Articles: postoperative.
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Numerous experimental studies have shown that systemic or regional administration of analgesics prior to a nociceptive stimulus results in a significant reduction of analgesic requirements compared with the administration of the same analgesic dose given after the nociceptive stimulus. This phenomenon is called "preemptive analgesia". Recently several clinical studies have been conducted to determine whether "preemptive analgesia" also occurs in humans. ⋯ Most studies have failed to show a significant reduction in postoperative analgesic requirements with preemptive analgesia. Even in studies with positive results the reduction in analgesic requirements was limited and without clinical relevance. Further studies should focus on the questions which analgesics and which administration routes might provide clinically significant "preemptive analgesia" and how long analgesia should be prolonged into the postoperative period.
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Pain and pain-related sympathoadrenergic reactions (hypertension, tachycardia) accompanied by nausea, vomiting and shivering are the most common side effects of recovery from anaesthesia. The alpha(2)agonist clonidine acts as a sedative, anxiolytic, antihypertensive, antiemetic, antisialogogue and decreases the incidence of shivering. Thus, we studied the effects of intraoperatively administered clonidine on the recovery period and the postoperative analgesic requirements in patients undergoing maxillofacial surgery. ⋯ Opiates are frequently used as analgesics after maxillofacial surgery, even though their most common side effect-respiratory depression, nausea and vomiting-are particularly dangerous in these patients because of the obstruction of the upper respiratory tract. Self-titration of the opiate dosage on demand can decrease the incidence of serious side effects. Clonidine administered intraoperatively caused a profound reduction in analgesic requirements in this study. Additional opiate administration in the postoperative period was unnecessary in nearly all clonidine-treated patients. The attenuating effect on sympathoadrenergic reactions leads to lowering of the rate-pressure product and may be of advantage for patients suffering from arterial hypertension, angina pectoris or bronchial asthma. The slower emergence from anaesthesia following clonidine administration is probably caused by double-blind study properties preventing full consideration of the decreased isoflurane requirements after clonidine.
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Interpleural analgesia is a method of postoperative analgesia that was developed by Kvalheim and Reiestad in 1984. The main indication is postoperative pain after unilateral thoracic and upper abdominal surgery. Many authors report good analgesic effects and better postoperative lung function following cholecystectomy. ⋯ The local anaesthetic of choice is bupivacaine (in concentrations of 0.25-0.75%, injection volumes of 10-40 ml, with or without epinephrine, applied as bolus or infusion), but others, such as lidocaine or morphine, are also being tested. Risks involved in this method are pneumothorax when the catheter is placed blind and the systemic toxicity of the local anaesthetic. This review provides information on the mechanism of action, the technique, the clinical use to date and possible risks.
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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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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.