Research

Mathews Journal of Anesthesia

Postoperative Scheduled Intravenous Acetaminophen in Patients Undergoing
Laparoscopic Cholecystectomy in Japan
Hideki Taniguchi1, Masaki Takenouchi1, Masaharu Imaura1, Mari Nagahuchi2, Hideki Tachibana2, Takaaki Kamada2, Kikuko Suga2, Tomoyuki Sato2, Kan Handa3, Tomohisa Egawa3
Perioperative Support Center, Saiseikai Yokohamashi Tobu Hospital
Department of Anesthesiology, Saiseikai Yokohamashi Tobu Hospital3
Department of Gastrointestinal surgery, Saiseikai Yokohamashi Tobu Hospital
Corresponding Author: Hideki Taniguchi, Perioperative Support Center, Saiseikai Yokohamashi Tobu Hospital, 3-6-1 ShimoSueyoshi, Tsurumi-Ku, Yokohama, Kanagawa, Japan, Email: hstani@aol.jp
12

Received Date: 30 Dec 2017
Accepted Date: 09 Jan 2018
Published Date: 12 Jan 2018

Copyright © 2018 Taniguchi H
Citation: Taniguchi H, Takenouchi M, Imaura M, Nagahuchi
M, et al. (2018). Postoperative Scheduled Intravenous Acetaminophen in Patients Undergoing Laparoscopic Cholecystectomy in Japan. M J Anes. 1(2): 009.

ABSTRACT
Background: The aim of this study was to assess the economic burden and effect of scheduled intravenous acetaminophen(SIVA) on the analgesic activity in patients undergoing laparoscopic cholecystectomy (LC) following our hospital’s management protocol.
Methods: Patients undergoing LC were enrolled prospectively and consecutively, and managed using the old protocol (GroupC), and managed following the new protocol using SIVA (Group S). Primary outcome was postoperative pain assessment
estimated by the Numerical Rating Scale (NRS) on postoperative day 1. Secondary outcomes were the number of rescue
medicines and length of hospitalization (LOH).
Results: The NRS was lower in group S than in group C (group S; 1.0 [0,0–2.75,8.0] vs. group C; 4.0 [0,05.75,6.0]: P < .0001).
The number of rescue medicines was lower in group S compared to group C (0 [0,0-0,3.0] vs. 1.0 [0,0-2.25,5.0]: P < .0001).
LOH after surgery was also shorter in group S than in group C (3.0 [3.0,3.0-3.0,7.0] days vs. 3.0 [3.0,3.0-3.0,12.0] days: P =0.0462)Conclusion: Introduction of SIVA into the postoperative pain management protocol of LC reduced the postoperative NRS,
the number of rescue medicines and the LOH. We recommend the standardization of postoperative pain management inclinical management protocols in Japan.

KEYWORDS
Scheduled Intravenous Acetaminophen; Acetaminophen; Postoperative Pain Laparoscopic Cholecystectomy; Clinical Management Protocols Enhanced Recovery After Surgery (ERAS).

INTRODUCTION
Evidence-based guidelines for the perioperative care of colon[1] and rectal [2] surgery were published by the enhanced recovery after surgery (ERAS) society.
The guidelines recommend minimizing opioids for earlier return of bowel function and a shorter length of hospitalization(LOH) [3]. One of the simplest methods to limit opioid intake isto schedule narcotic alternatives, such as acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and gabapentin,
rather than giving them on an as needed basis [4]. The scheduled use of non-selective or selective NSAIDs, cyclooxygenase(COX) 2 inhibitors, and acetaminophen (orally or intravenously[4]) has been shown to improve postoperative analgesia andreduce the consumption of systemic opioids as well as theirdose-dependent adverse effects [5,6]. A meta-analysis of 30
randomized controlled trials (RCTs), including 2364 patients,
showed that the use of IV acetaminophen given either before
surgery or prior to the arrival to the post-anesthesia care unit
reduced the risk of nausea and pain, which were shown todelay surgical recovery [6].
In 2011, the clinical doses of IV acetaminophen in Japan increased from a maximum of 1500 mg to 4000 mg per day to

Citation: Taniguchi H, Takenouchi M, Imaura M, Nagahuchi M, et al. (2018). Postoperative Scheduled Intravenous Acetaminophen in
Patients Undergoing Laparoscopic Cholecystectomy in Japan. M J Anes. 1(2): 009.

