Individual research recommendation details

Recommendation ID

NG180/7

Question

What is the most clinically and cost-effective timing and dose of a single administration of gabapentin to relieve pain in people undergoing surgery whose pain is expected to be moderate to severe?

Any explanatory notes
(if applicable)

Why the committee made the recommendations

Planning pain management

Based on their experience, the committee agreed that people having surgery should be informed of the options for pain management and be actively involved in choosing their own pain management whenever possible.

Selecting analgesia

The committee agreed, based on their experience, that multimodal analgesia provides more effective pain relief and reduces the need for opioids and the occurrence of opioid-related complications. They also agreed that prescribing pre‑emptive analgesia should be considered to ensure that pain is managed when local anaesthesia wears off.

Paracetamol

Some evidence suggested that paracetamol used alongside opioid analgesia reduces the amount of opioid needed to manage pain. The committee therefore agreed that paracetamol is beneficial in reducing opioid consumption. There was no evidence showing a significant difference in effectiveness between oral and intravenous paracetamol. Intravenous paracetamol is much more expensive so the committee did not recommend it for people who can take oral medicines.

Non-steroidal anti-inflammatory drugs (NSAIDs)

The evidence showed that NSAIDs provide effective additional pain relief, reducing the amount of other types of analgesia needed. Traditional NSAIDs are more cost effective than COX‑2 (cyclo‑oxygenase‑2) inhibitors, and oral ibuprofen is the most cost-effective traditional NSAID. There was no evidence showing a significant difference in effectiveness between NSAIDs or routes of administration. Intravenous NSAIDs are more expensive so the committee did not recommend them for people who can take oral medicines.

Opioids

There was no evidence showing a significant difference in effectiveness between oral and intravenous opioids. Intravenous opioids are more expensive so the committee did not recommend them for people who can take oral medicines.

For people who cannot take an oral opioid, the committee agreed that a choice of PCA (patient-controlled analgesia) or epidural should be offered because there was no evidence favouring either mode of administration for most people having surgery. An exception is the group having major or complex open-torso surgery, who may benefit from the early pain relief provided by a continuous epidural. The committee pointed out that factors such as patient preference and ability to use a PCA pump effectively should be taken into account when choosing between PCA and continuous epidural. The committee looked at the possible benefits of spinal administration and agreed that there was insufficient evidence to support a recommendation.

Intravenous ketamine

There was evidence showing that adding intravenous ketamine to an intravenous opioid can reduce both pain and opioid consumption. The committee noted that ketamine has an additive analgesic effect. They agreed, based on their experience, that intravenous ketamine is helpful if an intravenous opioid alone does not provide adequate pain relief, or if the person is opioid sensitive (abnormal pain sensitivity). Based on the evidence and their experience, the committee agreed that a single dose of 0.25 mg/kg to 1 mg/kg should be considered in these situations.

Gabapentin

Evidence showed that a single dose of gabapentin can lessen postoperative pain and reduce the amount of opioid needed. However, the studies used a range of doses and administered the gabapentin at different times, so the optimal dose and timing of administration remain uncertain. The committee therefore made a recommendation for research on single-dose gabapentin.

How the recommendations might affect practice

Planning pain management

The committee noted that pain management is usually planned during a preoperative assessment. Although preoperative assessments are standard in current practice, actively involving the person in decisions about their pain management may lead to a small increase in staff time required.

Selecting analgesia

A multimodal approach is current practice and the recommendation is not expected to change this.

Paracetamol

The recommendations can be expected to result in cost savings by reducing the use of intravenous paracetamol. They are also expected to lead to dose reductions in opioid analgesia, resulting in fewer side effects from opioid consumption.

NSAIDs

Concerns about cardiac and renal complications have limited the use of NSAIDs in people having surgery. These recommendations can be expected to change practice by increasing the use of short courses of traditional oral NSAIDs for people having surgery.

Opioids

Intravenous opioid administration is often used in current practice because it is perceived to be more convenient and offer better pain relief. The recommendations are expected to lead to a change in this practice, with a reduction in intravenous opioid administration and a concomitant increase in the use of oral opioids.

PCA and continuous epidurals are used routinely in current practice, although there are variations in their use across services.

Because these recommendations are for the perioperative period only, an opiate withdrawal plan is not necessary, but one would need to be considered if opioids were used in the longer term.

This recommendation is not expected to lead to major changes in practice.

Intravenous ketamine

The use of intravenous ketamine in postoperative pain management has increased in recent years. Although ketamine is more expensive than other analgesics, the recommendation is not expected to have a significant impact because it is restricted to a single dose and only one-third of people having surgery are expected to experience moderate to severe pain.

Source guidance details

Comes from guidance

Perioperative care in adults

Number

NG180

Date issued

August 2020

Other details