Anesthesia-education.com

REVIEW ARTICLE
The Role of Non-Opioid Analgesic Techniques in theManagement of Pain After Ambulatory Surgery Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas In describing how patients feel after surgery, adelayeddischargefromtheday-surgeryfacilityorto Armitage (1) stated that “slapping the patient on the unanticipated hospital admissions. The intraoperative face and telling him or her that it’s all over is a use of large bolus doses or continuous infusions of complete inversion of the truth” because as far as the potent short-acting opioid analgesics (e.g., alfentanil patient is concerned, “it is often just the beginning.” and remifentanil) may actually increase postoperative Although the current armamentarium of analgesic drugs pain as a result of their rapid elimination and the and techniques is impressive, effective management of development of acute tolerance (4). Therefore, anes- postoperative pain still poses some unique challenges in thesiologists practicing in the ambulatory environ- the ambulatory setting. The increasing number and com- ment are increasingly using non-opioid analgesics as plexity of operations being performed on an outpatient adjuvants during the perioperative period (Table 1).
basis has presented anesthesia practitioners with new To minimize the adverse effects of analgesic medi- challenges with respect to acute pain management. Out- cations, “balanced” analgesic techniques involving the patients undergoing day-care procedures require a peri- use of smaller doses of opioids in combination with operative analgesic technique that is effective, has mini- non-opioid analgesic drugs (e.g., local anesthetics and mal side effects, is intrinsically safe, and can be easily nonsteroidal antiinflammatory drugs [NSAIDs]) are managed away from the hospital or surgery center.
becoming increasingly popular approaches during The adequacy of postoperative pain control is one of and after ambulatory surgery (5,6). The rationale for the most important factors in determining when a pa- the perioperative use of non-opioid analgesic drugs tient can be safely discharged from the outpatient facility and techniques in the ambulatory setting will be re- (2). Because inadequately treated pain is a major cause of prolonged stays or unanticipated hospital admissionsafter ambulatory surgery, the ability to provide effectivepain relief by simple methods that are readily available to an outpatient in his or her home environment will beone of the major challenges for providers of ambulatory Peripheral nerve blocks and wound infiltration with anesthesia in the future (3). Unfortunately, there are very local anesthetics are commonly used adjuvants to both few well controlled studies that have carefully examined monitored anesthesia care (MAC) and general anes- the optimal approaches to managing postdischarge pain thetic techniques because they can provide intra- and postoperative analgesia (Table 2). As a result, these Perioperative analgesia has traditionally been pro- techniques can decrease the anesthetic and analgesic vided by opioid analgesics. However, the use of large requirements during surgery and reduce the need for doses of opioids during ambulatory surgery can be opioid analgesics in the postoperative period. More associated with an increased incidence of postopera- effective pain relief in the early postoperative period tive complications (e.g., ventilatory depression, seda- from the residual sensory block provided by local tion, postoperative nausea and vomiting, pruritus, dif- anesthesia can facilitate the recovery process, enabling ficulty voiding, and ileus), which in turn contribute to earlier ambulation and discharge home (i.e., fast-tracking). The use of local anesthetic techniques alsodecreases the incidence of postoperative nausea and Supported by the White Mountain Institute, Los Altos, CA (Paul vomiting and thereby decreases the incidence of pro- Accepted for publication November 7, 2001.
longed recovery stays and unanticipated hospital ad- Address correspondence to Paul F. White, PhD, MD, Department missions related to intractable emetic symptoms.
of Anesthesiology and Pain Management, UT Southwestern Medi- Although additional clinical studies are needed to cal Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9068. Address identify the most cost-effective anesthetic techniques e-mail to [email protected]. No reprints will beavailable.
for ambulatory surgery, it would seem that peripheral 2002 by the International Anesthesia Research Society0003-2999/02 NON-OPIOID ANALGESICS AND POSTOPERATIVE PAIN Table 1. Commonly Used Non-Opioid Drugs and
Table 2. Commonly Used Techniques for Administering
Nonpharmacologic Techniques for Minimizing Pain After Local Anesthesia During Ambulatory Surgery Ilioinguinal/hypogastric (e.g., herniorrhaphy) Paracervical (e.g., dilation/curettage, cone biopsy) Peroneal/femoral/saphenous/tibial/sural (e.g., Femoral/obturator/lateral femoral cutaneous/sciatic Brachial plexus/axillary/ulnar/median/radial (e.g., arm Peribulbar/retrobulbar (e.g., ophthalmologic Mandibular/maxillary (e.g., oral surgery) IV regional (Bier block) (e.g., arms, legs) Tissue infiltration and wound instillation Cosmetic and wound procedures (e.g., blepharoplasty, Excision of masses and biopsies (e.g., breast, axilla, Field blocks or “splash” technique (e.g., hernia repair, Transcutaneous electrical nerve stimulation Transcutaneous acupoint electrical stimulation Laparoscopic procedures (e.g., cholecystectomy, tubal Acupuncture-like transcutaneous electrical nerve Arthroscopic procedures (e.g., knees, shoulders) PO ϭ oral; PR ϭ per rectum; SC ϭ subcutaneous/tissue.