1

www.mathewsopenaccess.com
allow for an optimal analgesic effect. Moreover, it was only
prescribed as needed based on the pain levels with no special
recommendations for scheduled prescription to postoperative patients. The aim of this study was to assess the economic
burden and effect of scheduled intravenous acetaminophen(SIVA) on the analgesic activity in patients undergoing laparoscopic cholecystectomy (LC) following our hospital’s management protocol. Based on the results, SIVA can be introduced
into the management protocols of several procedures in Japan. We chose LC as it would allow us to assess the isolated
effect of SIVA on pain control without the effect of epidural
anesthesia.

Information sharing/patient education (before and after surgery)a

500-mL plastic bottles (OS-1, classified as a food in Japan. Otuka Pharmaceutical Factory, Inc., Tokushima, Japan). We provided 1500 mL of the solution to the patients at 20:00 on the night before surgery and allowed themto drink it at least 500 mL at any time they wanted until 2 hours before
entering the operating room.
b

While the body surface was covered with blankets or towels, the patientswere warmed with Bair Hugger (3M , St. Paul, MN) set at 38 degrees C. The
target body temperature was set at a bladder temperature of 36 - 37 degrees C. The fluids used were warmed to 35 -36 degrees C with a warming
device before transfusioncFigure 1:

MATERIALS AND METHODS
The present study was approved by the Institutional Review
Board of Saiseikai Yokohamashi Tobu Hospital (Study-2017092),
registered with the Center for Clinical Trials, Japan Medical
Association (JMA) Clinical Trials Registry (JMA registration
number: JMA-IIA00317), and conducted after disclosure of
information. Subjects included were patients scheduled toundergo elective LC for gallstone, inflammation of the gall
bladder (GB), or GB polyp. In our hospital’s LC management
protocol, patients are discharged in the morning of postoperative day 3. In addition, NSAIDs, tramadol, or acetaminophen
are conventionally used randomly and as needed (table1). On
February 1, 2017, our hospital included SIVA in a new LC postoperative management protocol (Table1, Figure1).
Table 1: Management protocol of laparoscopic cholecystectomy.

PeriodThe old protocol(Group C)

Preoperative

Major componenta
Intake of oral rehydration solutionb until 2hours before surgery
No laxative medication and premedication
Thorough oral cavity care

Intraoperative

Use of short-acting anaesthetics
Keeping the patient warmc
Intravenous acetaminophen was injected 30
min before the end of surgery. Wound infiltration with local anesthetic is performed.
Prevent of PONV during operation

Postoperative

Early ambulationand oral diet (POD
1)
On the operativeday, intravenous
infusion of acetaminophen ,flurbiprofen axetil ortramadol are taken
as needed repeatedly.

The new protocol(Group S)

Early ambulation andoral diet (POD 1)
Scheduled intravenous
acetaminophen and asneeded basis administration of NSAIDs.

Figure 1: A new laparoscopic cholecystectomy postoperative management protocol.
IV acetaminophen was injected 30 min prior to the end of surgery and every 6 h for 48 h, with a total of 7 doses , at doses of 1000 mg for patientsweighing ≥ 50 kg, and 15 mg/kg for patients weighing < 50 kg. Wounds
were infiltrated with a local anesthetic (0.2% ropivacaine; 20–40 ml).On
postoperative day 1 patients were given oral etodolac, on postoperative
day 2 acetaminophen was changed from IV to oral from.

