Oral Versus Intravenous Acetaminophen within an Enhanced Recovery after Surgery Protocol in Colorectal Surgery

Background: Multimodal pain management within enhanced recovery after surgery (ERAS)protocols is designed to decrease opioid use, promote mobilization, and decrease postoperativecomplications.Objectives: To evaluate the role of intravenous (IV) versus oral (PO) acetaminophen within anestablished ERAS protocol in colorectal surgery.Study Design: This was a retrospective observational study.Setting: This research took place within an established perioperative colorectal surgery protocol.Methods: A total of 91 consecutive elective colorectal resections performed according to an ERASprotocol using only IV acetaminophen (IV group) were compared with 84 consecutive resectionsperformed using one dose of IV acetaminophen followed by subsequent administration of oralacetaminophen (PO group). Our multimodal pain management strategy also included transverseabdominis plane blocks, celecoxib, and ketorolac medications for both groups. Opioid requirements,maximum and average daily pain scores by the Visual Analog Scale, and postoperative outcomeswere compared between groups.Results: There were no differences in maximum or average pain scores on postoperative days0-3 or at time of discharge between IV and PO groups. Compared with the IV acetaminophenonly group, the PO group received significantly more perioperative opioids through 72 hourspostoperatively (68.8 oral morphine equivalents [OME] IV group vs. 93.7 OME PO group; P <0.0001), were more likely to require opioid patient-controlled analgesia (8.9% IV group vs. 46.4%PO group; P < 0.0001), and were more likely to experience postoperative nausea and vomiting(33.0% IV group vs. 48.8% PO group; P = 0.0449).Limitations: Significant limitations include the studies’ retrospective nature and that it wasperformed at a single institution.Conclusions: Restriction of IV acetaminophen within an ERAS protocol in colorectal surgery wasassociated with increased opioid use, greater need for opioid patient-controlled analgesia, andincreased incidence of postoperative nausea and vomiting. IV acetaminophen may be superior tooral acetaminophen in the early postoperative setting.Key words: Perioperative pain management, enhanced recovery after surgery, acetaminophen,multimodal pain control, nonopioid