Summary Effective peri‐operative pain management is a prerequisite for optimal recovery after surgery. Despite published evidence‐based guidelines from several professional groups, postoperative pain management remains inadequate. The procedure‐specific pain management (PROSPECT) collaboration consists of anaesthetists and surgeons with broad international representation that provide healthcare professionals with practical and evidence‐based recommendations formulated in a way that facilitates clinical decision‐making across all stages of the peri‐operative period on a procedure‐specific basis. The aim of this manuscript is to provide a detailed description of the current PROSPECT methodology with the intention of providing the rigour and transparency in which procedure‐specific pain management recommendations are developed. The high methodological standards of the recommendations should improve the quality of clinical practice.

Efficacité analgésique d'une anesthésie avec opioïdes versus sans opioïdes : une revue systématique de la littérature avec méta-analyses [Analgesic impact of intra-operative opioids versus opioid free anesthesia: a systematic review and meta-analysis] Les opioïdes sont administrés durant l'intervention afin de contrôler la réponse sympathique à un stimulus chirurgical, mais aussi pour soulager la douleur postopératoire. Récemment, l'utilisation des opioïdes durant la chirurgie a été remise en question en raison de l'absence probable de bénéfice dans la phase postopératoire immédiat, mais aussi en raison des effets secondaires, tels que les nausées et vomissements postopératoires. Le but de cette méta-analyse est d'investiguer si l'utilisation d'opioïde intraopératoire comparée à une stratégie sans opioïde permet de diminuer les douleurs postopératoires sans augmenter le taux de nausées et vomissements postopératoires. Nous avons inclus des essais cliniques randomisés et contrôlés effectués chez des patients adultes pour tout type de chirurgie qui ont étudié l'efficacité analgésique postopératoire d'une administration intraopératoire d'opioïde avec soit l'administration d'un placebo, soit l'absence d'administration. L'analyse des 23 études identifiées avec plus de 1300 patients inclus a démontré que les scores de douleurs au repos (échelle de 0 à 10, 0 étant aucune douleur et 10 la pire douleur imaginable) à 2h postopératoire étaient équivalents dans les deux groupes, avec une différence moyenne (IC 95%) de 0,2 point (-0,2 à 0,5), p=0,38. Les taux de nausées et vomissements postopératoires étaient de 24% dans le groupe avec opioïde et 19% dans le groupe sans ce qui représente un risque relatif (IC 95%) de 0,77 (0,61 à 0,97), p=0,03. En conclusion, l'utilisation d'opioïde intraopératoire ne diminue pas les douleurs postopératoires, mais est associée à une augmentation des nausées et vomissements postopératoire.

SummaryIntravenous magnesium has been reported to improve postoperative pain; however, the evidence is inconsistent. The objective of this quantitative systematic review is to evaluate whether or not the peri-operative administration of intravenous magnesium can reduce postoperative pain. Twenty-five trials comparing magnesium with placebo were identified. Independent of the mode of administration (bolus or continuous infusion), peri-operative magnesium reduced cumulative intravenous morphine consumption by 24.4% (mean difference: 7.6 mg, 95% CI )9.5 to )5.8 mg; p < 0.00001) at 24 h postoperatively. Numeric pain scores at rest and on movement at 24 h postoperatively were reduced by 4.2 (95% CI )6.3 to )2.1; p < 0.0001) and 9.2 (95% CI )16.1 to )2.3; p = 0.009) out of 100, respectively. We conclude that peri-operative intravenous magnesium reduces opioid consumption, and to a lesser extent, pain scores, in the first 24 h postoperatively, without any reported serious adverse effects. Magnesium has been reported to produce important analgesic effects including the suppression of neuropathic pain [1], potentiation of morphine analgesia, and attenuation of morphine tolerance [2]. Although the exact mechanism is not yet fully understood, the analgesic properties of magnesium are believed to stem from regulation of calcium influx into the cell [3] and antagonism of N-methyl-D-aspartate (NMDA) receptors in the central nervous system [1,4]. Since the completion of the first positive randomised controlled trial investigating magnesium as an analgesic adjuvant in 1996 [5], several additional trials have been published, with conflicting results [6][7][8]. Two narrative review articles [9,10] recently concluded that peri-operative magnesium does not confer any important analgesic benefit, but these conclusions were drawn from a small number of trials [9] and subject to inaccuracies in data reporting [10]. The administration of intravenous magnesium in the peri-operative setting is not without risk and should be based on evidence, as it may prolong neuromuscular blockade after administration of neuromuscular blocking drugs [11,12], increase sedation [13] and contribute to serious cardiac morbidity [14]. Consequently, the aim of this review is to define quantitatively the effect of peri-operative intravenous magnesium on acute postoperative pain.

Caesarean section is associated with moderate-to-severe postoperative pain, which can influence postoperative recovery and patient satisfaction as well as breastfeeding success and mother-child bonding. The aim of this systematic review was to update the available literature and develop recommendations for optimal pain management after elective caesarean section under neuraxial anaesthesia. A systematic review utilising procedure-specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials published in the English language between 1 May 2014 and 22 October 2020 evaluating the effects of analgesic, anaesthetic and surgical interventions were retrieved from MEDLINE, Embase and Cochrane databases. Studies evaluating pain management for emergency or unplanned operative deliveries or caesarean section performed under general anaesthesia were excluded. A total of 145 studies met the inclusion criteria. For patients undergoing elective caesarean section performed under neuraxial anaesthesia, recommendations include intrathecal morphine 50-100 µg or diamorphine 300 µg administered pre-operatively; paracetamol; non-steroidal anti-inflammatory drugs; and intravenous dexamethasone administered after delivery. If intrathecal opioid was not administered, single-injection local anaesthetic wound infiltration; continuous wound local anaesthetic infusion; and/or fascial plane blocks such as transversus abdominis plane or quadratus lumborum blocks are recommended. The postoperative regimen should include regular paracetamol and non-steroidal anti-inflammatory drugs with opioids used for rescue. The surgical technique should include a Joel-Cohen incision; non-closure of the peritoneum; and abdominal binders. Transcutaneous electrical nerve stimulation could be used as analgesic adjunct. Some of the interventions, although effective, carry risks, and consequentially were omitted from the recommendations. Some interventions were not recommended due to insufficient, inconsistent or lack of evidence. Of note, these recommendations may not be applicable to unplanned deliveries or caesarean section performed under general anaesthesia.