The switchover to the new protocol took place in a transition
period between February 1 to 28, 2017. Between August 1,
2016 and January 31, 2017, patients undergoing LC were enrolled prospectively and consecutively, and managed using
the old protocol. They were designated as the control group(Group C). Those enrolled between March 1, 2017 and August
31, 2017, were managed following the new protocol using
SIVA in the initial 24-h period, and they were designated as
the study group (Group S).
The inclusion criteria included patients aged 20 years or older
classified as class I or II by the American Society of Anesthesiologists Physical Status (ASA-PS) scale. The exclusion criteria
included patients with renal dysfunction (estimated creatinine
clearance < 20 ml/min or ongoing hemodialysis), liver dysfunction (AST or ALT > 100 U/L), and/or deviating from our
hospital’s LC management protocols.
This was a retrospective observational study comparing patients following two different management protocols (withand without SIVA) (table1). The primary outcome was painscore on postoperative day 1. The secondary outcomes included the LOH, and the incidence of postoperative nausea

Citation: Taniguchi H, Takenouchi M, Imaura M, Nagahuchi M, et al. (2018). Postoperative Scheduled Intravenous Acetaminophen in
Patients Undergoing Laparoscopic Cholecystectomy in Japan. M J Anes. 1(2): 009.

2

www.mathewsopenaccess.com
and vomiting (PONV) from postoperative day 0 to 1.

Postoperative pain assessment was estimated by the Numerical Rating Scale (NRS) on postoperative day 1 at 9:00 AM atrest. A pharmacist estimated the NRS from patients during
Acute Pain Services (APS) rounds.

muscle relaxation was reversed. When the swallow reflex recovered, the patient could follow our directions and grasp ourhand, the spontaneous breathing rate was ≥ 12 breaths/min,end tidal CO2 was < 45 mmHg, and SpO2 was ≥ 95%, the endotracheal tube was removed. Epidural and total IV anesthesia(continuous infusion of propofol and remifentanil) were notselected for this surgery.

Secondary outcomes

Postoperative pain management

The postoperative use of non-opioid analgesics was assessedby calculating the frequency of prescribed analgesics including NSAIDs, tramadol, and acetaminophen. The incidence of
PONV was assessed by calculating the frequency of prescriptions of metoclopramide, droperidol, and dimenhydrinate.
Data on sex, age, body mass index (BMI), ASA-PS, disease
type, maintenance of anesthesia, operation time, and LOH)
were retrieved from the database.

In group C medicines were taken as needed. When the patient’s pain was over 4 at rest on NRS, the nurse would administer one rescue medication from the ordered medications by
the physician. The first-choice drug was acetaminophen, thesecond was an NSAIDs, and the third was tramadol. On the
day of the procedure, IV infusion of acetaminophen (Acelio
IV Injection; Terumo corporation, Tokyo, Japan), flurbiprofen
axetil (Ropion IV Injection; Kaken Pharmaceutical Co., Tokyo,
Japan) or tramadol (Tramal IV Injection; Nippon Shinyaku Co.,
Kyoto, Japan) was performed as needed. On postoperative

