JOURNAL HOME CME HOME THIS MONTH PAST ISSUES ETOC COLLECTIONS AUTHORS REVIEWERS EDITORIAL BOARD FEEDBACK RSS HELP
		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ræder, J. C. Articles by Vatsgar, T. T. Search for Related Content PubMed PubMed Citation Articles by Ræder, J. C. Articles by Vatsgar, T. T. Related Collections Pharmacology Ambulatory

---

AMBULATORY ANESTHESIA

Oral Ibuprofen Versus Paracetamol Plus Codeine for Analgesia After Ambulatory Surgery

Johan C. Ræder, MD, PhD^*, Siri Steine, MD, PhD, and Tor T. Vatsgar^*

Departments of *Anesthesia and General Practice Medicine, Ullevaal University Hospital, Oslo, Norway

Address correspondence to Johan C. Ræder, MD, PhD, Department of Anaesthesia, Ullevaal University Hospital, N-0407 Oslo. Address e-mail to johan.rader{at}ioks.uio.no

	Introduction

Top Introduction Methods Results Discussion References

 
The combination of oral codeine and acetaminophen is often used for postdischarge pain control after ambulatory surgery. However, frequently reported side effects include sedation, constipation, and nausea (1). Furthermore, drugs containing codeine may be abused (2) and may result in serious side effects when combined with alcohol or benzodiazepines. Nonsteroidal antiinflammatory drugs are a nonprescription alternative to these drugs.

The aim of this study was to compare ibuprofen with codeine/acetaminophen for pain control during the first 72 h after ambulatory surgery.

	Methods

Top Introduction Methods Results Discussion References

 
The study was approved by the Regional Ethical Committee, and adult patients scheduled for elective hernia repair, hemorrhoidectomy, or varicose vein resection were included after informed, written consent was obtained. Exclusionary criteria included a history of allergic reactions or side effects with aspirin, acetaminophen, or nonsteroidal antiinflammatory drugs, and opioid-containing oral analgesic use.

After IV premedication with 1–2 mg midazolam, anesthesia was induced with fentanyl 1.5 µg/kg IV and a propofol target control infusion of 4 µg/mL IV. Anesthesia was maintained with a propofol target control infusion of 2.0–2.5 µg/mL, 66% nitrous oxide in oxygen, and alfentanil 10 µg/kg IV as needed. The patients had spontaneous or assisted ventilation with a laryngeal mask airway with standard intraoperative monitoring. Before the end of the anesthesia, all patients received ketorolac 30 mg IV in addition to local anesthesia with 10–20 mL of lidocaine 10 mg/mL at the incision site and paracetamol 1 g rectally. On the recovery ward, the patients received fentanyl 0.5 µg/kg IV for pain control and metoclopramide 10 mg for nausea. According to a double-blinded, randomized study design, the patients received identical-appearing tablets for analgesia at home; these tablets contained either ibuprofen 800 mg or paracetamol 800 mg and codeine 60 mg and were to be taken three times a day for 3 days.

The patients received a written questionnaire, which was to be completed 24 and 72 h after surgery, about their pain experience, general functioning, and side effects. The patients were asked to grade their pain experience from 1 (no pain) to 10 (worst pain possible); average pain and worst pain experienced; and pain during defecating, sitting, coughing, and moving. The patients were asked about their general functioning at home (1 = all their time in bed to 5 = full normal activity) and whether the global experience of the postoperative period was worse, similar, or better compared with what they had expected. The patients were also asked specifically about side effects such as nausea, vomiting, dizziness, constipation (i.e., absence of defecation), nightmares, or anxiety.

The two groups were compared with Student’s t-test for parametric variables and the Mann-Whitney U-test or ² test for nonparametric variables, with P values < 0.05 considered statistically significant.

	Results

Top Introduction Methods Results Discussion References

 
Although 116 patients were enrolled in the study, 12 patients did not answer the questionnaire; therefore, only 104 patients were used in the analyses. There was no difference between the groups in demographic data, surgical characteristics, drugs given, pain experience, or side effects during the hospital stay or time to discharge eligibility (data not shown), except for more nausea in the recovery ward in the Ibuprofen group (19% vs 4%).

There was no statistically significant difference between the two groups with respect to pain control during the 3-day postoperative observation period (Table 1). There were no significant differences between the groups in postoperative side effects except for significantly more constipation (i.e., absence of defecation) in the Paracetamol plus Codeine patients, both at Day 1 and Day 3 (Table 2). At 72 h after surgery, significantly more patients in the Ibuprofen group rated the global postoperative experience as better than expected (Table 2).

