Acknowledgements section

INTRODUCTION AND HYPOTHESIS

Enhanced recovery after surgery (ERAS) evidence-based protocols for perioperative care can lead to improvements in clinical outcomes and cost savings. This article aims to present consensus recommendations for the optimal perioperative management of patients undergoing urogynecological surgery.

METHODS

A review of meta-analyses, randomized clinical trials, large nonrandomized studies, and review articles was conducted via PubMed and other databases for ERAS and urogynecological surgery. ERAS protocol components were established, and then quality of the evidence was both graded and used to form consensus recommendations for each topic. These recommendations were developed and endorsed by the writing group, which is comprised of the American Urogynecologic Society and the International Urogynecological Association members.

RESULTS

All recommendations on ERAS protocol items are based on best available evidence. The level of evidence for each item is presented accordingly. The components of ERAS with a high level of evidence to support their use include fasting for 6 h and taking clear fluids up to 2 h preoperatively, euvolemia, normothermia, surgical site preparation, antibiotic and antithrombotic prophylaxis, strong antiemetics and dexamethasone to reduce postoperative nausea and vomiting, multimodal analgesia and restrictive use of opiates, use of chewing gum to reduce ileus, removal of catheter as soon as feasible after surgery and avoiding systematic use of drains/vaginal packs.

CONCLUSIONS

The evidence base and recommendations for a urogynecology-relevant ERAS perioperative care pathway are presented in this consensus review. There are several elements of ERAS with strong evidence of benefit in urogynecological surgery.

Nonopioid Analgesics for the Perioperative Geriatric Patient: A Narrative Review

Management of acute perioperative pain in the geriatric patient can be challenging as the physiologic and pharmacokinetic changes associated with aging may predispose older patients to opioid-related side effects. Furthermore, elderly adults are more susceptible to postoperative delirium and postoperative cognitive dysfunction, which may be exacerbated by both poorly controlled postoperative pain and commonly used pain medications. This narrative review summarizes the literature published in the past 10 years for several nonopioid analgesics commonly prescribed to the geriatric patient in the perioperative period. Nonopioid analgesics are broken down as follows: medications prescribed throughout the perioperative period (acetaminophen and nonsteroidal anti-inflammatory drugs), medications limited to the acute perioperative setting (N-methyl-D-aspartate receptor antagonists, dexmedetomidine, dexamethasone, and local anesthetics), and medications to be used with caution in the geriatric patient population (gabapentinoids and muscle relaxants). Our search identified 1757 citations, but only 33 specifically focused on geriatric analgesia. Of these, only 21 were randomized clinical trials' and 1 was a systematic review. While guidance in tailoring pain regimens that focus on the use of nonopioid medications in the geriatric patient is lacking, we summarize the current literature and highlight that some nonopioid medications may extend benefits to the geriatric patient beyond analgesia.

Effects of yoga on the intervention of levator ani hiatus in postpartum women: a prospective study

[Purpose] This study aimed to explore the application value of yoga intervention in early postpartum recovery of the levator ani muscle hiatus (LAH) area. [Participants and Methods] Females in natural labor from May 2020 to November 2020 in the Third People’s Hospital of Sun Yat-sen University Ultrasound Research Center were prospectively included for a pelvic ultrasound examination. The control group received no intervention. The experimental group received 60-min yoga once a week from week 1 to week 12 postpartum. A pelvic ultrasound examination was performed on the week 6 and week 12 postpartum. The LAH area was measured at rest, during contraction and Valsalva maneuver. [Results] A total of 128 participants who met the inclusion criteria were selected and randomly assigned to the control group (n=66) and the experimental group (n=62) in pre and post intervention design. No significant differences were found in age, parity, body mass index, and fetal weight between the control and experimental groups. Further, no significant difference was observed in the LAH area between the control and experimental groups at rest, during contraction and Valsalva maneuver on the week 6 postpartum. However, the LAH area in experimental group significantly reduced at rest, during contraction and Valsalva maneuver on the week 12 postpartum. The differences of LAH area (date week 6 minus date week 12) in the control group at rest, during contraction and Valsalva maneuver were 0.12 ± 3.12 cm², 0.80 ± 2.29 cm², and 0.80 ± 4.22 cm², while in the control these were 1.95 ± 3.41 cm², 1.39 ± 1.91 cm², and 3.81 ± 5.49 cm², respectively. Compared with control group, the differences of LAH area significantly increased in experimental group at rest and during Valsalva maneuver. [Conclusion] Yoga intervention can help in the recovery of LAH.

Assessing efficacy of intravenous acetaminophen for perioperative pain control for oocyte retrieval: a randomized, double-blind, placebo-controlled trial

OBJECTIVE

To compare the effect of preoperative intravenous (IV) acetaminophen versus oral (PO) acetaminophen or placebo on postoperative pain scores and the time to discharge in women undergoing oocyte retrieval.

DESIGN

Randomized, double-blind, placebo-controlled trial.

SETTING

Single academic fertility center.

PATIENT(S)

Women aged 18-43 years undergoing oocyte retrieval.