Primary outcome

Operative procedure
Four ports were used including a 10 mm optical, two 5 mm
operating, and a 5 mm assisting ports. The optical port wasplaced at the umbilicus and a flexible laparoscope was routinely used. The fundus of the GB was grasped by the assistant and flipped upwards and over the superior edge of theright lobe of liver. The triangle of Calot and the cystic duct’s
infundibular junction were identified. The infundibulum wasretracted infero-laterally, whereas the fundus was retracted
towards the right shoulder. The plane of dissection of Calot’s
triangle was anterior and above to Rouvier’s Sulcus. The medial areolar tissue between the liver and infundibulum was divided. The inferior part of the GB was freed from the GB fossa.
The cystic duct and artery were defined, and Strasberg’s Critical view of Safety was established. The cystic duct and artery
were clipped then divided by scissors. The superior part of the
GB was separated from the liver and extracted through the
10-mm umbilical port.
Maintenance of anesthesia
No pre-anesthetic medications were administered. Anesthesia was induced with propofol (1–2 mg/kg) and remifentanil(0.5 μg/kg/min). Following muscle relaxation with rocuronium(1 mg/kg), the trachea was intubated. Anesthesia was maintained with inhalation anesthesia (4–5% desflurane or 1–1.5％ sevoflurane) without nitrous oxide and remifentanil, whilefentanyl and rocuronium were intermittently administered asneeded. IV acetaminophen was injected 30 min prior to theend of surgery and every 6 h, at doses of 1000 mg for patientsweighing ≥ 50 kg, and 15 mg/kg for patients weighing < 50 kg.
Wounds were infiltrated with a local anesthetic (0.2% ropivacaine; 20–40 ml). After completion of the surgical procedure,
the remifentanil and inhalation anesthesia were stopped, andday 1, oral acetaminophen, NSAIDs, or tramadol were provided as needed. The medicines were administered at intervalsof over 4 h.
In group S, patients were given all medications in a standardized manner receiving a SIVA every 6 h, for 48 h, with a totalof 7 doses (1000 mg/dose every 6 h for patients weighing withpatients weighing ≥ 50 kg, and 15 mg/kg/dose every 6 h forpatients weighing < 50 kg). On postoperative day 1 patientswere given oral etodolac, on postoperative day 2 acetaminophen was changed from IV to oral from. When a patient’s pain
was over 4 at rest on the NRS, the nurse would administer
one rescue medication from the ordered medications by thephysician. The first-choice drug was an NSAIDs, and if kidney
dysfunction or symptoms originating from a digestive organ
were observed, then tramadol was chosen. The medicines
were administered at intervals of over 4 h. We drew a sample
to test for AST and ALT on the morning of postoperative day 1.
If the values of AST and ALT were greater than 100 U/L , thenthe SIVA was stopped.
Prevention of PONV
In both groups, patients with high PONV risk (≧ 60%; scoring
system by Apfel et al. [7]) were given antiemetics during theprocedure. Dexamethasone (6.6 mg) was injected after induction of anesthesia and droperidol (0.625–1.25 mg) was given
at the end of surgery. When PONV occurred, rescue therapy
with antiemetics was provided (metoclopramide, droperidol,or dimenhydrinate).
Statistical analysis
Statistical analysis was performed with JMP10.0.2 (SAS Institute, Cary, NA). For categorical variables, the frequency

Citation: Taniguchi H, Takenouchi M, Imaura M, Nagahuchi M, et al. (2018). Postoperative Scheduled Intravenous Acetaminophen in
Patients Undergoing Laparoscopic Cholecystectomy in Japan. M J Anes. 1(2): 009.

3

www.mathewsopenaccess.com(number and background of patients) was determined foreach group. The results of the two groups were compared by
Fisher’s exact test for binary categorical variables. NRS, LOH
and the number of medicinal use were compared between
the groups and expressed with a median value (minimum value, bottom quartile, top quartile, maximum value), for which
Wilcoxon rank-sum test were used. For continuous variables,
results were expressed with a mean value, standard deviation(SD), for which a two-sample t-test was performed. The twotailed significance level (P value) was set at 5%.
Discharge criteria
Discharge was at the morning of postoperative day 3 basedon the management protocol. Patients were discharged when
they met the following criteria: (a) had good pain management with oral analgesia; (b) were able to have solid foodwithout abdominal symptoms; (c) were independently mobile
or had the same mobility level as prior to their admission; (d)met all of the above and were willing to go home.

RESULTSOperative
duration(min)115.2±40.5

113.9±31.3 0.861†: Wilcoxon rank-sum test: significant when p <0.05, ††: Fisher exact
probability test: significant when p <0.05, Continuous variables: mean ±standard deviation
Group C: control group , Group S: SIVA group

There were no statistically significant differences in sex, age,
ASA-PS, BMI, disease type, or operation time between bothgroups. With regard to the maintenance of anesthesia, nopatient received an epidural; total IV anesthesia was used in
two patients. Because there were no exclusion criteria basedon the method of anesthesia, these 2 patients were also included. There were no statistically significant differences in
the maintenance of anesthesia.
Primary outcome
Figure 2 compares the NRS on postoperative day 1 at 9:00
AM between both groups. The NRS was lower in group S
than in group C (group S; 1.0 [0,0–2.75,8.0] vs. group C; 4.0[0,05.75,6.0]: P < .0001).

