Does acetazolamide (Diamox) IV help with Laparoscopic gas discomfort? Is there evidence for giving acetazolamide at the end after desufflation?

Comment by InpharmD Researcher

A meta-analysis of 5 abdominal laparoscopic procedure studies suggest that acetazolamide significantly reduces postoperative visual analog scale pain scores compared to control groups. However, a recent study investigating use in robotic laparoscopic procedures for prostatectomy did not find a benefit in reducing pain score (Table 1). None of the studies specifically examined the reconstitution of 500 mg IV acetazolamide with 10 mL sterile water, nor were any studies conducted in which it was administered at the end of desufflation.

Background

A 2022 meta-analysis investigated the use of acetazolamide for managing postoperative pain after laparoscopy. Acetazolamide is a carbonic anhydrase inhibitor that may decrease the amount of carbonic acid production from CO2 and water after a laparoscopic procedure, thereby decreasing diaphragm irritation. A total of 5 clinical trials (N= 253) of patients undergoing abdominal laparoscopy with 24-hour post-operative pain assessment using a visual analog scale (VAS) were included for analysis. Publication bias for four of five studies was generally considered low except for one study with a moderate risk of randomization bias due to insufficient blinding. Comparator groups consisted of either placebo, no treatment, or bupivacaine administered preoperatively as either oral or intravenous injections. Acetazolamide significantly reduced average pain scores compared to control groups by -0.726 points on the VAS score (95% credible interval; -1.175 to -0.264). However, the outcome was of generalized postoperative pain and not specific to managing gas discomfort in a particular location. The diversity in procedures may also influence patient outcomes. None of the studies were reported to assess acetazolamide 500 mg IV with 10 mL of sterile water. Dosing was primarily weight-based (5 mg/kg) or 250 mg (preparation unspecified). [1]

References:

[1] McGrail K, Chapple AG, Stone G, Sutton EF, Chappell NR. Systematic Review and Meta-Analysis of Perioperative Administration of Acetazolamide for Management of Postoperative Pain after Laparoscopy. JSLS. 2022;26(3):e2022.00032. doi:10.4293/JSLS.2022.00032
Literature Review

A search of the published medical literature revealed 1 study investigating the researchable question:

Does acetazolamide (Diamox) IV help with Laparoscopic gas discomfort? Is there evidence for giving acetazolamide 500mg IV reconstitute with 10ml of sterile water, IV push at the end after desufflation?

Please see Table 1 for your response.

 

Impact of Acetazolamide on Perioperative Pain Control in Robotic Assisted Laparoscopic Prostatectomy

Design

Randomized, controlled trial

N= 31

Objective

 To evaluate the efficacy of peri-operative acetazolamide for pain control in robotic assisted laparoscopic prostatectomy (RALP)

Study Groups

Acetazolamide (n= 16)

Placebo (n= 15)

Inclusion Criteria

 Diagnosed with clinically localized prostate cancer, elected for robotic assisted laparoscopic prostatectomy

Exclusion Criteria

 Renal insufficiency, pre-existing metabolic acidosis, American Society of Anesthesiology score 4 or higher

Methods

Patients were randomized at the time of surgery to receive either 250 mg acetazolamide intravenously (IV) versus a saline placebo of 10 mL. Though not stated, the 250 mg acetazolamide would have been administered as 10 mL to maintain blinding, but the reconstituting agent was not specified.

Duration

 24 hours

Outcome Measures

Primary: pain scores

Secondary: procedural characteristics, morphine use

Baseline Characteristics

  

Acetazolamide (n= 16)

Placebo (n= 15)

  

Age, years

 56.4 ± 5.8 64.5 ± 5.7  

Race, n

Caucasian

African American

 

14

2

 

11

4

  

American Society of Anesthesiology score

2.8 ± 0.5

2.5 ± 0.5

  

Body Mass Index, kg/m2

28.5 ± 3.5

29.9 ± 4.2

  

Total Gleason Score

7.06 ± 0.44

7.00 ± 0.76

  

Comorbidity, n

Hypertension

Diabetes mellitus

Coronary artery disease

Chronic obstructive pulmonary disease

Smoking history

 

7

5

0

0

6

 

9

1

1

1

3

  

Results

Endpoint

Acetazolamide (n= 16)

Placebo (n= 15)

p-Value

Pain score

Post-anesthesia care unit (PACU)

PACU discharge

4 hours

24 hours

 

3.5 ± 3.1

2.8 ± 2.9

3.1 ± 3.0

2.3 ± 1.7

 

4.1 ± 1.7

2.9 ± 2.9

2.9 ± 1.8

2.2 ± 1.6

 

0.2757

0.48

0.362

0.5

Procedural characteristics

Length of surgery, hours

Pelvic lymph node dissection

TAP block

 

3.4 ± 0.8

6 (38%)

16 (100%)

 

3.2 ± 0.6

7 (47%)

15 (100%)

 

0.4

0.6

1

Post-operative total morphine equivalent (MME)

 2.53 ± 2.88 3.02 ± 4.69 0.364

Study Author Conclusions

 Acetazolamide does not appear to impact overall pain or shoulder tip pain in the observed cohort of patients undergoing RALP.

InpharmD Researcher Critique

 There is limited information regarding the preparation of acetazolamide before administration. The study was carried out to verify the ongoing trend of acetazolamide's effectiveness in alleviating laparoscopic gas discomfort. The results were unexpectedly negative, and the limited scope of the study does not allow for confirmation of any relationship between the findings and patients undergoing RALP.



References:

Medairos R, Lankford J, Everett R, et al. Impact of Acetazolamide on Perioperative Pain Control in Robotic Assisted Laparoscopic Prostatectomy. Urology. 2023;172:126-130. doi:10.1016/j.urology.2022.11.014