Multimodal opioid-sparing postoperative pain regimen compared with the standard postoperative pain regimen in vaginal pelvic reconstructive surgery: a multicenter randomized controlled trial


      Postoperative pain control after urogynecological surgery has traditionally been opioid centered with frequent narcotic administration. Few studies have addressed optimal pain control strategies for vaginal pelvic reconstructive surgery that limit opioid use.


      The objective of the study was to determine whether, ice packs, Tylenol, and Toradol, a novel opioid-sparing multimodal postoperative pain regimen has improved pain control compared with the standard postoperative pain regimen in patients undergoing inpatient vaginal pelvic reconstructive surgery.

      Study Design

      This was a multicenter randomized controlled trial of women undergoing vaginal pelvic reconstructive surgery. Patients were randomized to the ice packs, Tylenol, and Toradol postoperative pain regimen or the standard regimen. The ice packs, Tylenol, and Toradol regimen consists of around-the-clock ice packs, around-the-clock oral acetaminophen, around-the-clock intravenous ketorolac, and intravenous hydromorphone for breakthrough pain. The standard regimen consists of as-needed ibuprofen, as-needed acetaminophen/oxycodone, and intravenous hydromorphone for breakthrough pain. The primary outcome was postoperative day 1 pain evaluated the morning after surgery using a visual analog scale. Secondary outcomes included the validated Quality of Recovery Questionnaire, satisfaction scores, inpatient narcotic consumption, outpatient pain medication consumption, and visual analog scale scores at other time intervals. In all, 27 patients in each arm were required to detect a mean difference of 25 mm on a 100 mm visual analog scale (90% power).


      Thirty patients were randomized to ice packs, Tylenol, and Toradol and 33 to the standard therapy. Patient and surgical demographics were similar. The median morning visual analog scale pain score was lower in the ice packs, Tylenol, and Toradol group (20 mm vs 40 mm, P = .03). Numerical median pain scores were lower at the 96 hour phone call in the ice packs, Tylenol, and Toradol group (2 vs 3, P = .04). Patients randomized to the ICE-T regimen received fewer narcotics (expressed in oral morphine equivalents) from the postanesthesia care unit exit to discharge (2.9 vs 20.4, P < .001) and received fewer narcotics during the entire hospitalization (55.7 vs 91.2, P < .001). At 96 hour follow up, patients in the ice packs, Tylenol, and Toradol group used 4.9 ketorolac tablets compared with 4.6 oxycodone/acetaminophen tablets in the standard group (P = .81); however, ice packs, Tylenol, and Toradol patients required more acetaminophen than ibuprofen by patients in the standard arm (10.7 vs 6.2 tablets, P = .012). There were no differences in Quality of Recovery Questionnaire or satisfaction scores either in the morning after surgery or at 96 hour follow up.


      The ice packs, Tylenol, and Toradol multimodal pain regimen offers improved pain control the morning after surgery and 96 hours postoperatively compared with the standard regimen with no differences in patient satisfaction and quality of recovery. Ice packs, Tylenol, and Toradol can significantly limit postoperative inpatient narcotic use and eliminate outpatient narcotic use in patients undergoing vaginal pelvic reconstructive surgery.

