Postoperative analgesia

Bristow A, Orlikowski C. Subcutaneous ketamine analgesia postoperative analgesia using subcutaneous infusions of ketamine and morphine. Ann R Coll Surg Engl 1989 71(l) 64-6. 

Anesthesia Anesthesia is a loss of sensation or feeling. Anesthesia (or "anesthetics") is often used deliberately by doctors and dentists to block pain and other sensations during surgical procedures. Treatment for pre- or postoperative pain is called analgesia. 

Remifentanil (Ultiva) is used for induction and maintenance of general anesthesia and for continued analgesia during the immediate postoperative period. This drug is used cautiously in patients witii a history of hypersensitivity to fentanyl. 

A study on racial differences in receipt of analgesics found that nearly three-fourths (74%) of white patients compared with 57% of African American patients received analgesics for lower extremity fractures in emergency departments (Todd et al., 2001). An assessment of racial/ethnic differences in physicians prescriptions of patient-controlled analgesia for postoperative pain found that after adjustment for age, gender, preoperative... 

Forbes JA, Beaver WT, Jones KF, Kehm G, Smith WK, Gongloff CM, Zeleznock JR, Smith JW. (1991). Effect of caffeine on ibuprofen analgesia in postoperative oral surgery pain. Clin Pharmacol Ther. 49(6) 674-84. 

In postoperative patients, excessive dosage may result in excitement and significant reversal of analgesia, hypotension, hypertension, pulmonary edema, and ventricular tachycardia and fibrillation. 

Subcutaneous/IM Relief of severe pain relieve preoperative apprehension preoperative sedation control postoperative pain supplement to anesthesia analgesia during labor acute pulmonary edema allay anxiety. 

Total moderate dose 2 to 20 meg/kg. In addition to adequate analgesia, some abolition of the stress response should occur. Respiratory depression necessitates artificial ventilation and careful observation of postoperative ventilation. 

Analgesia, adjunctive therapy (parenteral only) - As pre- and postoperative and pre- and postpartum adjunctive medication to permit reduction in narcotic dosage. 

Excessive dosage in postoperative patients may produce significant excitement, tremors, and reversal of analgesia. 

This agent is used due to certain advantages i.e. it provides profound analgesia and good relaxation of skeletal muscles, uterine contractions are not inhibited and postoperative nausea and vomiting are not troublesome. But, due to its renal toxicity, its use as a general anaesthetic is limited. 

These are the most commonly used drugs. Morphine (10-15 mg IM), pethidine (50-100 mg IM) are frequently used drugs for their sedative and analgesic property. They reduce the anxiety and apprehension, produce pre- and postoperative analgesia, help in smooth induction. They also reduce... 

It is indicated in rheumatoid and osteoarthritis, ankylosing spondylitis, mild to moderate pain including dysmenorrhoea, soft tissue injuries, fractures and postoperative analgesia. 

Epidural and intrathecal opioids are widely used for postoperative and obstetric analgesia. In contrast to local anaesthetics, spinal opioids cause minimal sympathetic efferent and motor blockade. Pethidine, which has local anaesthetic activity, can produce sensory and motor blockade. Because remifentanil is formulated with glycine as a vehicle, it should not be used epidurally or intrathecally, since glycine is neurotoxic. 

Recovery is sufficiently rapid with most intravenous drugs to permit their use for short ambulatory (outpatient) surgical procedures. In the case of propofol, recovery times are similar to those seen with sevoflurane and desflurane. Although most intravenous anesthetics lack antinociceptive (analgesic) properties, their potency is adequate for short superficial surgical procedures when combined with nitrous oxide or local anesthetics, or both. Adjunctive use of potent opioids (eg, fentanyl, sufentanil or remifentanil see Chapter 31) contributes to improved cardiovascular stability, enhanced sedation, and perioperative analgesia. However, opioid compounds also enhance the ventilatory depressant effects of the intravenous agents and increase postoperative emesis. Benzodiazepines (eg, midazolam, diazepam) have a slower onset and slower recovery than the barbiturates or propofol and are rarely used for induction of anesthesia. However, preanesthetic administration of benzodiazepines (eg, midazolam) can be used to provide anxiolysis, sedation, and amnesia when used as part of an inhalational, intravenous, or balanced anesthetic technique. 

