Rectal diclofenac analgesia after abdominal hysterectomy

Evidence-based anesthesia for major gynecologic surgery

Studies on enhanced recovery after gynecological surgery are limited but seem to report outcome benefits similar to those reported after colorectal surgery. Regional anesthesia is recommended in enhanced recovery protocols. Effective regional anesthetic techniques in gynecologic surgery include spinal anesthesia, epidural analgesia, transversus abdominis plane blocks, local anesthetic wound infusions and intraperitoneal instillation catheters. Non-opioid analgesics including pregabalin, gabapentin, NSAIDs, COX-2 inhibitors, and paracetamol reduce opioid consumption after surgery. This population is at high risk for PONV, thus, a multimodal anti-emetic strategy must be employed, including strategies to reduce the baseline risk of PONV in conjunction with combination antiemetic therapy.

Infiltration with ropivacaine plus lornoxicam reduces postoperative pain and opioid consumption

PURPOSE

To compare efficacy and patient outcome of wound infiltration with ropivacaine, lornoxicam, or their combination for control of pain following thyroid surgery.

METHODS

Eighty patients underwent thyroid surgery were randomly assigned to one of four groups. Before skin closure, local tissues were infiltrated with 12 mL saline in Group S, with 10 mL of ropivacaine 0.75% plus 2 mL saline in Group R, with 2 mL of lornoxicam (8 mg) plus 10 mL saline in Group L, and with 10 mL ropivacaine 0.75% plus 2 mL lornoxicam (8 mg) in Group RL. Pain scores, total and incremental meperidine con-eight, 12, 18, and 24 hr postoperatively. Time to first analgesic requirement, patient satisfaction, and duration of hospital stay were also compared after surgery.

RESULTS

The pain scores in Group RL were significantly lower in the first 12 hr than in Group S, and in the first four hours than in Groups R and L (P < 0.01). The time to first analgesic requirement was significantly longer (14.8 +/- 8.4 hr vs 5.9 +/- 5.2 hr; P < 0.01), the total pethidine consumption was significantly less than Group S (34.0 +/- 33.0 mg vs 78.0 +/- 29.8 mg; P<0.001), return of gastrointestinal function, ambulation time, length of hospital stay (P < 0.05) were significantly shorter, and patient satisfaction (P < 0.01) was significantly better in Group RL than in Group S (P < 0.05).

CONCLUSION

Wound infiltration with ropivacaine 0.75% plus lornoxicam 8 mg combination improved postoperative pain control and patient comfort, and decreased the need for opioids than the use of either drug alone.

The effect of preoperative intravenous use of tenoxicam: a prospective, double-blind, placebo-controlled study

In this study, we aimed to investigate the postoperative pain relief effect of preoperative tenoxicam usage in patients who undergo elective laparoscopic cholecystectomy or groin hernia repair. Eighty patients undergoing laparoscopic cholecystectomy or groin hernia repair procedures were randomized to receive either physiologic serum at 100 mL (group I, n = 40) or 20 mg iv tenoxicam (group II, n = 40) immediately before induction. Postoperative analgesic requirement, peroperative side effects and complications of drugs, operating time, post-operative mobilization time and pain score, hospitalization time, and patient pleasure were recorded. Postoperative pain was assessed by the visual analogue scale (VAS) on the recovery unit (RU), at 4, 8, and 24 h and every day at the same times in the morning. The RU median VAS score was also not different when Group 1 was compared with Group 2 (p = .97). However, the postoperative 4-h and 8-h median VAS score was significantly less (p = .01 and p = .03, respectively); first postoperative mobilization time was earlier in group 2 (p = .32). The median pain score and intramuscular analgesic requirement of patients were also reduced in Group 2 in postoperative day 1 (p = .015). The median duration of intramuscular analgesic requirement and total amount of intramuscular analgesic used in patients were also significantly less in Group 2 (p = .0001 and p = .0001, respectively). Thus, this study showed that preoperative use of iv tenoxicam is safe, simple, and effective for postoperative pain relief after laparoscopic cholecystectomy or inguinal hernia repair.

Rectal analgesia for the relief of perineal pain after childbirth: a randomised controlled trial of diclofenac suppositories

OBJECTIVE

To evaluate rectal diclofenac in the relief of perineal pain after trauma during childbirth.

DESIGN

A randomised, double-blind trial.

SETTING

Delivery Suite, Women's and Children's Hospital, South Australia.

POPULATION

Women with a second-degree (or greater) perineal tear or episiotomy.

METHODS

Women were randomly allocated to either diclofenac or placebo suppositories (Anusol), using a computer-generated randomisation schedule with stratification for parity and mode of birth. Treatment packs contained two x 100 mg diclofenac or two placebo suppositories, the first being inserted when suturing was complete, and the second 12-24 hours after birth. Women were asked to complete questionnaires at 24 and 48 hours after birth relating to their degree of perineal pain using the validated Short Form McGill Pain Questionnaire.

MAIN OUTCOME MEASURES

Pain scores at 24 and 48 hours after birth.

RESULTS

A total of 133 women were recruited, with 67 randomised to diclofenac suppositories and 66 to placebo. Women in the diclofenac group were significantly less likely to experience pain at 24 hours while walking (RR 0.8; 95% CI 0.6 to 1.0), sitting (RR 0.8; 95% CI 0.6 to 1.0), passing urine (RR 0.6; 95% CI 0.4 to 1.0) and on opening their bowels (RR 0.6; 95% CI 0.2 to 0.9) compared with those women who received placebo. These differences were not sustained 48 hours after birth.

CONCLUSIONS

The use of rectal non-steroidal anti-inflammatory drug suppositories is a simple, effective and safe method of reducing the pain experienced by women following perineal trauma within the first 24 hours after childbirth.

