Gartner, R., Kroman, N., Callesen, T., & Kehlet, H. (2010). Multimodal prevention of pain, nausea and vomiting after breast cancer surgery. Minerva Anestesiologica, 76(10), 805–813.

To evaluate the effect of a multidrug, opiate-sparing regimen for prevention of postoperative pain, nausea, and vomiting in patients after surgery for breast cancer

For 1–2 hours preoperatively, patients received a drug combination consisting of 1g oral paracetamol, 8 mg dexamethasone, 30 mg dextromethorphan, 400 mg celecoxib, and 1200 mg gabapentin. In addition, patients who were anxious received 0.125 mg triazolam on request. All patients received the same anesthesia regimen. In the postanesthesia care unit (PACU), immediately after surgery, symptoms were recorded at 15-minute intervals for 12 hours. Patients who had moderate to severe pain with mobilization received 0.1 mg/kg IV morphine and 1 g oral paracetamol every six hours and 200 mg oral celecoxib on the evening of the operation and in the morning and evening of the following day. Patients who needed pain medication after the first day received 600 mg oral ibuprofen every six hours and 1 g paracetamol every six hours. Rescue medication consisted of 15 g oral morphine.

• The sample was composed of 200 patients.
• Mean patient age was 62.7 years (SD = 12.5 years).
• All patients were female.
• All patients had breast cancer; 42% underwent a mastectomy and 58% had breast-conserving surgery.

• Single site
• Inpatient
• Denmark

Prospective trial

Four-point symptom rating scale, 0= no complaints and 3 = severe complaints

• In the first 36 hours, at rest after surgery, 30.3% of patients reported moderate to severe pain and 69.7% reported light to no pain.
• Of all patients, 22% required rescue morphine doses. The average total morphine used was 7.5 mg. The mean amount of morphine used was 2.2 mg (SD = 4.3 mg).
• Of all patients, 79% had no nausea or vomiting.
• The most common postoperative complaints were of dizziness, headache, diplopia, confusion, and memory disorder. These were similar to complaints present after administration of the preoperative regimen.

The preoperative drug combination used here appeared to be effective in preventing postoperative nausea and vomiting and may have reduced postoperative pain at rest.

• The study had a risk of bias due to no appropriate control group.
• The method of measuring pain and other symptoms is questionable.
• Whether grading was based on patient self-report or decided by hospital staff is unclear.
• The report reveals substantial differences in morphine intake based on subgroups of surgical extent; however, the sample was not large enough for authors to complete relevant subgroup analysis.
• All patients in this study received the same anesthetic regimen, so findings may not be applicable to individuals who receive different anesthesia.
• Whether pain rating was done only at rest or at rest and with mobilization is unclear.
• Only patients undergoing mastectomy were included. Findings may not apply to other surgical groups.

The specified combination of medications, administered preoperatively, appeared to reduce some postoperative symptoms in patients who had breast cancer surgery.