All patients were treated following a management protocol
during the investigation period and were registered. In bothgroups, eligible patients who met the inclusion and exclusion
criteria were selected from medical records of those undergoing elective LC during the study period. As a result, a total of
97 patients, a total of 98 patients, including 54 in group C and
44 in group S, were included in the analysis. Table 2 summarizes the patient characteristics of C- and S-groups.
Table 2 Patient characteristics

Age (year)

Group C
(n=54)

Group S
(n=44)

P

59.3±16.1

60.2±14.4

0.766

Sex

Figure 2: The NRS on postoperative day 1 at 9:00

0.2606Male(n)27

17

Female(n)272724.6±4.6

24.5±3.8

Body mass index(kg/m2)

Secondary outcomes

ASA-PS score0.6391

I(n)

22

20

II(n)

32

24

17

16

Gallbladder polyp(n) 1

2

The kind of disease
Gallstone(n)Inflammation(n)0.8784The NRS was lower in group S than in group C (group S; 1.0 [0,0–2.75,8.0]
vs. group C; 4.0 [0,05.75,6.0]: P < .0001). The NRS was compared between
the groups and expressed with a median value (minimum value, bottom
quartile, top quartile, maximum value), for which Wilcoxon rank-sum test
were used.

0.616936

26

Maintenance of anesthesia

0.1134

total IV anesthesia
(n)

0

2

Inhalation anesthesia (n)5442

The number of rescue medicines was lower in group S compared to group C (group S; 0 [0,0-0,3.0] vs. group C; 1.0 [0,02.25,5.0]: P < .0001) (Figure3).
LOH after surgery was also shorter in group S than in group C(group S; 3.0 [3.0,3.0-3.0,7.0] days vs. group C; 3.0 [3.0,3.03.0,12.0] days: P=0.0462) (group S; 3.1 ± 0.86 days vs. group C;
3.6 ± 1.8 days). In contrast, the incidence of PONV did not differ between both groups (group S; 25.0% vs. group C; 42.6%:
P=0.0688). No patients in either groups had elevated the levels of AST or ALT of more than 100 U/L on postoperative day 1.

Citation: Taniguchi H, Takenouchi M, Imaura M, Nagahuchi M, et al. (2018). Postoperative Scheduled Intravenous Acetaminophen in
Patients Undergoing Laparoscopic Cholecystectomy in Japan. M J Anes. 1(2): 009.

4

www.mathewsopenaccess.com

Figure 3: The number of using rescue medicine during postoperative 24hr
The number of rescue medicines was lower in group S compared togroup C (group S; 0 [0,0-0,3.0] vs. group C; 1.0 [0,0-2.25,5.0]: P < .0001).
The number of medicinal use was compared between the groups andexpressed with a median value (minimum value, bottom quartile, top
quartile, maximum value), for which Wilcoxon rank-sum test were used.
Table 3: The ratio of PONV and LOH after surgery.

Group C (n=54)

Group S (n=44) P

PONV(+) (%)

42.6%

25.0%

PONV(-) (%)

57.4%

75.0%

LOH after
surgery(day)

3 .0[3.0,3.03.0,12.0] *3.0 [3.0,3.03.0,7.0]*

0.06880.0462††: Wilcoxon rank-sum test: significant when p <0.05* median value [minimum value , bottom quartile- top quartile , maximum value]
PONV : postoperative nausea and vomiting
LOH : length of hospitalization

DISCUSSION
In this study, postoperative SIVA in patients undergoing LC reduced the NRS on postoperative day 1 at 9:00 AM. Furthermore, it reduced the LOH. During the first 24 h after surgery,postoperative SIVA reduced the number of rescue medicines
administered. However, it did not reduce the incidence of
PONV.
Acetaminophen has a long-standing history and a relatively
safe adverse event profile when used at appropriate doses[8]. In November 2010, the US Food and Drug Administration
approved the use of IV acetaminophen for the treatment of
acute pain and fever in adults and children older than 2 yearsof age [8,9]. In Japan, we have been able to use IV acetaminophen as well since November 2013 with an increase in the
maximum prescribing dose from 1500 mg a day to 4000 mg.
However, generally, its use has not been scheduled, with acetaminophen being administered as a one-shot medicine whenneeded. Therefore, a sufficient and sustained analgesic effectwas not usually achieved following surgeries in Japan, leading
to the patient’s difficulty to get out of bed because of poor
pain control. As a result, LOH was longer.

