To compare the opioid sparing effects Of combination Of dexamethasone , paracetamol and ketorolac(DexPak) VS paracetamol , ketorolac in patients undergoing total laparoscopic hysterectomy: a prospective double blind randomized controlled trial.

In recent times total laparoscopic hysterectomy has emerged as a new treatment modality which is quickly replacing the open abdominal hysterectomy. It has many advantages over abdominal hysterectomy of less postoperative morbidity, shorter hospital stay, being minimally invasive and faster recovery[1,2] . Despite these advantages, TLH is often associated with unexpectedly high levels of pain, most commonly due to inadequate pain control . Pain after TLH can be due various manipulation like pneumoperitonium, stretching of intra abdominal cavity and dissection of pelvic organs, apart from the incisional pain[3]

Opioids are one of the most common drugs used to alleviate postoperative pain, but they are associated with an array of side effects like sedation, reduced cognition, delirium, respiratory depression , nausea, vomiting ,ileus and pruritus[4]. These side effects cause delay in discharge and increase total cost of treatment.

In order to decrease these side effects multimodal analgesia using primarily non-opioid analgesics with additive or synergistic effects to produce superior analgesia while decreasing opioid use and side effects is being used. The most common non-opioid drugs used in multimodal analgesia regimen are acetaminophen, non-selective NSAIDS, selective COX-2(cyclooxygenase) NSAIDS, steroids , GABA agonists[gabapentin and pregabalin][5,6,7].

In our study we have used a combination of 3 drugs, Paracetamol, Ketorolac and Dexamethasone for a multimodal analgesia regime.

Paracetamol is a drug that is invariable used in multimodal analgesia regimens. Many clinical trial for gynaecological surgeries have shown that paracetamol provides better analgesia compared to a placebo and reduces opioid consumption[8,9,10]

 Ketorolac tromethamine is an NSAIDS which can be used intravenously. It has both analgesic and anti-inflammatory properties and can be used in moderate to severe post operative pain. It primarily act through inhabitation of prostaglandin synthesis via the Cox(cyclooxygenase) pathway. Studies have revealed that Ketorolac reduces postoperative pain and has opioid sparing effects but is less effective as a sole analgesic in moderate to severe postoperative pain[11,12]. Hence it is used in combination with other analgesic in multimodal analgesia regimes.

Dexamethasone is a glucocorticoids with a well established analgesic and anti-emetic properties.

 Thus the hypothesis of our study is that addition of preemptive Dexamethasone  to paracetamol and ketorolac combination will decrease cumulative opioid consumption as compared to paracetamol and ketorolac in women undergoing elective total laparoscopic hysterectomy.

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