Preoperative oral rofecoxib reduces postoperative pain and tramadol consumption in patients after abdominal hysterectomy

We designed this study to determine whether the administration of a preoperative dose of rofecoxib to patients undergoing abdominal hysterectomy would decrease patient-controlled analgesia (PCA) tramadol use or enhance analgesia. Sixty patients were randomized to receive either oral placebo or rofecoxib 50 mg 1 h before surgery. All patients received a standard anesthetic protocol. Intraoperative blood loss was determined. At the end of surgery, all patients received tramadol IV via a PCA-device. Pain scores, sedation scores, mean arterial blood pressure, heart rate, and peripheral oxygen saturation were assessed at 1, 2, 4, 6, 8, 12, and 24 h after surgery. Total and incremental tramadol consumption at the same times was recorded from the PCA-device. Antiemetic requirements and adverse effects were noted during the first postoperative 24 h. Duration of hospital stay was also recorded. The pain scores were significantly lower in the rofecoxib group compared with the placebo group at 6 times during the first 12 postoperative h (P < 0.05). The total consumption of tramadol (627 +/- 69 mg versus 535 +/- 45 mg; P < 0.05) and the incremental doses at 1, 2, 4, 6, 8, and 12 h after surgery were significantly more in the placebo group than in the rofecoxib group. There were no differences between groups in intraoperative blood loss, sedation scores, hemodynamic variables, peripheral oxygen saturation, antiemetic requirements, or adverse effects after surgery. The length of hospital stay was also similar in the groups. We conclude that the preoperative administration of oral rofecoxib provided a significant analgesic benefit and decreased the opioid requirements in patients undergoing abdominal hysterectomy.

IMPLICATIONS

This study was designed to determine whether the administration of a preoperative dose of rofecoxib to patients undergoing abdominal hysterectomy would decrease patient-controlled analgesia tramadol use or enhance analgesia. We conclude that the preoperative administration of oral rofecoxib provided a significant analgesic benefit and decreased the opioid requirements in patients undergoing abdominal hysterectomy.

Rectal analgesia for pain from perineal trauma following childbirth

BACKGROUND

Perineal pain from a tear and/or surgical cut (episiotomy) is a common problem following vaginal birth. Strategies to reduce perineal trauma and the appropriate repair of any perineal damage sustained are important for avoiding and alleviating pain. Where pain is present, numerous treatments are used in clinical practice, such as local anaesthetics, oral analgesics, therapeutic ultrasound, antiseptics and non-pharmacological applications such as ice packs and baths. This review assesses the evidence for using rectal analgesia for pain relief following perineal trauma.

OBJECTIVES

To assess the effectiveness of analgesic rectal suppositories for pain from perineal trauma following childbirth.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register (July 2002), CENTRAL (The Cochrane Library, Issue 2, 2002), CINAHL (May 2002) and MIDIRS (May 2002).

SELECTION CRITERIA

Randomised controlled trials comparing analgesic rectal suppositories with placebo or alternative treatment for the relief of perineal pain.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed trial quality and extracted data independently.

MAIN RESULTS

Three trials involving 249 women met the inclusion criteria. Only two of the trials identified for inclusion in this review had data that could be entered in a meta-analysis, with the third not providing data in a useable format. Women were less likely to experience pain at or close to 24 hours after birth if they received non-steroidal anti-inflammatory drugs (NSAID) suppositories compared with placebo (relative risk (RR) 0.37, 95% confidence interval (CI) 0.10 to 1.38, 2 trials, 150 women). Women in the NSAID suppositories group compared with women in the placebo group required less additional analgesia in the first 24 hours after birth (RR 0.31, 95% CI 0.17 to 0.54, 1 trial, 89 women) and this effect was still evident at 48 hours postpartum (RR 0.63, 95% CI 0.45 to 0.89, 1 trial, 89 women). No information was available on pain experienced more than 72 hours after birth or other outcomes of importance to women such as the impact on daily activities, resumption of sexual intercourse and the impact on the mother-baby relationship.

REVIEWER'S CONCLUSIONS

NSAID rectal suppositories are associated with less pain up to 24 hours after birth, and less additional analgesia is required. More research is required regarding long-term effects and maternal satisfaction with the treatment.

Does the opioid-sparing effect of rectal diclofenac following total abdominal hysterectomy benefit the patient?

BACKGROUND

The aim of this prospective, double-blind, randomized, placebo-controlled clinical trial was to investigate the opioid-sparing effects of rectal diclofenac following total abdominal hysterectomy.

METHODS

Forty ASA I-II patients, aged 20-60 yr, were randomized to receive identical-looking suppositories of either diclofenac 75 mg or placebo, twice daily. All patients were given a standardized anaesthetic, with intravenous morphine via a patient-controlled analgesia device and either diclofenac or placebo for postoperative analgesia.

RESULTS

The median 24 h morphine consumption (interquartile range) was significantly higher (P=0.02) in the placebo group [59 (45-85) mg] than in the diclofenac group [31 (14-65) mg]. In comparison with the placebo group, there were significant reductions in total pain score in the diclofenac group at rest (P=0.04) and on movement (P<0.01). Total (SD) sedation score was significantly lower (P=0.04) in the diclofenac group [90 (73) mm] than in the placebo group [148 (89) mm]. Total (interquartile range) nausea score was significantly lower (P<0.01) in the diclofenac group [14 (0-53) mm] than in the placebo group [64 (30-109) mm]. There was no significant difference between the two groups of patients in episodes of vomiting or number of rescue antiemetics.

CONCLUSIONS

Rectal diclofenac reduces morphine consumption, improves postoperative analgesia, and reduces the incidence of adverse effects such as sedation and nausea.