Acetaminophen vs Placebo for Postoperative Analgesia After Abdominal Surgery

Detailed Description:

Postoperative pain remains a major clinical challenge despite advances in analgesic pharmacology and surgical technique, contributing to delayed mobilization, prolonged hospital stay, and increased morbidity. Oral acetaminophen is widely used as part of multimodal analgesia regimens, but high-quality evidence supporting its independent analgesic effect - as distinct from placebo response - remains limited, particularly after major abdominal surgery.

This is a prospective, multicenter, randomized, double-blind, placebo-controlled trial enrolling adults undergoing elective non-cardiac abdominal surgery under general anesthesia, with an expected surgical duration of at least 2 hours and a planned hospital stay of at least 48 hours. Prior to the main trial, each participating site will enroll a minimum of 10 pilot patients to confirm proper implementation of the analgesic protocol.

Eligible patients will be randomized 1:1 using a web-based system (REDCap) with random-sized blocks to receive either oral acetaminophen 1000 mg or matching placebo tablets. The first dose will be administered 30 minutes before surgery, followed by repeat dosing every 6 hours for 48 hours postoperatively. All patients will receive a standardized intraoperative analgesic protocol (fentanyl 1.5 mcg/kg at induction; tramadol 2 mg/kg approximately 30 minutes before anticipated completion of surgery), with postoperative rescue analgesia provided via patient-controlled analgesia (tramadol; demand dose 10 mg, lockout 6 minutes, continuous baseline 10 mg/h) and per-patient-request dosing (tramadol 1 mg/kg for pain score >4).

The joint primary outcomes are (1) total opioid consumption (expressed as IV morphine milligram equivalents) and (2) average postoperative pain score (0-10 visual analog scale), both assessed over the first 48 postoperative hours. Acetaminophen will be considered superior to placebo only if it demonstrates both statistical superiority on opioid consumption and statistical noninferiority on pain score (noninferiority margin of 1 point), tested jointly at an overall one-sided alpha of 0.025. Opioid consumption will be analyzed using a linear regression model on log-transformed values; pain score will be analyzed using a repeated-measures linear regression model with an autoregressive correlation structure.

Secondary outcomes include patient-reported satisfaction with postoperative pain management at 24 and 48 hours. Exploratory outcomes include a composite measure of opioid-related side effects (Opioid-Related Symptom Distress Scale, ORSDS), capturing nausea, vomiting, constipation, sedation, dizziness, and related symptoms.

Based on a sample size calculation incorporating group sequential interim analyses (planned at each 25% of enrollment), a maximum of 1504 patients (752 per group) will be enrolled to achieve approximately 90% overall power at the 0.025 significance level. An internal pilot analysis at 25% enrollment will re-evaluate sample size assumptions based on observed variability in opioid consumption.

Data will be collected from electronic medical records at each participating site and centrally coordinated and analyzed at the trial coordinating center.

Inclusion criteria

• Written informed consent
• Age ≥ 18 years
• ASA physical status I, II, or III
• Scheduled for elective non-cardiac abdominal surgery with expected surgery duration ≥ 2 h-hours
• General anesthesia
• Planned hospital stay of at least 48 hours

Exclusion criteria

• Pregnant or nursing (breastfeeding) women
• Neurologic deficit or chronic pain disease
• Planned use of regional anesthesia techniques for postoperative pain
• Emergency surgery