Advertisement

Intravenous acetaminophen vs saline in perioperative analgesia with laparoscopic hysterectomy

Published:January 22, 2019DOI:https://doi.org/10.1016/j.ajog.2019.01.212

      Background

      Opioids are effective for the treatment of postoperative pain but can cause nausea and are associated with dependency with long-term use. Nonopioid medications such as acetaminophen offer the promise of decreasing these nondesirable effects while still providing patient comfort.

      Objective

      The purpose of this study was to compare intravenous acetaminophen with placebo and to evaluate postoperative pain control and opioid usage after laparoscopic hysterectomy.

      Study Design

      We conducted a prospective double-blind randomized study with 183 patients who were assigned randomly (1:1) to receive acetaminophen or placebo (Canadian Task Force Design Classification I). Patients received either 1000 mg of acetaminophen (n=91) or a placebo of saline solution (n=92) at the time of induction of anesthesia and a repeat dose 6 hours later. Both groups self-reported pain and nausea levels preoperatively and at 2, 4, 6, 12, and 24 hours after extubation with the use of a visual analog scale with a score of 0 for no pain to 10 for highest level of pain. Patients self-reported pain, nausea, and postoperative oral opiates that were taken after discharge. All opiates were converted to milligram equivalents of oral morphine for standardization.

      Results

      There were no significant differences in generalized abdominal pain at any time point postoperatively that included 2 hours (placebo 3.6±2.5 vs acetaminophen 4.4±2.5; P=.07) and up to 24 hours (placebo 3.3±2.4 vs acetaminophen 3.6±2.5; P=.28). Similar results were observed for nausea scores. There were no differences in opioid consumption at any time point including intraoperatively (placebo 4.4±3.9 vs acetaminophen 3.3±4.0; P=.06), post anesthesia care unit (placebo 10.5±10.3 vs acetaminophen 9.7±10.3; P=.59), and up to 24 hours after surgery (placebo 1.4±2.0 vs acetaminophen 1.6±2.1; P=.61). There were no differences in demographics or surgical data between groups.