ERAS protocol reduces surgical invasiveness, postoperativecomplications and shortens hospital stay. However, major limiting factors for the ERAS protocol include pain, gastrointestinal (GI) dysfunction, and immobility. Although those 3 factors
are interlinked, it is particularly important to control postoperative pain for the improvement of GI dysfunction and immobility. Epidural analgesia has been recommended as a postoperative pain management strategy in the ERAS protocol for
major colorectal surgery [10,11]. Though the level of evidence
for epidural analgesia during open surgery is high, it has beenreported that epidural analgesia is not essential during laparoscopic surgery [1]. However, specifically in laparoscopic surgery, trocar sites are infiltrated with local anesthesia prior toskin closure [12]. The EARS protocol recommends multimodal
analgesia (MMA) including opioid, non-opioid, epidural, andlocal anesthesia for pain management after GI surgery [13].
MMA regimen is based on the routine use of non-opioid analgesia (NSAIDs, COX-2, and acetaminophen) and is indicated inpatients undergoing open and laparoscopic abdominal procedures with the aim of reducing the consumption of opioid andtheir dose-dependent side effects, which delays recovery. For
pain management after LC, ERAS guidelines recommend nonopioid and opioid use with dexamethasone and ondansetron,
for the prevention of PONV, and not epidural anesthesia [14].
However, in Japan, ondansetron is not used perioperatively
because of the lack of insurance coverage. Therefore, in ourstudy, the pain management regimen for group S includes
wound infiltration with a local anesthetic and non-opioid analgesics with dexamethasone (6.6 mg) and droperidol (0.625–
1.25 mg) (figure 1).
In this study, we estimated the NRS on postoperative day 1 at
9:00 AM as we wanted to assess the effect of acetaminophen
at minimum blood and cerebrospinal fluid (CSF) concentrations. Previous research has shown that the concentrationsin the blood and CSF are minimum at this time. Had acetaminophen been administered immediately, the pain would
have been uniformly suppressed. We believe that the reason
that the NRS and the number of rescue medicines administered during the first 24 h after surgery were lower in group
S compared to group C was that the CSF concentration of acetaminophen was maintained by the SIVA. Neil K et al demonstrated that earlier and greater CSF penetration occurs as
a result of the earlier and higher plasma peak levels achieved
with IV acetaminophen administration compared with thoseadministered orally or rectally [15]. Studies showed that IV
acetaminophen reaches a higher peak plasma concentrationcompared to when administered orally. In addition, IV administration does so faster [16]. SIVA has repeatedly been shown
to be a safe and efficacious analgesic in major orthopedic sur-

Citation: Taniguchi H, Takenouchi M, Imaura M, Nagahuchi M, et al. (2018). Postoperative Scheduled Intravenous Acetaminophen in
Patients Undergoing Laparoscopic Cholecystectomy in Japan. M J Anes. 1(2): 009.

5

www.mathewsopenaccess.com
geries [17,18]. Similarly, it was efficacious in gastrointestinaland gynecological surgeries [19,20]. Although the incidence of
PONV was not different between both groups in our study, we
believe the reason to be the limited use of antiemetics perioperatively in Japan. Had we used ondansetron in this study, theincidence of PONV might have decreased as in other studies
on LC [21,22].
Our results showed that the LOH following surgery shortensby merely introducing SIVA in LC managed ERAS protocols. In
Japan, the LOH following surgery can be reimbursed for a relatively long period of time, which can affect LOH after surgery.
Because of this, the primary endpoint surgical studies in Japanis not LOH following surgery. However, in our study we believethat SIVA reduced postoperative pain and patients whose discharge was postponed was due to the lack of pain control.
Santoso JT et al. demonstrated that multimodal pain control
was associated with a significant reduction in the LOH following open abdominal hysterectomy [23]. Similarly, Shaffer EE
et al. demonstrated that opioid use including SIVA for postoperative pain management had the potential to decrease LOH,
opioid-related complication rates, and hospital expenses [24].
Because this study did not include the use of opioids in eithergroups, we concluded that the effect of analgesia induced by
SIVA reduced the LOH. In Japan, where the LOH following surgery is difficult to use as a primary endpoint, its shortening
is remarkable. We recommend the standardization of postoperative pain management in the clinical protocols in Japan. In
the future we expect the evaluation of SIVA in other types ofprocedures.
This study had several limitations. First, it was a retrospective
observational study and not a RCT. Although the LC surgicalprocedure was the same in both groups and the perioperative management was standardized, postoperative analgesic
regimens differed. As a result, the effect of postoperative SIVA
on pain control was noted. Hence, we believe this study to
be as informative as an RCT. Second, there was one evaluation time-point for NRS. Ideally, an average of scores at several
time-points would have been better. Furthermore, the evaluation of NRS was limited to during rest. It would have been
preferred to be evaluated while the patients were mobile aswell. However, since NRS was evaluated by the same memberof APS, its evaluation accuracy was considered high.
Third, in Japan, the LOH is not an index for medical economic burden. Therefore, the actual economic burden faced bythese patients could not be evaluated. DPC/PDPS (Diagnosis
Procedure Combination/Per-Diem Payment System) is a Japanese payment system. The medical cost incurred by a patientis the sum of the comprehensive evaluation and the high evaluation set for each DPC. Our results show that the overall cost