INTERVENTION(S)

Randomization to preoperative 1,000 mg IV acetaminophen and PO placebo (group A), IV placebo and 1,000 mg PO acetaminophen (group B), or IV and PO placebo (group C) MAIN OUTCOME MEASURE(S): Difference in patient-reported postoperative visual analog scale pain scores from baseline and the time to discharge.

RESULT(S)

Of the 159 women who completed the study, there were no differences in the mean postoperative pain score differences or the time to discharge. Although not statistically significant, the mean postoperative opioid dose requirement in group A was lower than that in groups B and C (0.24 vs. 0.59 vs. 0.58 mg IV morphine equivalents, respectively) due to fewer women in group A requiring rescue pain medication (8% vs. 19% vs. 15%, respectively). Group A also reported less constipation when compared with groups B and C (19% vs. 33% vs. 40%, respectively). The rates of postoperative nausea were similar, and there were no differences in embryology or early pregnancy outcomes between the study groups.

CONCLUSION(S)

Preoperative IV acetaminophen for women undergoing oocyte retrieval did not reduce postoperative pain scores or shorten the time to discharge when compared with PO acetaminophen or placebo and, thus, cannot currently be recommended routinely in this patient population.

CLINICAL TRIAL REGISTRATION NUMBER

NCT03073980.

The Efficacy of Acetominophen for Total Laparoscopic Hysterectomy

OBJECTIVE

Despite limited data, acetaminophen, along with other agents, is commonly included in enhanced recovery after surgery (ERAS) protocols following laparoscopic hysterectomy. We aimed to systematically review the efficacy of acetaminophen on the management of postoperative pain after laparoscopic hysterectomy.

METHODS

We searched PubMed, SCOPUS, Web of Science, and Cochrane Library databases for relevant clinical trials investigating the role of acetaminophen in the management of pain after laparoscopic hysterectomy. We performed the risk of bias according to Cochrane's risk of bias tool. We performed the analysis of homogeneous data under the fixed-effects model during the analysis of heterogeneous data under the random-effects model. The primary outcome was the assessment of pain score after 2, 6, 12, and 24 h.

RESULTS

A total of 495 patients in 13 trials were included in our meta-analysis. Acetaminophen was not superior at reducing postoperative pain scores. Further analysis at progressive temporal points revealed no further significance; effect size at after 2 h (SMD = -0.020, 95% CI (-0.216; 0.176)), 6 h (SMD = -0.115, 95% CI (-0.312; 0.083)), 12 h (SMD = -0.126, 95% CI (-0.277; 0.025)), or 24 h (SMD = 0.063, 95% CI (-0.065; 0.191)). Pooled analysis was heterogeneous (P < 0.1); therefore, we conducted a sensitivity analysis yielding homogeneous results. The drug did not reduce opioid need (MD = -0.16, 95% CI (-2.39, 2.06), P = 0.89).

CONCLUSION

We conclude that acetaminophen is not beneficial for reducing pain after laparoscopic hysterectomy. Other alternatives have better results. Caution should be given to the inclusion of acetaminophen in ERAS protocols designed for laparoscopic hysterectomy, especially as a single agent or to reduce opioid consumption.

Evidence for the Efficacy of an Opioid-Sparing Effect of Intravenous Acetaminophen in the Surgery Patient: A Systematic Review

BACKGROUND

Intravenous (IV) acetaminophen is used in multimodal analgesia to reduce the amount and duration of opioid use in the postoperative setting.

METHODS

A systematic review of published randomized controlled trials was conducted to define the opioid-sparing effect of IV acetaminophen in different types of surgeries. Eligible studies included prospective, randomized, double-blind trials of IV acetaminophen compared with either a placebo- or active-treatment group in adult (age ≥18 years) patients undergoing surgery. Trials had to be published in English in a peer-reviewed journal.

RESULTS

A total of 44 treatment cohorts included in 37 studies were included in the systematic analysis. Compared with active- or placebo-control treatments, IV acetaminophen produced a statistically significant opioid-sparing effect in 14 of 44 cohorts (32%). An opioid-sparing effect was more common in placebo-controlled comparisons. Of the 28 placebo treatment comparisons, IV acetaminophen produced an opioid-sparing effect in 13 (46%). IV acetaminophen produced an opioid-sparing effect in only 6% (one out of 16) of the active-control groups. Among the 16 active-control groups, opioid consumption was significantly greater with IV acetaminophen than the active comparator in seven cohorts and not significantly different than the active comparator in eight cohorts.

CONCLUSIONS

The results of this systematic analysis demonstrate that IV acetaminophen is not effective in reducing opioid consumption compared with other adjuvant analgesic agents in the postoperative patient. In patients where other adjuvant analgesic agents are contraindicated, IV acetaminophen may be an option.

Effect of Intravenous Acetaminophen on Postoperative Hypoxemia After Abdominal Surgery: The FACTOR Randomized Clinical Trial

IMPORTANCE

Opioid-induced ventilatory depression and hypoxemia is common, severe, and often unrecognized in postoperative patients. To the extent that nonopioid analgesics reduce opioid consumption, they may decrease postoperative hypoxemia.

OBJECTIVE

To test the hypothesis that duration of hypoxemia is less in patients given intravenous acetaminophen than those given placebo.

