Download which postoperative analgesia for day-care surgery?

WHICH POSTOPERATIVE ANALGESIA
FOR DAY-CARE SURGERY?
J-C. Ræder, Dept. of Anaesthesiology, Ullevaal University Hospital, N-0407 Oslo,
Norway.
INTRODUCTION
Day-care surgery is often performed for non-painful conditions, the patients are
elective with stable health and the procedure is usually minimal or medium
extensive. Progress in surgery towards less invasive methods (eg. by scopic
techniques) may also reduce the need for postoperative analgesia. However,
whereas surgery for a specific procedure may evolve towards less invasiveness, the
surgical repertoire considered appropriate for day-surgery is continously evolving
towards including more extensive procedures [1], such as laparoscopic
cholecystectomies and cruciate ligament repair [2]. With the new very shortacting
anaesthetic agents; such as sevoflurane, desflurane and remifentanil, the patient
wake up shortly and rapidly after end of surgery and the need of supplemental
analgesia may be increased [3].
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1. PAIN PROBLEMS AND NEED OF POSTOPERATIVE ANALGESICS IN
DAY-CARE SURGERY
We also have extensive documentation for pain as one of the major problems
after day-care surgery [4, 5], other problems including nausea, vomiting, drowsiness
and surgical complications [5]. In a study of Meeks [6], pain was one of the three
main reasons for unplanned admission to overnight stay after day-care surgery,
whereas other have reported pain as the number one reason [7]. In a study of why
patients took contact with the health care system after discharge for day-care
surgery, pain was the most frequent reason [8]. In our own study, 10 % of the daycare patients had medium or strong pain upon arrival in the recovery unit [9]. After
discharge 24 % of our patient had medium pain for the next 24 h, whereas 10 % had
strong pain. As much as 52 % had some pain interferring with normal sleep during
the first post-operative night [9].
Apart from improving the patient comfort, proper pain management may also
add to improved somatic health and better overall economy in day-care surgery.
Analgesia may prevent untoward strains and reflex movements in the wound area,
which may provoke haematoma formation and slow down wound healing [10].
On the other hand, reliable analgesia is a prerequisite of mobilization; which is
important in order to prevent venous trombosis and may be crucial for joint physiotherapy and muscle training after some orthopedic procedures. Efficacious dealing
with pain may also releave concommitant nausea, which often accompanies
pain [11]. Although extra analgesia is associated with extra drug costs, pain
treatment may still result in overall cost-reduction by reducing lenght of recovery
room stay and workload [8], as well as reducing the frequency of unplanned
admissions.
2. ISSUES OF PAIN PHYSIOLOGY AND PHARMACOLOGY
Understanding of pain physiology is the basis of proper pain management in the
day-care setting as well as in general. Some principles; such as the principles of pain
prevention, a multilevel approach, a multimodal approach and non-opioid analgesia;
are highly useful. Others, such as preemptive analgesia are controversial, although
with potentials for usefullness.
The principle of pain prevention applies both to level of analgesic effect and to
timing. Whereas subjective pain sensation is mainly of cerebral cortical origin, pain
stimuli and humoral mediators are mediated from the peripheral area of surgical
trauma and modulated at a spinal level before transmission to higher centers within
the central nervous system. Thus, reducing the pain stimuli in the periphery or
before entering the spinal cord is very effective, such as when a local or regional
analgesic method is used. NSAIDs [12, 13] were also thought to act in the
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periphery, but evidence as to central nervous system effects are increasing [14]. The
opioids have strong effects in the spinal cord, but also within the brain and in the
periphery [15]. Although the number of opiod receptors in peripheral tissue is low,
they increase in number and importance during inflammatory stimulation [15].
Whether preventive analgesia also reduce the pain generating mechanisms with
clinical effects after the drug effect has vanished, eg. preemptive analgesia, is highly
controversial. There are extensive animal data showing a preemptive effect [16, 17],
especially with local anaesthesia. However, only few clinical studies have been able
to confirm this principle in vivo [18, 19]; most have been negative [20].
Timing is important as to tailor analgesia to be present when the analgesic
effects of the peroperative drugs vanish and to ensue a rapid effect when the patient
is in pain. Intravenous administration, in general, provides a fast action; although
the peak effect of morphine (eg. at 5-10 min) are slower than with fentanyl and
meperidine (3-5 min). With injectable NSAIDs the peak effect is slow, occuring at
15-30 min [21]. Rectal administration usually provides faster, but more unreliable
action compared with the oral route. Still faster, and comparable to the iv route, may
the intranasal (eg. fentanyl) and sublingual route be (eg. buprenorphine). In
Scandinavia, rectal administration is much used, but patient acceptability of this
method may be considerably less in other cultures [22]. However, the rectal route is
available also during general anaesthesia, and may be used peroperatively in order
to have analgesic effect present when the patient wakes up.
