Potential adverse effects associated with the use of NSAIDs include an increased risk of renal compromise (particularly in patients suffering from acute hypovolemia), gastrointestinal side effects, hypersensitivity reactions, and bleeding. The effects of ketorolac on bleeding are inconsistent. Studies of ketorolac on healthy volunteers showed transient increases in bleeding time and decreases in platelet aggregation, but these changes were not clinically significant (54). A retrospective cohort study showed increased risk of gastrointestinal and operative site bleeding in elderly patients receiving high doses of ketorolac, between 105 and 120 mg per day. Increased risk for all gastrointestinal bleeding was associated with use of ketorolac for more than 5 days (55). Controlled prospective studies did not show a significant increase in blood loss in patients who receive NSAIDs perioperatively. Ketorolac may be associated with elevated rates of acute renal failure when therapy exceeds 5 days (56). A meta-analyses of the use of postoperative NSAIDs in patients with normal preoperative renal function showed a clinically insignificant reduction in renal function (57). These agents should be used with extreme care, if at all, in patients with asthma, because 5% to 10% of adult patients with asthma are sensitive to aspirin and other NSAID preparations.
With the advantages of less gastrointestinal toxicity and a lack of antiplatelet effects, selective cyclooxygenase-2 (COX-2) inhibitors are a valuable option in perioperative pain management (58). Although evidence exists showing an increased risk of serious cardiovascular events associated with COX-2 inhibitors, short-term use of these agents in the perioperative setting can be considered in low-risk patients without existing cardiovascular disease (59–64).
In addition to NSAIDs, other adjuvant analgesics are being explored to minimize opioid use and the accompanying side effects, which can delay recovery. Capsaicin is a nonnarcotic that promotes release of substance P, a neurotransmitter for pain and heat, which initially results in a burning sensation, but eventually leads to substance P depletion and a reduction in pain. It is available in both topical and injectable preparations. Ketamine blocks centrally located N-methyld-aspartate pain receptors, and at low subanesthetic doses can reduce central sensitization caused by surgery and prevent opioid-induced hyperalgesia. At higher doses, ketamine is associated with hallucinations, dizziness, nausea, and vomiting. Gabapentin and pregabalin are nonnarcotics that prevent the release of excitatory neurotransmitters that relay pain signals. They reduce opioid requirements and are effective antihyperalgesic agents (64).
Gynecologic procedures often involve breaching the reproductive and gastrointestinal tracts, which harbor endogenous bacteria capable of causing polymicrobial infections in the postoperative period (Table 22.6). Despite great advances in aseptic technique and drug development, bacterial contamination of the operative site and postoperative infections are an inevitable part of the practice of gynecologic surgery. Prevention of these surgical complications includes
Table 22.6 Bacteria Indigenous to the Lower Genital Tract
Lactobacillus Enterobacter agglomerans Diphtheroids Klebsiella pneumoniae Staphylococcus aureus Proteus mirabilis Staphylococcus epidermidis Proteus vulgaris Streptococcus agalactiae Morganella morganii Streptococcus faecalis Citrobacter diversus α-Hemolytic streptococci Bacteroides species Group D streptococci B. disiens Peptostreptococci B. fragilis Peptococcus B. melaninogenicus Clostridium Gaffky anaerobia Escherichia coli Fusobacterium Enterobacter cloacae