“Comparison of Preemptive Intravenous Paracetamol, Paracetamol–Diclofenac, and Paracetamol–Ketorolac for Postoperative Analgesia Following Elective Abdominal Surgery under General Anaesthesia: A Prospective Randomized Double-Blind Study”
Abstract
Neha Parmar, Sandeep Singh Jadon, Ashish Mathur and Preeti Goyal
Background: Effective postoperative pain management is an essential component of perioperative care. Preemptive analgesia, as a part of multimodal analgesic strategies, aims to reduce central sensitization and postoperative pain while minimizing opioid requirements. Paracetamol, diclofenac, and ketorolac are commonly used non-opioid analgesics; however, comparative evidence regarding their preemptive combinations remains limited. This study evaluated the efficacy of intravenous paracetamol alone, paracetamol–diclofenac, and paracetamol–ketorolac combinations in patients undergoing elective abdominal surgery under general anaesthesia.
Methods: In this prospective, randomized, double-blind study, 99 patients aged 20–60 years with American Society of Anesthesiologists (ASA) physical status I–II undergoing elective abdominal surgery were enrolled and randomly allocated into three equal groups (n = 33 each). Group P received intravenous paracetamol 1 g, Group PD received intravenous paracetamol 1 g plus diclofenac 75 mg, and Group PK received intravenous paracetamol 1 g plus ketorolac 30 mg before surgical incision. The primary outcome was time to first rescue analgesia. Secondary outcomes included postoperative pain intensity assessed using the Visual Analogue Scale (VAS), haemodynamic parameters, and incidence of adverse effects. Rescue analgesia was administered with intravenous tramadol when VAS was ≥4.
Results: Ninety-nine patients were randomized equally into three groups (n = 33 each). The primary outcome, time to first rescue analgesic requirement, differed significantly among the groups and was longest in Group PK (148.76 ± 15.39 min), followed by Group PD (113.27 ± 9.59 min) and Group P (95.52 ± 6.82 min) (F = 193.768, p < 0.001). Postoperative pain scores also demonstrated significant intergroup differences. Group PK showed lower VAS scores during the immediate postoperative period (0 h, 30 min, and 1 h), whereas Group PD demonstrated lower pain scores at 2 and 4 hours postoperatively. At later assessment intervals, both combination therapy groups maintained lower pain scores than paracetamol alone. Haemodynamic parameters remained stable and comparable among the groups. The incidence of postoperative adverse effects was low, with no statistically significant differences observed among the three groups.
Conclusions: Both paracetamol–ketorolac and paracetamol–diclofenac combinations provided superior postoperative analgesia compared with paracetamol alone in patients undergoing elective abdominal surgery under general anaesthesia. The paracetamol–ketorolac combination provided superior analgesia during the immediate postoperative period and significantly prolonged the time to first rescue analgesic requirement, whereas the paracetamol–diclofenac combination demonstrated superior analgesia during the intermediate postoperative period. Both multimodal analgesic regimens were associated with stable haemodynamic parameters and a favorable safety profile. These findings support the use of paracetamol–NSAID combinations as effective opioid-sparing strategies for postoperative pain management following elective abdominal surgery.