The principle of non-opioid or opioid-reducing analgesia is important because
opioids have somnolescense and nausea as frequent, dose-depending sideeffects [23]. This also implies to peroperative use of opioids, if too large doses of
fentanyl are used close to the end of surgery, recovery may in addition be
complicated by respiratory depression. Thus the use of weak, non-opioid analgesics
may be beneficial even with strong pain because the need of opioid may be
reduced [24].
The arguments for a multimodal approach fall into two categories [25]. First,
some of the analgesics are weak and have a ceiling effect making them insufficient
as monotherapy for medium or strong pain. Secondly, if different agents with
analgesic effect in common, but with a different pattern of side-effects are
combined, the dose of each drug may be reduced. Since side-effects usually are dose
dependant, the total risk of side-effects with a multimodal low-dose approach may
be lowered, whereas the analgesic effect may be additive. If the drugs act analgesic
by different sites and mechanisms of action, they often have a synergistic analgesic
effect when used together [26].
3. METHODS OF POSTOPERATIVE ANALGESIA
The methods of analgesic prophylaxis and treatment may be categorized as to
site of application, mode of application and type of analgesic drug or principle.
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The more complicated and extensive pain preventing measures, such as
continous epidural or spinal, interpleural technique or PCA are rarely used in the
day-surgery setting. After all, one of the main criteria for discharge of a day-care
patient is a level of pain controllable by non-injection methods [27]. However, there
may be an issue for a shortlasting period of opioid or opioid+NSAID PCA after
more extensive procedures in order to control initial pain [28]. This may specially
be applicable if the definition of day-care is extended up to 23 h, as in the USA.
3.1. LOCO-REGIONAL ANAESTHESIA
The use of spinal or epidural anaesthesia for the surgical procedure may have
important benefits in terms of excellent pain control in the initial postoperative
phase where pain stimuli may be strong. Some data indicate an analgesic effect
lasting for longer than the block itself [29]. Whereas the patient may be awake and
non-nauseated by such a technique; the circulation instability, bed confinement and
risk of urinary retention may provide extra workload for the recovery
personnel [29]. Thus it is important to use shortacting agents [eg. lidocaine) for
these blocks. With children, however, these problems are not a major concern and
dilluted bupivacaine may be used caudally for prolonged postoperative analgesia in
the outpatient setting.
For the use of local anaesthetic topically, the longacting agents bupivacaine or
ropivacaine (best; lower toxicity) should be used, since prolonged side-effects are
not a concern. The use for wound infiltration is well documented and positive [30],
whereas the beneficial use in joints and the peritoneal cavity is more disputed [31].
With other regional blocks, such as axillary plexus or ancle blocks; longacting local
anaesthetics may be used without delaying discharge. However, for many procedures the pain may readily be treated with weak analgesics when a lidocaine block
wears off.
3.2. NSAIDS
The NSAIDs have a « ceiling » of analgesic effect and are less efficacious than
the opioids [32]. However, they do have an opioid sparing effect and may thus
facilitate recovery and decrease the time to discharge after day-care surgery [32].
The potential of side-effects; such as renal failure, allergic reactions and gastric
ulcer necessitates an individual evaluation of indication and dose in each patient
before NSAID is given. Increased tendency of post-operative bleeding have been
claimed in plastic surgery and demonstrated after tosillectomy [33], but are not well
documenteed for other procedures [32]. The risk of gastric ulcer during a short postoperative treatment periode is probably quite different from the risk seen with
chronic treatment for inflammatory diseases. The different NSAIDs have a different
profile as to inhibition of cyclooxygenase type I versus type II enzyme. Naproxen,
diclofenac and ibuprofen have a stronger type II inhibitory action, which may imply
less interference with the beneficial physiological actions of cyclooxygenase type
I [34].
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Whether this should have practical clinical implications in the choice between
different NSAIDs remains to be seen.
