What is adequate pain medication for inpatient pain control prior to cholecystectomy (surgical removal of the gallbladder)?

From the Guidelines

For adequate pain control in patients awaiting cholecystectomy, I recommend a multimodal approach starting with acetaminophen 1000 mg orally every 6 hours as a baseline analgesic, adding NSAIDs such as ketorolac 30 mg IV initially, then 15-30 mg IV every 6 hours if not contraindicated, and using opioids like fentanyl or oxycodone for moderate to severe pain, with patient-controlled analgesia (PCA) as needed. This approach is based on the most recent evidence from the World Journal of Emergency Surgery 1, which suggests that a multimodal approach to pain management is effective in reducing opioid requirements and side effects. The use of acetaminophen and NSAIDs as baseline analgesics is supported by studies that show their effectiveness in reducing pain and opioid consumption 1. For moderate to severe pain, opioids such as fentanyl or oxycodone can be used, with PCA as an option for severe pain management 1. It is essential to regularly assess pain levels using a numerical rating scale and adjust medication accordingly, while also monitoring for potential side effects such as respiratory depression, renal dysfunction, and hepatotoxicity. Key points to consider include:

• The use of oral administration of analgesic drugs whenever feasible 1
• The avoidance of intramuscular route for postoperative pain management 1
• The consideration of epidural and regional anesthesia in emergency general surgery, whenever feasible 1
• The monitoring of patients with neuraxial anesthesia for adequate assessment 1
• The potential benefits of using gabapentinoids, alpha-2-agonists, and ketamine in multimodal analgesia 1
• The importance of caution when using coxib and NSAIDs together due to increased risk of myocardial infarction and kidney function affects 1.

From the Research

Adequate Pain Medication for Inpatient Pain Control Prior to Cholecystectomy

• The use of paracetamol and NSAIDs is recommended for pain management after laparoscopic cholecystectomy 2, 3.
• These medications should be started before or during the operation, and opioid should be reserved for rescue analgesia only 2, 3.
• Intra-operative intravenous dexamethasone, port-site wound infiltration, or intraperitoneal local anaesthetic instillation are also recommended 3.
• A combined approach to pain management is often the best option, as acute pain after laparoscopic cholecystectomy is complicated in nature and has multiple causes 4.
• The choice of anesthetic technique for laparoscopic cholecystectomy is limited, and general anesthesia is most frequently used 5.

Recommended Pain Management Strategies

• Paracetamol combined with NSAIDs or cyclo-oxygenase-2 inhibitors should be given either pre-operatively or intra-operatively, unless contraindicated 3.
• Intra-operative intravenous dexamethasone, port-site wound infiltration, or intraperitoneal local anaesthetic instillation are recommended 3.
• Opioids should be used for rescue analgesia only 2, 3.
• Erector spinae plane block or transversus abdominis plane block may be reserved for patients with a heightened risk of postoperative pain 3.

Non-Recommended Interventions

• Single port or mini-port techniques, routine drainage, low flow insufflation, natural orifice transluminal endoscopic surgery (NOTES), infra-umbilical incision, i.v. clonidine, nefopam, and regional techniques such as quadratus lumborum block or rectus sheath block are not recommended due to limited or no evidence on improved pain scores 3.
• Spinal or epidural anaesthesia, gabapentinoids, i.v. lidocaine, i.v. ketamine, and i.v. dexmedetomidine are not recommended due to risk of side effects 3.