A 0.1% ophthalmic preparation is recommended for prevention of postoperative ophthalmic inflammation and can be used after intraocular lens implantation and strabismus surgery. A topical gel containing 3% diclofenac is effective for solar keratoses. Diclofenac in rectal suppository form can be considered for preemptive analgesia and postoperative nausea. In Europe, diclofenac is also available as an oral mouthwash and for intramuscular administration. 

Dosages and routes of administration Morphine is available in different salt forms but the hydrochloride and sulfate (Vermeire and Remon, 1999) are used preferentially. The compound can be administered by the oral, parenteral or intraspinal route. Oral application is preferred for chronic pain treatment and various slow release forms have been developed to reduce the administration frequency to 2-3 times per day (Bourke et al., 2000). Parenteral morphine is used in intravenous or intramuscular doses of 10 mg, mostly for postoperative pain and self-administration devices are available for patient-controlled analgesia (PCA). Morphine is additionally used for intraspinal (epidural or intrathecal) administration. Morphine is absorbed reasonably well in the lower gastrointestinal tract and can be given as suppositories. 

Lehmann, K.A., Tenbuhs, B., Hoeckle, W. Patient-controlled analgesia with piritramid for the treatment of postoperative pain, Acta Anaesthesiol. Belg. 1986, 37, 247-257. 

Levine, J. D., Gordon, N. C., Smith, R., McBryde, R. Desipramine enhances opiate postoperative analgesia, Pain 1986, 27, 45-49. 

Motsch, J., Graber, E., Ludwig, K. Addition ofclonidine enhances postoperative pain analgesia from epidural morphine a double blind study, Anesthesiology 1990, 73, 1067-1073. 

Clinical use The indications for levobupivacaine include wound infiltration (0.25 % solution), nerve conduction block (0.25 - 0.5 %), spinal analgesia (0.5 %) and epidural anesthesia (0.5 to 0.75 %). For labour analgesia, lower concentrations of levobupivacaine are recommended when administered as epidural injection (0.125 to 0.25 % up to 25 mg) or infusion (0.25 %). The maximum dose for ilioinguinal or iliohypogastric block in children is 1.25 mg/kg/side (0.25 to 0.5 % solutions). For postoperative pain management, levobupivacaine can be applied epidurally in combination with the opioids fentanyl or morphine or with the a2-agonist clonidine. 

Clinical use Ropivacaine is used for local infiltrations such as field block (0.75 % solution) and for nerve block (0.75 %) up to 300 mg and for epidural anesthesia (0.75 and 1.0 %) up to 200 mg. When used for labour analgesia, epidural doses up to 40 mg are recommended. A combination of opioids is often administered via the epidural route for postoperative analgesia. 

Scott, D. A., Blake, D., Buckland, M, Etches, R., Halliwell, R., Marsland, C., Merridew, G., Murphy, D., Paech, M., Schug, S. A., Turner, G., Walker, S., Huizar, K., Gustafsson, U.. A comparison of epidural ropivacaine infusion alone and in combination with 1.2 and 4 pg/mL fentanyl for seventy-two hours of postoperative analgesia after major abdominal surgery, Anesth. Analg. 1999, 88, 857-864. 

Tramer, M. R., Schneider, J., Marti, R.-A., Rifat, K. Role of magnesium sulfate in postoperative analgesia, Anaesthesiology 1996, 84, 340-347. 

Aygun S, Kocoglu H, Goksu S, et al. Postoperative patient-controlled analgesia with intravenous tramadol, intravenous fentanyl, epidural tramadol and epidural ropivacaine + fentanyl combination. EurJ Gynaecol Oncol. 2004 25 498-501. 

Block BM, Liu SS, Rowlingson AJ, et al. Efficacy of postoperative epidural analgesia a meta-analysis. JAMA. 2003 290 2455-2463. 

ChellyJE, Grass J, Houseman TW, et al. The safety and efficacy of a fentanyl patient-controlled transder-mal system for acute postoperative analgesia a multicenter, placebo-controlled trial. Anesth Analg. 2004 98 427-433. 

Paech MJ, Lim CB, Banks SL, Rucklidge MW, Doherty DA. A new formulation of nasal fentanyl spray for postoperative analgesia a pilot study. Anaesthesia. 2003 58 740-744. 

Viscusi ER. Emerging techniques for postoperative analgesia in orthopedic surgery. AmJ Orthop. 2004 ... 

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