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Parecoxib or Metamizole for Postoperative Analgesia after Vaginal Hysterectomy. A Randomized, Double-Blinded Clinical Trial
Christian Byhahn, M.D., Gösta Lotz, M.D., Diana A. Mäser, M.D., Paul Kessler, M.D., Klaus Westphal, M.D.
Department of Anesthesiology, J.W. Goethe-University Hospital Center, D-60590 Frankfurt, Germany.
Objective: Both postoperative pain and nausea and vomiting (PONV) represent the most common and distressing impairments of patient´s well-being in the postoperative period. In order to achieve effective pain relief after vaginal hysterectomy, metamizole has often to be supplemented by opiods. On the other hand, the use of opioids increases the occurrence of PONV. Hence it was the aim of the study to investigate if the use of parecoxib - a novel selective inhibitor of cyclooxygenase-2 - instead of metamizole/opiods is a comparably sufficient treatment for postoperative pain after vaginal hysterectomy, and if the incidence of PONV can be reduced.

Methods: After approval by the institutional review board, 80 adults (ASA physical status I- III) undergoing vaginal hysterectomy received general anesthesia with propofol, fentanyl and air in oxygen 50%. Patients were randomly assigned to receive either IV metamizole 2.5g or IV parecoxib 40mg intraoperatively. All patients were evaluated for their risk of PONV according to the Apfel score (1). Additionally, the incidence of PONV was consequently registered and divided in early PONV (less than 2 hours after surgery) and late PONV (2 – 24 hours after surgery).

Results: The risk score for PONV, established by Apfel et al., was identical in both groups (median:3, range: 1-4, P: not significant). Opioid requirements (IV piritramide, a potent μ-receptor agonist commonly used in Europe) in the post anesthesia care unit were slightly, but not significantly, higher in patients who received parecoxib intraoperatively (P=0.06). No significant differences were seen regarding the incidence of early and late PONV in both groups (see Table). No renal side effects after parecoxib medication were observed.Conclusion: Both groups required a comparable supplementary dose of opioids after vaginal hysterectomy for sufficient postoperative pain relief, hence the incidence of PONV was similar in both groups. Based on our data parecoxib is no effective analgesic alternative after vaginal hysterectomy compared to metamizole.

Reference: Apfel CC, Laara E, Koivuranta M, Greim CA, Roewer N. A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers. Anesthesiology 1999;91:693-700.

Anesthesiology 2003; 99: A1002
Postoperative opioid requirements and incidence of PONV
Piritramide (mg)Early PONVDelayed PONV
Metamizole 2.5g14.4 ± 11.227,5%55.0%
Parecoxib 40mg19.4 ± 11.822.5%45.0%
P: not significant