      Conclusion

      There was no difference between acetaminophen and placebo groups in postoperative pain, satisfaction scores, or opioid requirements. Given the relatively high cost ($23.20 per dose in our study), lack of benefit, and available oral alternatives, our results do not support routine use during hysterectomy.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Obstetrics & Gynecology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Cho J.
        • Shamshirsaz A.
        • Nezhat C.
        • et al.
        New technologies for reproductive medicine: laparoscopy, endoscopy, robotic surgery and gynecology: a review of the literature.
        Minerva Ginecol. 2010; 62: 137-167
        • Fengling J.
        • Frances C.
        Multimodal analgesia for postoperative pain control.
        J Clin Anesth. 2001; 13: 524-539
        • Garimella V.
        • Cellini C.
        Postoperative pain control.
        Clin Colon Rectal Surg. 2013; 26: 191-196
        • Pasero C.
        • Stannard D.
        The role of intravenous acetaminophen in acute pain management: a case-illustrated review.
        Pain Manag Nurs. 2012; 13: 107-124
        • Singla N.K.
        • Parulan C.
        • Samson R.
        • et al.
        Plasma and cerebrospinal fluid pharmacokinetic parameters after single- dose administration of intravenous, oral, or rectal acetaminophen.
        Pain Pract. 2012; 12: 523-532
        • Wininger S.
        • Miller H.
        • Minkowitz H.
        • et al.
        A randomized, double-blind, placebo-controlled, multicenter, repeat-dose study of two intravenous acetaminophen dosing regimens for the treatment of pain after abdominal laparoscopic surgery.
        Clin Ther. 2010; 32: 2348-2369
        • Memis D.
        • Inal M.
        • Kavalci G.
        • Sezer A.
        • Sut N.
        Intravenous paracetamol reduced the use of opioids, extubation time, and opioid-related adverse effects after major surgery in intensive care unit.
        J Crit Care. 2010; 25: 458-462
        • Khalili G.
        • Janghorbani M.
        • Saryazdi H.
        • Emaminejad A.
        Effect of preemptive and preventive acetaminophen on postoperative pain score: a randomized, double-blind trial of patients undergoing lower extremity surgery.
        J Clin Anesth. 2013; 25: 188-192
        • Bektas F.
        • Eken C.
        • Karadeniz O.
        • Goksu E.
        • Cubuk M.
        • Cete Y.
        Intravenous paracetamol or morphine for the treatment of renal colic: a randomized, placebo-controlled trial.
        Ann Emerg Med. 2009; 54: 568-574
        • Sinatra R.
        • Jahr J.
        • Reynolds L.
        • Viscusi E.
        • Groudine S.
        • Payen-Champenois C.
        Efficacy and safety of single and repeated administration of 1 gram intravenous acetaminophen injection (paracetamol) for pain management after major orthopedic surgery.
        Anesthesiology. 2005; 102: 822-831
        • Hansen R.
        • Pham A.
        • Lovelace B.
        • Balaban S.
        • Wan G.
        Comparative analysis of inpatient costs for obstetrics and gynecology surgery patients treated with IV acetaminophen and IV opioids versus IV opioid-only analgesia for postoperative pain.
        Ann Pharmacother. 2017; 51: 834-839
        • Crisp C.
        • Khan M.
        • Lambers D.
        • et al.
        The effect of intravenous acetaminophen on postoperative pain and narcotic consumption after vaginal reconstructive surgery: a double-blind randomized placebo controlled study.
        Female Pelvic Med Reconstr Surg. 2017; 23: 80-85
        • Perron-Burdick M.
        • Yamamoto M.
        • Zaritsky E.
        Same-day discharge after laparoscopic hysterectomy.
        Obstet Gynecol. 2011; 117: 1136-1141
        • Gien L.
        • Kupets R.
        • Covens A.
        Feasibility of same-day discharge after laparoscopic surgery in gynecologic oncology.
        Gynecol Oncol. 2011; 121: 339-343
        • Hawker G.A.
        • Mian S.
        • Kendzerska T.
        • French M.
        “Measures of adult pain: visual analog scale for pain (vas pain), numeric rating scale for pain (NRS pain), McGill pain questionnaire (MPQ), short form McGill pain questionnaire (SFMPQ), chronic pain grade scale (CPGS), short form 36 bodily pain scale (SF36 BPS), and measure of intermittent and constant osteoarthritis pain (ICOAP)”.
        Arthritis Care Res. 2011; 63: S240-S252
        • Myles P.S.
        • Weitkamp B.
        • Jones K.
        • Melick J.
        • Hensen S.
        Validity and reliability of a postoperative quality of recovery score: the QoR-40.
        Br J Anaesth. 2000; 84: 11-15
        • Arden D.
        • Seifert E.
        • Donnellan N.
        • et al.
        Intraperitoneal instillation of bupivacaine for reduction of postoperative pain after laparoscopic hysterectomy: a double-blind randomized controlled trial.
        J Minim Invasive Gynecol. 2013; 20: 620-626
        • American Pain Society
        Principles of analgesic use in the treatment of acute pain and cancer pain.
        6th ed. American Pain Society, Glenview (IL)2008
        • Anderson R.
        • Saiers J.H.
        • Abram S.
        • et al.
        Accuracy in equianalgesic dosing. conversion dilemmas.
        J Pain Symptom Manage. 2001; 21: 397-406
        • Pereira J.
        • Lawlor P.
        • Vigano A.
        • et al.
        Equianalgesic dose ratios for opioids. a critical review and proposals for long-term dosing.
        J Pain Symptom Manage. 2001; 22: 672-687
        • Reagan K.
        • O’Sullivan D.
        • Gannon R.
        • et al.
        Decreasing postoperative narcotics in reconstructive pelvic surgery: a randomized controlled trial.
        Am J Obstet Gynecol. 2017; 217 (325.e1–10): 672-687