3.3. PARACETAMOL (ACETAMINOPHEN) [35]
Paracetamol acts on the cyclooxygenase enzyme by a mechanismen somewhat
different from the NSAIDs, and may be administered as a routine to virtually all
patients, due to a low incidence of side-effects in clinical doses. In many
comparative studies paracetamol have been less effective than NSAIDs, but most of
these studies have been done with paracetamol in a dose less than optimal, which
probably is about 1-1.5 g in adults. Whether paracetamol acts additive or synergistic
to NSAIDs when given in maximum doses is not clear, but some studies suggest a
« NSAID-sparing » effect of paracetamol which may be beneficial in terms of
reducing side-effects [36]. The introduction of the injectable paracetamol prodrug
propacetamol in recent years have increased the versatility of paracetamol.
3.4. OPIOIDS
The opiods may be divided into partial agonists and pure agonists. Whereas the
former has a ceiling of effect which may make them more safe in terms of
inadvertant strong sedation and respiratory depression, they still have a high
frequency of nausea associated with them [37, 38]. The pure agonists are more easy
to titrate and the effect versus side-effect profile seems quite similar [39]. Thus, the
choice among them should be from a pharmokinetic point of view as to route of
administration, onset time and duration of action. Rapid action and thus good
titrability is important as minimal effective dose should always be the goal. Codeine
is still the preferred opioid for oral administration due to high bioavailability (eg.
about 2/3 of the dose), which is beneficial in terms of less intra- and inter-individual
variation in dose-response.
3.5. NEW DRUGS AND METHODS
Basic pain science have provided us with a lot of methods very effective in
experimental conditions or controlled animal studies; still waiting to be tested or
proven efficacious in the postoperative setting.
Ketamin is a strong analgesic with a promising, but unconfirmed, longlasting
opioidsparing effect after a 0.2 mg/kg dose in inpatient cholecystectomy [40]. At
this doselevel side-effects, such as hallucinations and nausea, do not seem to be a
problem.
From a theoretical point of view, corticosteroids should be efficacious inhibitors
of the cyclooxygenase, thus providing analgesia at least as well as the NSAIDs. And
additional advantage may be the possibility of prolonged effect from depot
formulations and the abscence of NSAID side-effects such as bleeding, allergy and
renal toxicity. Studies of dental surgery have confirmed the promising analgesic
effect of these drugs [41].
The alfa-2 agonists, such as clonidine and the more specific dexmedethomidine,
have a well proven analgesic and opioidsparing effect [42]. However, reluctance as
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to their use in the day-care setting comes from their sedative action and the
occurence of incidental bradycardia which may occur hours after administration [43].
An interesting new concept is the transdermal fentanyl which may be
administered in a PCA-like fashion via an electronic disposable skinpad [44]. By
pushing a button, a small current of iontophoresis of fentanyl into the skin is
supplied when the patient feels pain.
Quite extensive research involves the use of traditional or new agents directly
into the operation site or epidurally/spinally. So far, local application of local
analgesia and opioid into joints after more extensive procedures seems quite
established, whereas most of the other suggestions in this field should be considered
experimental, so far.
SOME PERSONAL CONCLUSIONS: HOW TO I DO IT?
We do not give analgesic premedication, unless the patient have preoperative
pain. Regional anaesthesia with lidocaine is used quite extensively for surgery, as
well as local infiltration into the wound with bupivacaine afterwards. General
anaesthesia is based on propofol induction and propofol + nitrous oxide
maintenance, supplied with fentanyl at the start and alfentanil for maintennace.
Intravenous NSAID (eg. ketorolac) is supplied peroperatively or by the end of the
procedure to all cases where postoperative pain is expected and no contraindications
are present. By the end of surgery all the patients receive paracetamol rectally.
When the patient have pain during the first 1-2 postoperative hours, small titrated
doses of either meperidine or fentanyl are given iv. If pain occurs later, additional
NSAID or codeine+paracetamol is considered. By discharge, all the patients receive
4 paracetamol+codeine tablets (eg. recommended dose until the next morning) and a
recepe of 20 more tablets. All the patients receive a phone call from the anesthesiologist the day after, and further adjustments may be made.
CHALLENGES FOR THE FUTURE
We think further refinement of non-opioid analgesia and the multimodal
approach is possible. At present projects with ketamine enantiomers and
corticosteroids are going on in our unit. The introduction of ropivacaine may further
extend the use of local infiltration, as higher doses may be used with less toxicity
than bupivacaine. Pain treatment after discharge have been an area of little interest
in research so far. In our experience, pain is the most important complaint after
discharge and a lot more interest and vigour should be put into this phase in the
future.
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