DESIGN, SETTING, AND PARTICIPANTS

Randomized, placebo-controlled, double-blind trial conducted at 2 US academic hospitals among 570 patients who were undergoing abdominal surgery, enrolled from February 2015 through October 2018 and followed up until February 2019.

INTERVENTIONS

Participants were randomized to receive either intravenous acetaminophen, 1 g (n = 289), or normal saline placebo (n = 291) starting at the beginning of surgery and repeated every 6 hours until 48 postoperative hours or hospital discharge, whichever occurred first.

MAIN OUTCOMES AND MEASURES

The primary outcome was the total duration of hypoxemia (hemoglobin oxygen saturation [Spo2] <90%) per hour, with oxygen saturation measured continuously for 48 postoperative hours. Secondary outcomes were postoperative opioid consumption, pain (0- 10-point scale; 0: no pain; 10: the most pain imaginable), nausea and vomiting, sedation, minimal alveolar concentration of volatile anesthetic, fatigue, active time, and respiratory function.

RESULTS

Among 580 patients randomized (mean age, 49 years; 48% women), 570 (98%) completed the trial. The primary outcome, median duration with Spo2 of less than 90%, was 0.7 (interquartile range [IQR], 0.1-5.1) minutes per hour among patients in the acetaminophen group and 1.1 (IQR, 0.1-6.6) minutes per hour among patients in the placebo group (P = .29), with an estimated median difference of -0.04 (95% CI,-0.18 to 0.11) minutes per hour. None of the 8 secondary end points differed significantly between the acetaminophen and placebo groups. Mean pain scores within initial 48 postoperative hours were 4.2 (SD, 1.8) in the acetaminophen group and 4.4 (SD, 1.8) in the placebo group (difference, -0.28; 95% CI, -0.71 to 0.15); median opioid use in morphine equivalents was 50 mg (IQR, 18-122 mg) and 58 mg (IQR, 24-151 mg) , respectively, with a ratio of geometric means of 0.86 (95% CI, 0.61-1.21).

CONCLUSIONS AND RELEVANCE

Among patients who underwent abdominal surgery, use of postoperative intravenous acetaminophen, compared with placebo, did not significantly reduce the duration of postoperative hypoxemia over 48 hours. The study findings do not support the use of intravenous acetaminophen for this purpose.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02156154.

A systematic review of best practices for the perioperative management of abdominal sacrocolpopexy

PURPOSE

Enhanced recovery after surgery (ERAS) pathways have been shown to reduce surgical morbidity and length of stay across various procedures. Our objective was to systematically evaluate the literature for best practices of ERAS elements in abdominal sacrocolpopexy (ASC), to determine if there is sufficient evidence to create best practice guidelines for this procedure.

MATERIALS AND METHODS

Following the preferred reporting items for systematic review and meta-analysis (PRISMA) statement, we performed a review using Pubmed, Embase, and Cochrane Library. Eligible articles contained ERAS components and postoperative outcomes of ASC published in English since 1997. Thirty-five full-text articles were selected for final qualitative analysis.

RESULTS

Poor functional status before ASC was associated with a longer length of hospital stay. Laparoscopic ASC was associated with a shorter postoperative hospital stay, with no difference between laparoscopic and robotic approaches. Epidural analgesia in addition to spinal anesthesia lowered levels of pain throughout the postoperative stay in laparoscopic ASC. A multimodal bowel regimen shortened time to first bowel movement compared to a single agent regimen. Removing a Foley catheter may lead to sooner first spontaneous void but may result in higher rates of urinary retention and urinary tract infection. Studies investigating preoperative bowel preparation, preanesthesia medication, and multidose antimicrobial prophylaxis did not show significant benefit.

CONCLUSIONS

Best practices for ASC can be developed based on current findings from the literature and extrapolation of evidence from other surgeries where ASC-specific elements are missing, with the ability to modify the pathways as new data become available.

Perioperative pain management in minimally invasive gynecologic surgery

PURPOSE OF REVIEW

The purpose of this review is to summarize the most recent evidence-based interventions for perioperative pain management in minimally invasive gynecologic surgery.

RECENT FINDINGS

With particular emphasis on preemptive interventions in recent studies, we found preoperative counseling, nutrition, exercise, psychological interventions, and a combination of acetaminophen, celecoxib, and gabapentin are highly important and effective measures to reduce postoperative pain and opioid demand. Intraoperative local anesthetics may help at incision sites, as a paracervical block, and a transversus abdominus plane block. Postoperatively, an effort should be made to utilize non-narcotic interventions such as abdominal binders, ice packs, simethicone, bowel regimens, gabapentin, and scheduled NSAIDs and acetaminophen. When prescribing narcotics, providers should be aware of recommended amounts of opioids required per procedure so as to avoid overprescribing.

SUMMARY

Our findings emphasize the evolving importance of preemptive interventions, including prehabilitation and pharmacologic agents, to improve postoperative pain after minimally invasive gynecologic surgery. Additionally, a multimodal approach to nonnarcotic intraoperative and postoperative interventions decreases narcotic requirement and improves opioid stewardship.