Multimodal approach to control postoperative pathophysiology and rehabilitation

Abstract

Major surgery is still associated with undesirable sequelae such as pain, cardiopulmonary, infective and thromboembolic complications, cerebral dysfunction, nausea and gastrointestinal paralysis, fatigue and prolonged convalescence. The key pathogenic factor in postoperative morbidity, excluding failures of surgical and anaesthetic technique, is the surgical stress response with subsequent increased demands on organ function. These changes in organ function are thought to be mediated by trauma-induced endocrine metabolic changes and activation of several biological cascade systems (cytokines, complement, arachidonic acid metabolites, nitric oxide, free oxygen radicals, etc). To understand postoperative morbidity it is therefore necessary to understand the pathophysiological role of the various components of the surgical stress response and to determine if modification of such responses may improve surgical outcome. While no single technique or drug regimen has been shown to eliminate postoperative morbidity and mortality, multimodal interventions may lead to a major reduction in the undesirable sequelae of surgical injury with improved recovery and reduction in postoperative morbidity and overall costs.

Cost-effectiveness analysis of the analgesic therapy of postoperative pain

“…These results confirm literature recommendations which state that multimodal schemes are more effective for the treatment of PO pain (2,8,(13)(14) . Table 4 shows that, according to scenario 1, the (D) and (E) schemes presented similar effectiveness (43.0%), while the (C) scheme was the worst (33.0%).…”

Eficacia analgésica de una dosis única de dexametasona perineural en el bloqueo ecoguiado del nervio femoral en cirugía de prótesis total de rodilla

“…El control eficaz y activo del dolor postoperatorio se ha convertido en una parte esencial de los cuidados perioperatorios y una prioridad médico quirúrgica, ya que existe una fuerte evidencia [46][47][48] de que su adecuado control, junto a otros factores como la movilización y la nutrición precoces, no sólo aumentan el confort y la satisfacción de los pacientes, sino que además contribuyen a disminuir la morbi-mortalidad postoperatoria, estando su escaso control directamente relacionado con un aumento en la incidencia de trombosis venosa profunda, tromboembolismo pulmonar, infarto agudo de miocardio, neumonía, mala cicatrización de las heridas, insomnio y malestar del paciente [49][50][51] .…”

“…La USPSTF ha encontrado evidencia moderada de que la medida mejora de manera importante los resultados en salud y concluye que los beneficios superan a los riesgos. En un intento de mejorar la analgesia postoperatoria de los pacientes, los Anestesiólogos hemos venido utilizando en los últimos años la analgesia multimodal o balanceada, entendida como la consecución del alivio del dolor mediante diferentes regímenes analgésicos, en ocasiones administrados a diferentes niveles anatómicos (periférico, espinal), que actúen por distintos mecanismos de acción 48 . Esta técnica permite la administración de menores dosis de fármacos, lo que conlleva una reducción importante de los efectos secundarios de los mismos.…”

Péridurale thoracique: tout ce que nous voulons c’est l’analgésie?

“…21 The classic catabolic response to operation (the surgical stress response), a key pathogenic factor in postoperative morbidity, is attenuated by blocking the afferent neural stimulus with epidural local anesthetic. 22 Extensive epidural anesthesia (T4-Ss) is easily achieved by the thoracic route without approaching toxic local anesthetic concentrations and, when instituted before surgery and followed by epidural analgesia with local anesthetic, results in the greatest observed reduction of the perioperative stress response. 16 Kehlet has hypothesized that, with multimodal interventions including the use of epidural anesthesia to control the surgical stress response and prolonged effective pain relief, the undesirable surgical sequelae and overall costs may be reduced.…”