related to the comprehensive evaluation decreased; however,
we could not determine how the high evaluation affected thecost incurred.

CONCLUSION
Introduction of SIVA into the postoperative pain management protocol of LC reduced the NRS on postoperative day
1, the number of rescue medicines administered during thefirst 24 h following surgery, and the LOH. We recommend thestandardization of postoperative pain management in clinicalmanagement protocols in Japan.

CONFLICTS OF INTEREST
The authors report no conflicts of interest in this work.

ACKNOWLEDGMENT
All authors contributed equally to the study design, data collection, data interpretation,
figure creation, and writing of the manuscript.
We would like to thank Editage (www.editage.jp) for English
language editing.

REFERENCES
1.

2.

3.

4.

5.

Gustafsson UO, Scott MJ, Schwenk W, Demartines N, etal. (2013). Enhanced Recovery After Surgery (ERAS) Society, for Perioperative Care; European Society for ClinicalNutrition and Metabolism (ESPEN); International Association for Surgical Metabolism and Nutrition (IASMEN).
Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society
recommendations. World J Surg. 37(2): 259-284.
Nygren J, Thacker J, Carli F, Fearon KC, et al. (2012). Enhanced Recovery After Surgery Society. Guidelines forperioperative care in elective rectal/ pelvic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clin Nutr. 31(6): 801-816.
Thiele RH, Rea KM, Turrentine FE, Friel CM, et al. (2015).
Standardization of care: impact of an enhanced recovery
protocol on length of stay, complications, and direct costs
after colorectal surgery. J Am Coll Surg. 220(4): 430-443.
Khoo CK, Vickery CJ, Forsyth N, Vinall NS, et al. (2007).
A prospective randomized controlled trial of multimodal
perioperative management protocol in patients undergoing elective colorectal resection for cancer. Ann Surg.
245(6): 867-872.
Amir Aryaie, C. Juergens, C. Ogg, W. Sergent, et al. (2015).
Decreased narcotic consumption with the addition of IVacetaminophen in colorectal patients: a prospective, randomized, double-blinded, placebo controlled study. Dis
Colon Rectum. 58 e123.

Citation: Taniguchi H, Takenouchi M, Imaura M, Nagahuchi M, et al. (2018). Postoperative Scheduled Intravenous Acetaminophen in
Patients Undergoing Laparoscopic Cholecystectomy in Japan. M J Anes. 1(2): 009.

6

www.mathewsopenaccess.com
6.

