Comparison between paracetamol, piroxicam, their combination, and placebo in postoperative pain management of upper limb orthopedic surgery (a randomized double blind clinical trial)

Abstract

Background:Therapeutic superiority of a combination of Paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) over either drug alone remains controversial. We evaluated the efficiency of a combination of Paracetamol and Piroxicam versus each drug alone and also placebo in the management of postoperative pain, in patients who had undergone elective upper limb orthopedic surgery under general anesthesia.Materials and Methods:A total of 100 patients were randomly divided into four groups to receive either intravenous (IV) infusion of Paracetamol, 15 mg/kg., intramuscular (IM) injection of Piroxicam 0.4 mg/kg., their combination or placebo. The pain scores were recorded at the first; second, fourth, sixth, twelfth, and 24 hours after Post Anesthesia Care Unit (PACU) admission. After the operation 0.1 mg/kg of morphine was administered, if the patient needed.Result:The means of the pain scores were 5.26 ± 1.53, 4.09 ± 0.88, 4.36 ± 1.48, and 4.11 ± 1.29, in groups A, B, C, and D, respectively, (Group A: received placebo; Group B: received both Paracetamol and Piroxicam; Group C received Piroxicam; Group D received Paracetamol). Except for differences between the mean pain scores in Groups B and D, the other differences were statistically significant (P value < 0.05). No adverse effect was reported in the four groups.Conclusion:IV infusion of 15 mg/kg Paracetamol used as a preventive may provide effective analgesia in comparison with IM 0.4 mg/kg Piroxicam or placebo. Addition of Piroxicam to Paracetamol has not much more benefit than Paracetamol alone, in reducing pain after upper limb orthopedic surgery.

Risk Factors for Increased Postoperative Pain and Recommended Orderset for Postoperative Analgesic Usage

“…Relevant literature was reviewed to identify “at risk” factors for inadequate pain control. 4 – 16 The team identified a list of potential “at risk” factors based on the literature and then categorized them into 7 different categories that may put patients at risk for inadequate pain control postoperatively. These included: (1) history of physical, emotional, or sexual abuse; (2) history of anxiety; (3) history of illicit drug (nonopioid) or alcohol abuse; (4) preoperative nonsteroidal anti-inflammatory drug (NSAID) (aspirin, choline and magnesium salicylates, choline salicylate, celecoxib, diclofenac potassium, diclofenac sodium, diflunisal, etodolac, fenoprofen, flurbiprofen, ibuprofen, indomethacin, keoprofen, magnesium salicylate, meclofenamate sodium, mefanamic acid, meloxicam, nabumetone, naproxen, naproxen sodium, oxaprozin, piroxicam, salsalate, sodium salicylate, sulindac, tolmetin sodium, tolmetin sodium) or disease-modifying antirheumatic drug (DMARD) (azathioprine, chlorambucil, cyclophosphamide, cyclosporine, gold sodium, thiomalate, hydroxychloroquine, leflunomide, methotrexate, minocycline, mycophenolate mofetil, sulfasalazine, tofacitinib) use; (5) history of current opioid (oxyCODONE, HYDROcodone, codeine, fentanyl, meperidine, morphine, traMADol, HYDROmorphone, oxyMORPHONE, methadone, buprenorphine) use; (6) psychological conditions other than anxiety (ie, depression, bipolar disorder, schizophrenia, obsessive-compulsive disorder, anorexia, delusional disorder); and (7) current smoker.…”

Analgesic Efficacy of Intrathecal Bupivacaine with or without Morphine in Lower Limb Orthopedic Surgery. A Comparative Study

“…When compared to pain management techniques used within an enhanced recovery after surgery (ERAS) pathway, traditional approaches for major abdominal and traumatic surgery, such as opioid-based intravenous patient-controlled analgesia (IVPCA) or epidural analgesia, were associated with superior pain control [17]. Other pain management techniques that can be used in lower limb orthopedic surgery include the use of non-steroidal anti-inflammatory drugs (NSAIDs) [18] such as ibuprofen or naproxen, acetaminophen (paracetamol), regional anesthetic techniques [18] [19], such as a femoral nerve block or lumbar plexus block which can provide targeted pain relief to the lower limb, transcutaneous electrical nerve stimulation (TENS) which is a non-pharmacological method that uses electrical impulses to stimulate nerve fibers and relieve pain, physiotherapy, which can help improve range of motion, strengthen the muscles and decrease pain in the postoperative period.…”