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        • Kirby A.
        • Luber K.M.
        • Menefee S.A.
        An update on the current and future demand for care of pelvic floor disorders in the United States.
        Am J Obstet Gynecol. 2013; 209 (584.el–5)
        • Vincent G.K.
        The next four decades, the older population in the United States: 2010 to 2050.
        US Census Bureau, Washington, DC2010
        • Momeni M.
        • Crucitti M.
        • Kock M.
        Patient-controlled analgesia in the management of postoperative pain.
        Drugs. 2006; 66: 2321-2337
        • Collins S.A.
        • Quiroz L.H.
        • Steinberg A.C.
        • et al.
        Pain management strategies for urogynecologic surgery: A review.
        Female Pelvic Med Reconstr Surg. 2014; 20: 310-315
        • Crisp C.C.
        • Bandi S.
        • Kleeman S.D.
        • et al.
        Patient-controlled versus scheduled, nurse-administered analgesia following vaginal reconstructive surgery: a randomized trial.
        Am J Obstet Gynecol. 2012; 207: 433.e431-433.e436
        • Rudd R.A.
        • Seth P.
        • David F.
        • et al.
        Increases in drug and opioid-involved overdose deaths- United States, 2010–2015.
        MMWR Morb Mortal Wkly Rep. 2016; 65: 1445-1452
        • Costello M.F.
        • Abbott J.
        • Katz S.
        • et al.
        A prospective, randomized, double-blind, placebo-controlled trial of multimodal intraoperative analgesia for laparoscopic excision of endometriosis.
        Fertil Steril. 2010; 94: 436-443
        • Xiromeritis P.
        • Kalogiannidis I.
        • Papadopoulos E.
        • et al.
        Improved recovery using multimodal perioperative analgesia in minimally invasive myomectomy: a randomized study.
        Aust N Z J Obstet Gynaecol. 2011; 51: 301-306
        • Reagan K.M.L.
        • O’Sullivan D.M.
        • Gannon R.
        • et al.
        Decreasing postoperative narcotics in reconstructive pelvic surgery: a randomized controlled trial.
        Am J Obstet Gynecol. 2017; 217: 325.e1-325.e10
        • Watkins A.A.
        • Johnson T.V.
        • Shresberry A.B.
        • et al.
        Ice packs reduce postoperative midline incision pain and narcotic use: a randomized controlled trial.
        J Am Coll Surg. 2014; 219: 511.e 517
        • East C.E.
        • Begg L.
        • Henshall N.E.
        • Marchant P.R.
        • Wallace K.
        Local cooling for relieving pain from perineal trauma sustained during childbirth.
        Cochrane Database Syst Rev. 2012; 5: CD006304
        • De Oliveira G.S.
        • Agarwal D.
        • Benzon H.T.
        Perioperative single dose ketorolac to prevent postoperative pain: a meta-analysis of randomized trials.
        Anesth Analg. 2012; 114: 424-433
        • Cassinelli E.Z.
        • Dean C.L.
        • Garcia R.M.
        • et al.
        Ketorolac use for postoperative pain management following lumbar decompression surgery.
        Spine. 2008; 33: 1313-1317
        • Lowder J.L.
        • Shackelford D.P.
        • Holbert D.
        • et al.
        A randomized, controlled trial to compare ketorolac tromethamine versus placebo after cesarean section to reduce pain and narcotic usage.
        Am J Obstet Gynecol. 2003; 189: 1559-1562
        • Gilron I.
        • Tu D.
        • Dumerton-Shore D.
        • et al.
        The effect of triple vs. double nonopioid therapy on postoperative pain and functional outcome after abdominal hysterectomy.
        Eu J Anaesthesiol. 2015; 32: 269-276
        • Toms L.
        • McQuay H.J.
        • Derry S.
        • Moore R.A.
        Single dose oral paracetamol (acetaminophen) for postoperative pain in adults.
        Cochrane Database Syst Rev. 2008; 4: CD004602
        • Schulz K.
        • Altman D.
        • Moher D.
        CONSORT 2010 Statement: updated guidelines for reporting parallel group randomized trials.
        Ann Intern Med. 2010; 152: 726-732
        • Myels P.S.
        • Hunt J.O.
        • Nightingale C.E.
        • et al.
        Development and psychometric testing of a quality of recovery score after general anesthesia and surgery in adults.
        Anesth Analg. 1999; 88: 83
        • Myles P.S.
        • Weitkamp B.
        • Jones K.
        • et al.
        Validity and reliability of a postoperative quality of recovery score: the QoR-40.
        Br J Anaesth. 2000; 84: 11-15
        • Herrera F.J.
        • Wong J.
        • Chung F.
        A systematic review of postoperative recovery outcomes measurements after ambulatory surgery.
        Anesth Analg. 2007; 105: 63-69
        • Farrar J.T.
        • Berlin J.A.
        • Strom B.L.
        Clinically important changes in acute pain outcome measures: a validation study.
        J Pain Sympt Manage. 2003; 25: 406-411
        • Cepeda M.S.
        • Africano J.M.
        • Polo R.
        What decline in pain intensity is meaningful to patients with acute?.
        Pain. 2003; 105: 151-157
        • Ferrando C.A.
        • Walters M.D.
        A randomized double-blind placebo-controlled trial on the effect of local analgesia on postoperative gluteal pain in patients undergoing sacrospinous ligament colpopexy.
        Am J Obstet Gynecol. 2018; 218: 599.e1-599.e8
        • Centers for Disease Control and Prevention
        Injury and prevention control: prescription drug overdose.
        (Available at:) (Updated Oct. 27, 2017. Accessed May 18, 2018)
        • Mankes R.F.
        • Silver C.D.
        Quantitative study of controlled substance bedside wasting, disposal, and evaluation of potential ecologic effects.
        Sci Total Environ. 2013; 444: 298-310
        • Madsen A.M.
        • Stark L.M.
        • Has P.
        Opioid knowledge and prescribing practices among obstetrician-gynecologists.
        Obstet Gynecol. 2018; 131: 150-157
        • White P.F.
        The changing role of non-opioid analgesic techniques in the management of post-operative pain.
        Anesth Analg. 2005; 101: S5-S22
        • Swenson C.W.
        • Kelley A.M.
        • Fenner D.E.
        • et al.
        Outpatient narcotic use after minimally invasive urogynecologic surgery.
        Female Pelvic Med Reconstr Surg. 2016; 22: 377-381
        • Hota L.S.
        • Warda H.A.
        • Haviland M.J.
        • et al.
        Opioid use following gynecologic and pelvic reconstructive surgery.
        Int Urogynecol. 2018; 29: 1441-1445