Apfel CC, Turan A, Souza K, Pergolizzi J, et al. (2013). Intravenous acetaminophen reduces postoperative nausea
and vomiting: a systematic review and meta-analysis.
Pain. 154(5): 677-689.
7. Apfel CC, Korttila K, Abdalla M, Kerger H, et al. (2004).
A factorial trial of six interventions for the preventionof postoperative nausea and vomiting. N Engl J Med.
350(24): 2441-2451.
8. Pasero C and Stannard D. (2012). The Role of Intravenous
Acetaminophen in Acute Pain Management: A Case-Illustrated Review. Pain Manag Nurs. 13(2): 107-124.
9. Pickens LA and Meinke SM. (2011). OFIRMEV: a recently
introduced drug. J Pediatr Nurs. 26(5): 494-497.
10. 10.Fearon KC, Ljungqvist O, Von MM, Revhaug A, et al.
(2005). Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr. 24(3): 466-477.
11. Kehlet H and Wilmore DW. (2008). Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg.

17. Sinatra RS, Jahr JS, Reynolds L, Groudine SB, et al. (2012).
Intravenous acetaminophen for pain after major orthopedic surgery: an expanded analysis. Pain Pract. 12(5):357-365.
18. Lachiewicz PF. (2013). The role of intravenous acetaminophen in multimodal pain protocols for perioperative orthopedic patients. Orthopedics. 36(2 suppl): 15-19.
19. Saurabh S, Smith JK, Pedersen M, Jose P, et al. (2015).
Scheduled intravenous acetaminophen reduces postoperative narcotic analgesic demand and requirement after
laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat
Dis. 11(2): 424-430.
20. Herring BO, Ader S, Maldonado A, Hawkins C, et al.
(2014). Impact of intravenous acetaminophen on reducing opioid use after hysterectomy. Pharmacotherapy. 34
Suppl 1: 27S-33S.
21. Ahsan K, Abbas N, Naqvi SM, Murtaza G, et al. (2014).
Comparison of efficacy of ondansetron and dexamethasone combination and ondansetron alone in preventing

248(2): 189-198.
12. Bisgaard T, Klarskov B, Kristiansen VB, Callesen T, et al.
(1999). Multi-regional local anesthetic infiltration during
laparoscopic cholecystectomy in patients receiving prophylactic multi-modal analgesia: a randomized, doubleblinded, placebo-controlled study. Anesth Analg . 89(4):1017-1024.
13. Feldheiser A, Aziz O, Baldini G, Cox BP, et al . (2016).Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia
practice. Acta Anaesthesiol Scand. 60(3): 289-334.
14. Jensen K, Kehlet H and Lund CM. (2007). Post-operative
recovery profile after laparoscopic cholecystectomy: aprospective, observational study of a multimodal anaesthetic regime. Acta Anaesthesiol Scand. 51(4): 464-471.
15. Singla NK, Parulan C, Samson R, Hutchinson J, et al. (2012).
Plasma and cerebrospinal fluid pharmacokinetic parameters after single-dose administration of intravenous, oral,
or rectal acetaminophen. Pain Pract. 12(7): 523-532.
16. Van der Westhuizen J, Kuo PY, Reed PW and Holder K.
(2011). Randomized controlled trial comparing oral andintravenous paracetamol (acetaminophen) plasma levels
when given as preoperative analgesia. Anaesth Intensive
Care. 39(2): 242-246.

postoperative nausea and vomiting after laparoscopiccholecystectomy. J Pak Med Assoc. 64(3): 242-246.
22. Isazadehfar K, Entezariasl M, Shahbazzadegan B, NouraniZ, et al. (2017). The Comparative Study of Ondansetronand Metoclopramide Effects in reducing Nausea andVomiting After Laparoscopic Cholecystectomy. Acta Med
Iran. 55(4): 254-258.
23. Santoso JT, Ulm MA, Jennings PW and Wan JY. (2014).
Multimodal pain control is associated with reduced hospital stay following open abdominal hysterectomy. Eur J
Obstet Gynecol Reprod Biol. 183: 48-51.
24. Shaffer EE, Pham A, Woldman RL, Spiegelman A, et al.
(2017). Estimating the Effect of Intravenous Acetaminophen for Postoperative Pain Management on Length of
Stay and Inpatient Hospital Costs. Adv Ther. 33(12): 22112228.

Citation: Taniguchi H, Takenouchi M, Imaura M, Nagahuchi M, et al. (2018). Postoperative Scheduled Intravenous Acetaminophen in
Patients Undergoing Laparoscopic Cholecystectomy in Japan. M J Anes. 1(2): 009.

7