Articles: postoperative.
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In the last few years great interest has developed in new modes of opioid administration; oral transmucosal, transdermal, peripheral, and nasal administration. Oral transmucosal administration of fentanyl citrate (OTFC) has most often been used for premedication in children. Meanwhile, studies on the use of OTFC in cancer patients for postoperative pain management have also been published. ⋯ Nonetheless, intranasal opioids guarantee a rapid rise in opioid plasma concentrations as well as a rapid onset of pain relief. This mode of administration seems to be especially suitable for the treatment of acute pain syndromes, such as breakthrough cancer pain or incident pain. Patient acceptance is high, and no local problems were reported.
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In a double-blind, randomized, placebo-controlled study, 86 patients (44 verum, 42 placebo), scheduled for knee-joint arthrotomies or minor orthopaedic operations received either naproxen, a nonsteroidal antiinflammatory analgesic, or placebo orally in three doses: the first immediately before the operation and the others 6 h and 12 h after the first. The verum group received 1250 mg naproxen in total. Postoperative pain intensity was measured by the category splitting procedure. ⋯ The intensity of typical side effects of opioids and antipyretic anti-inflammatory analgesics (nausea, vomiting, stomachache, headache, vertigo) was low and they were easily controlled in all cases. Lowering of respiratory frequency was not observed. Perioperative administration of the nonsteroidal anti-inflammatory analgesic naproxen results in better pain relief and significantly lower opioid requirements (by about 46%) after minor orthopaedic surgery.
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The spectrum of perioperative pain treatment is discussed in the present review. The analgesic efficacy of various drugs and the dosage methods of administration and side effects reported for them in such reference works as the practical guide on the management of acute pain recently published by the International Association for the Study of Pain (IASP) are described. Effective postoperative analgesia can diminish stress reactions following surgery. ⋯ Investigations performed by the author of this review have shown that epidural infusion of highly diluted mixtures of bupivacaine/fentanyl is highly effective in the analgesic treatment of patients undergoing prostatectomy, providing excellent physical mobilization. The potential dangers of drug combinations and contraindications are also discussed. The concept of using balanced analgesia to induce additive or synergistic effects following the administration of analgesic drugs requires further clinical studies.
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Journal of anesthesia · Jul 1993
Differences in the assessment of postoperative pain when evaluated by patients and doctors.
This study was undertaken to compare the assessment of pain intensity by 59 patients and by their doctors according to a visual analogue scale (VAS) at rest and when coughing at 5 and 20 hr after major abdominal surgery. The rating given by the patients, who received epidural analgesia to relieve postoperative pain, was significantly above, and moreover, significantly correlated with that given by the doctors at any time or under any condition of the assessment. ⋯ Our findings indicate that the assessment of postoperative pain may be associated with some unreliability, especially during early periods, when using the subjective or objective-rated VAS at rest separately, and thus requires the combined use or the concomitant use of the VAS when coughing. Substitutional use of the objective-rated VAS for the subjective-rated VAS is not advised.
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Postoperative pain can intensify the sympathoadrenergic reaction, which is commonly seen after surgery, and thus possibly pave the way for certain complications, such as coronary ischemia, bronchopneumonia, intestinal stasis, thromboembolism, infection, sepsis, and metabolic disturbances. Investigations of cardiovascular, respiratory, gastrointestinal, metabolic, and immunologic function indicate that high-quality pain relief can diminish postoperative organ impairment and failure. Some aspects of the improvements attributed to the quality of analgesia, such as prevention of tachycardia and hypertension, attenuation of hyperglycemia and catabolism, improvement of gastrointestinal motility and cellular immunity cannot be definitely distinguished from the effects of sympathetic blockade due to epidural analgesia with local anesthetics, however. ⋯ Some studies indicate that better analgesia is advantageous for the patient, especially with respect to postoperative complications, hospital stay, long-term well being, and costs. In other clinical trials incorporating more patients, however, this hypothesis had to be rejected. At present, therefore, we cannot state that effective pain relief influences postoperative morbidity and mortality.