Oral Versus Intravenous Acetaminophen within an Enhanced Recovery after Surgery Protocol in Colorectal Surgery

Abstract

Background: Multimodal pain management within enhanced recovery after surgery (ERAS) protocols is designed to decrease opioid use, promote mobilization, and decrease postoperative complications. Objectives: To evaluate the role of intravenous (IV) versus oral (PO) acetaminophen within an established ERAS protocol in colorectal surgery. Study Design: This was a retrospective observational study. Setting: This research took place within an established perioperative colorectal surgery protocol. Methods: A total of 91 consecutive elective colorectal resections performed according to an ERAS protocol using only IV acetaminophen (IV group) were compared with 84 consecutive resections performed using one dose of IV acetaminophen followed by subsequent administration of oral acetaminophen (PO group). Our multimodal pain management strategy also included transverse abdominis plane blocks, celecoxib, and ketorolac medications for both groups. Opioid requirements, maximum and average daily pain scores by the Visual Analog Scale, and postoperative outcomes were compared between groups. Results: There were no differences in maximum or average pain scores on postoperative days 0-3 or at time of discharge between IV and PO groups. Compared with the IV acetaminophen only group, the PO group received significantly more perioperative opioids through 72 hours postoperatively (68.8 oral morphine equivalents [OME] IV group vs. 93.7 OME PO group; P < 0.0001), were more likely to require opioid patient-controlled analgesia (8.9% IV group vs. 46.4% PO group; P < 0.0001), and were more likely to experience postoperative nausea and vomiting (33.0% IV group vs. 48.8% PO group; P = 0.0449). Limitations: Significant limitations include the studies’ retrospective nature and that it was performed at a single institution. Conclusions: Restriction of IV acetaminophen within an ERAS protocol in colorectal surgery was associated with increased opioid use, greater need for opioid patient-controlled analgesia, and increased incidence of postoperative nausea and vomiting. IV acetaminophen may be superior to oral acetaminophen in the early postoperative setting. Key words: Perioperative pain management, enhanced recovery after surgery, acetaminophen, multimodal pain control, nonopioid

Comparison of Preoperative Intravenous and Oral Acetaminophen: Methodological Issues

“…We recognize that since our initial inquiry and literature search in early 2017, there are multiple published studies at the time of publication of our study (2020). [5][6][7][8][9][10][11][12][13][14][15] Because at the time of protocol development there was no published effect size of the primary outcome variable, the authors calculated a sample size required to detect a clinically significant difference in pain scores. The consensus of the study team was that a 2point difference on a 0 to 10 pain rating scale would be clinically significant.…”

The Effects of Bariatric Surgery and Gastrectomy on the Absorption of Drugs, Vitamins, and Mineral Elements

“…This drug is mainly absorbed by passive transport in the small intestine [31]. The oral route of administration of acetaminophen increases the risk of postoperative nausea and vomiting, as compared with the intravenous route, but the efficacy of both routes of administration is comparable [32]. Porat et al, conducted a clinical, crossover study on the pharmacokinetics of paracetamol in obese patients enrolled for LSG.…”

Letter to the Editor regarding “Influences of Gender on Intravenous Nalbuphine Actions After Major Abdominal Surgery: A Multicenter Study”

“…Because the severity of postoperative pain is mainly dependent on the type and site of surgery [ 3 ], the inclusion of different types of surgeries is undoubtedly an important confounding factor that can affect postoperative pain assessment. To avoid this issue, a better study design would comprise patients undergoing a single type of abdominal surgery as study objects, as performed in previous work [ 4 ].…”