	Discussion

Top Introduction Methods Results Discussion References

An important issue is whether the results are applicable to a wider population of outpatients with postoperative pain. In our study, 6.4% of the patients declined to participate in the study because they had had a previous bad experience (i.e., side effects) with paracetamol plus codeine medication. It is interesting to note that more patients in the Ibuprofen group experienced nausea in the recovery ward before receiving any study medication. It would seem that short-term treatment with NSAID is relatively free of side effects unless there is a preexisting contraindication to using these nonopioid analgesic drugs (5,6). The most significant side effect in this study was constipation resulting from codeine. This complication may add to the patients’ feeling of discomfort and explain why the total experience was significantly better in the ibuprofen-treated patients.

In conclusion, oral ibuprofen 800 mg is equianalgesic to paracetamol 800 mg plus codeine 60 mg when given every eight hours for three days after ambulatory surgery. Use of ibuprofen also results in better global satisfaction and significantly less constipation.

	Acknowledgments

 
This study was supported with a research grant from Weiders Pharmaceuticals, Norway.

	References

Top Introduction Methods Results Discussion References

 

1. Breivik EKD, Barkvoll PP, Skovlund EP. Combining diclofenac with acetaminophen or acetaminophen-codeine after oral surgery: a randomized, double-blind single-dose study. Clin Pharmacol Ther 1999; 66: 625–35.[ISI][Medline]
2. Sproule BA, Busto UE, Somer G, et al. Characteristics of dependent and nondependent regular users of codeine. J Clin Psychopharmacol 1999; 19: 367–72.[ISI][Medline]
3. Korpela R, Olkkola KT. Paracetamol: misused good old drug? Acta Anaesthesiol Scand 1999; 43: 245–7.[Medline]
4. Heidrich G, Slavic-Svircev V, Kaiko RF. Efficacy and quality of ibuprofen and acetaminophen plus codeine analgesia. Pain 1985; 22: 385–97.[Medline]
5. Souter A, Fredman B, White PF. Controversies in the perioperative use of non-steroidal antiinflammatory drugs. Anesth Analg 1994; 79: 1178–90.[Free Full Text]
6. Kellstein DE, Waksman JA, Furey SA, et al. The safety profile of nonprescription ibuprofen in multiple-dose use: a meta-analysis. J Clin Pharmacol 1999; 39: 520–32.[Abstract]

This article has been cited by other articles:

				P. F. White Pain management after ambulatory surgery - Where is the disconnect?/La prise en charge de la douleur apres une chirurgie ambulatoire : ou est-ce que ca coince ? Can J Anesth, April 1, 2008; 55(4): 201 - 207. [Full Text] [PDF]

				P. F. White, H. Kehlet, J. M. Neal, T. Schricker, D. B. Carr, F. Carli, and the Fast-Track Surgery Study Group The Role of the Anesthesiologist in Fast-Track Surgery: From Multimodal Analgesia to Perioperative Medical Care Anesth. Analg., June 1, 2007; 104(6): 1380 - 1396. [Abstract] [Full Text] [PDF]

				P. F. White The Changing Role of Non-Opioid Analgesic Techniques in the Management of Postoperative Pain Anesth. Analg., November 1, 2005; 101(5S_Suppl): S5 - 22. [Abstract] [Full Text] [PDF]

				P. F. White Update on ambulatory anesthesia Can J Anesth, June 1, 2005; 52(suppl_1): R10 - R10. [Full Text] [PDF]

				L. A. Rosseland, K. G. Helgesen, H. Breivik, and A. Stubhaug Moderate-to-Severe Pain After Knee Arthroscopy Is Relieved by Intraarticular Saline: A Randomized Controlled Trial Anesth. Analg., June 1, 2004; 98(6): 1546 - 1551. [Abstract] [Full Text] [PDF]

				T. Issioui, K. W. Klein, P. F. White, M. F. Watcha, M. Coloma, G. D. Skrivanek, S. B. Jones, K. C. Thornton, and B. F. Marple The Efficacy of Premedication with Celecoxib and Acetaminophen in Preventing Pain After Otolaryngologic Surgery Anesth. Analg., May 1, 2002; 94(5): 1188 - 1193. [Abstract] [Full Text] [PDF]

				P. F. White The Role of Non-Opioid Analgesic Techniques in the Management of Pain After Ambulatory Surgery Anesth. Analg., March 1, 2002; 94(3): 577 - 585. [Abstract] [Full Text] [PDF]

				Ibuprofen Takes on APAP with Codeine: Who Wins? Journal Watch Emergency Medicine, June 21, 2001; 2001(621): 5 - 5. [Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ræder, J. C. Articles by Vatsgar, T. T. Search for Related Content PubMed PubMed Citation Articles by Ræder, J. C. Articles by Vatsgar, T. T. Related Collections Pharmacology Ambulatory

Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999