Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Mar 2007
ReviewThe clinical role of NMDA receptor antagonists for the treatment of postoperative pain.
Recent advances in the understanding of postoperative pain have demonstrated its association with sensitization of the central nervous system (CNS) which clinically elicits pain hypersensitivity. N-methyl-D-aspartate (NMDA) receptors play a major role in synaptic plasticity and are specifically implicated in CNS facilitation of pain processing. ⋯ However, the mechanisms underlying ketamine anti-hyperalgesic effect are not totally understood, and neither is the relationship between central sensitization and the risk of developing residual pain after surgery. This chapter examines the role of low doses of ketamine as an adjuvant drug in current perioperative pain management and questions the anti-hyperalgesic mechanisms involved.
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Best Pract Res Clin Anaesthesiol · Mar 2007
ReviewPostoperative pain treatment for ambulatory surgery.
One of the most significant changes in surgical practice during the last two decades has been the growth of ambulatory surgery. Adequate postoperative analgesia is a prerequisite for successful ambulatory surgery. Recent studies have shown that large numbers of patients suffer from moderate to severe pain during the first 24-48 hr. ⋯ However, in the ambulatory setting many patients suffer from pain at home in spite of multimodal analgesic regimens. Sending patients home with perineural, incisional, and intra-articular catheters is a new and evolving area of postoperative pain management. Current evidence suggests that these techniques are effective, feasible and safe in the home environment if appropriate patient selection routines and organization for follow-up are in place.
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Best Pract Res Clin Anaesthesiol · Mar 2007
ReviewPostoperative pain management and outcome after surgery.
Postoperative pain management aims not only to decrease pain intensity but also to increase patient comfort and to improve postoperative outcome. Better pain control is achieved through a multimodal combination of regional analgesic techniques and systemic administration of analgesic agents. To guarantee uneventful follow-up and unnecessary prolongation of hospital stay, it is important to avoid side-effects of analgesic agents, especially those of opioids which are dose-related, by decreasing opioid demand through combination with non-opioid agents. ⋯ Unfortunately, a reduction in postoperative morbidity and mortality by epidural analgesia has not actually been demonstrated. Inclusion of postoperative pain treatment in a multimodal approach of patient rehabilitation may improve recovery and shorten hospital stay. Effective treatment of postoperative pain is also likely to prevent chronic pain syndrome after surgery, but further studies are needed to support this hypothesis.
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Best Pract Res Clin Anaesthesiol · Mar 2007
ReviewPostoperative pain--clinical implications of basic research.
Postoperative incisional pain is a unique and common form of acute pain. Although ample evidence indicates that an efficeous postoperative pain treatment reduces patient morbidity and patient outcome, recent studies demonstrate that about 50-70% of patients experience moderate to severe pain after surgery indicating that postoperative pain remains poorly treated. ⋯ Basic research offers important insights in the mechanisms of postsurgical incisional pain and the translation of experimental results into clinical practice will have important implications on the improvement of new multimodal treatment regimens based postoperative pain mechanisms. In the present review, recent developments in experimental postsurgical incisional pain research will be described and their possible relevance for clinical practice discussed.
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Best Pract Res Clin Anaesthesiol · Mar 2007
ReviewThe elderly patient and postoperative pain treatment.
The management of postoperative pain in elderly patients can be a difficult task. Older patients have co-existing diseases and concurrent medications, diminished functional status and physiological reserve and age-related pharmacodynamic and pharmacokinetic changes. Pain assessment presents numerous problems arising from differences in reporting cognitive impairment and difficulties in measurement. ⋯ Drug titration in the post-anaesthesia care unit should be encouraged together with analgesia on request in the wards. Multimodal analgesia, using acetaminophen, non-steroidal anti-inflammatory drugs or other non opioid drugs, is the best way to decrease opioid consumption and thus opioid-related adverse events. Sophisticated analgesic methods like PCA, regional analgesia and PCEA are not contraindicated in the elderly but pain relief and side effects should be monitored.