Pain treatment and prophylaxis on pain

Abstract

Purpose of reviewAlso in ambulatory surgery, there will usually be a need for analgesic medication to deal with postoperative pain. Even so, a significant proportion of ambulatory surgery patients have unacceptable postoperative pain, and there is a need for better education in how to provide proper prophylaxis and treatment.Recent findingsPostoperative pain should be addressed both pre, intra- and postoperatively. The management should be with a multimodal nonopioid-based procedure specific guideline for the routine cases. In 10–20% of cases, there will be a need to adjust and supplement the basic guideline with extra analgesic measures. This may be because there are contraindications for a drug in the guideline, the procedure is more extensive than usual or the patient has extra risk factors for strong postoperative pain. Opioids should only be used when needed on top of multimodal nonopioid prophylaxis. Opioids should be with nondepot formulations, titrated to effect in the postoperative care unit and eventually continued only when needed for a few days at maximum.SummaryMultimodal analgesia should start pre or per-operatively and include paracetamol, nonsteroidal anti-inflammatory drug (NSAID), dexamethasone (or alternative glucocorticoid) and local anaesthetic wound infiltration, unless contraindicated in the individual case. Paracetamol and NSAID should be continued postoperatively, supplemented with opioid on top as needed. Extra analgesia may be considered when appropriate and needed. First-line options include nerve blocks or interfascial plane blocks and i.v. lidocaine infusion. In addition, gabapentinnoids, dexmedetomidine, ketamine infusion and clonidine may be used, but adverse effects of sedation, dizziness and hypotension must be carefully considered in the ambulatory setting.

Perioperative pain management for cleft palate surgery: a systematic review and procedure-specific postoperative pain management (PROSPECT) recommendations

“…43 Also, local wound infiltration is a key component of multimodal analgesia in numerous surgical procedures. 44 However, the analgesic effects of local anesthetic infiltration for cleft palate repair are only supported by one study. 29 Similarly, dexamethasone that was used intraoperatively in some of the studies, most likely for antiemetic prophylaxis, could have provided some analgesia.…”

“…Ideally, basic analgesia should have included a combination of acetaminophen with NSAIDs or COX-2-specific inhibitors. 44 In patients receiving a comprehensive basic analgesia treatment, the effects of analgesic interventions, for example, nerve block and additives, might be smaller or even insignificant. According to the PROSPECT methodology, recommended interventions must add a clinically relevant analgesic effect when added to a basic analgesic regimen.…”