Eutectic mixture of local anesthetics (e.g., skin lesions)Lidocaine spray (e.g., bronchoscopy, endoscopy, hernia nerve blocks with sedation (i.e., MAC techniques) of- Lidocaine gel or cream (e.g., circumcision or urologic or fer significant advantages over central neuraxis block- ade and general anesthesia in the ambulatory setting Cocaine paste (e.g., nasal or endosinus surgery) (7–9). In outpatients undergoing saphenous vein-stripping surgery, use of a femoral/genitofemoralnerve block significantly improved patient satisfaction It has been suggested that performing neural blockade with the anesthetic experience (7). Blockade of the with local anesthetics before the surgical incision may ilioinguinal and iliohypogastric nerves can signifi- prevent the nociceptive input from altering the excitabil-ity of the central nervous system (e.g., preemptively cantly decrease the anesthetic and analgesic require- blocking the N-methyl-d-aspartate-induced “wind up” ments in both children and adults undergoing ingui- phenomena and release of inflammatory mediators) (18).
nal herniorrhaphy, providing 6 – 8 h of postoperative The concept of preemptive analgesia (or treating post- analgesia (10,11). Similarly, subcutaneous ring block operative pain by preventing the establishment of cen- of the penis provides effective perioperative analgesia tral sensitization) seems very logical (18); however, its for circumcision procedures (12). Local anesthetic in- clinical relevance has been questioned. Only one well filtration of the mesosalpinx significantly decreases controlled study has demonstrated any benefits of pre- the pain and cramping after laparoscopic tubal liga- versus postincisional local anesthetic administration in tion procedures (13). Pain after arthroscopic shoulder the ambulatory setting (19). A recent qualitative and surgery was decreased significantly by a simple su- quantitative review by Møiniche et al. (20) suggested prascapular nerve block (14), and pain after knee sur- that evidence is still lacking that the timing of single- gery was minimized with a femoral nerve block (15).
dose or continuous postoperative pain treatment is im- However, more complete perioperative analgesia for portant in the management of postsurgical pain. These shoulder and knee surgery requires the use of an investigators concluded that there is no convincing evi- interscalene brachial plexus block (16) and combined dence that preemptive treatment with centrally or pe- femoral, obturator, lateral femoral cutaneous, and sci- ripherally administered local anesthetics, NSAIDs, opi- atic nerve (17) blocks, respectively. Although addi- oid analgesics, or ketamine offers any advantage with tional preparation time may be required when these respect to postoperative pain relief compared with a major peripheral nerve blocks are performed before similar postsurgical analgesic regimen. Nevertheless, surgery, these block techniques can offer advantages preincisional administration offers advantages over in- in the postoperative period compared with general or filtration at the end of surgery with respect to intraop- NON-OPIOID ANALGESICS AND POSTOPERATIVE PAIN Preincisional infiltration with local anesthetics in duration of analgesia and greater opioid-sparing ef- combination with general anesthesia is clearly supe- fects than when it was given at the end of surgery (37), rior to general (or spinal) anesthesia alone in relieving the clinical advantages of preemptive analgesia re- postoperative pain (21,22). In fact, preincisional infil- tration of the tonsillar bed with bupivacaine decreased Local anesthetic supplementation clearly decreases both constant pain and pain on swallowing for up to the severity of incisional pain in the early postopera- 5 days after tonsillectomy procedures in children (22).
tive period. However, outpatients may still experience Preincisional ilioinguinal hypogastric nerve block not significant pain after they have been discharged home only improves intraoperative pain control during in- because of difficulty in anticipating the degree of pain guinal hernia repair, but also reduces the need for oral when the local anesthetic effect wears off. Continuous opioid-containing analgesics after discharge (23). Al- (38,39) or intermittent perfusion (40) of the surgical though preincisional infiltration of the operative site wound with local anesthetic solutions is an old- with local anesthetics remains a popular technique for fashioned but highly effective technique for extending reducing the perioperative opioid analgesic require- incisional pain relief into the postdischarge period.
ment, other more simplified local anesthetic delivery Recently, this technique has been modified to allow systems (e.g., topical applications) have also been de- for patient-controlled local anesthetic administration scribed in the anesthesia literature (24,25). Topical an- after discharge home (41). However, some investiga- algesia with lidocaine aerosol was found to be highly tors have failed to find significant differences in pain effective in decreasing pain, as well as the opioid scores or opioid analgesic requirements when the local analgesic requirement, after inguinal herniorrhaphy in anesthetic was instilled or injected at the incision site adults (24), and instillation of 0.25% bupivacaine be- (42,43). The response to local analgesia appears to be fore surgical closure provided comparable postopera- influenced by the location, concentration, and volume tive pain relief to an ilioinguinal/iliohypogastric of the injected local anesthetic solution. For example, nerve block in children undergoing hernia repair (25).
Yndgaard et al. (44) demonstrated that subfascially Furthermore, the simple application of topical lido- administered lidocaine was significantly more effec- caine jelly or ointment is as effective as peripheral tive in reducing pain compared with subcutaneous nerve blocks or parenteral opioids in providing pain injection after inguinal herniotomy. Finally, combin- relief after outpatient circumcision (26).
ing local anesthetic techniques with other analgesic Intracavitary instillation of local anesthetics is an- modalities as part of multimodal (or “balanced”) an- other simple, yet effective, technique for providing algesic therapy can improve pain control throughout pain relief during the early postoperative period after the perioperative period (45). The concept of balanced laparoscopic and arthroscopic procedures. Intraperito- analgesia consists of administering several different neal administration of local anesthetics during lapa- analgesic drugs to alter the pathophysiologic pro- roscopy was found to be an efficient method of reduc- cesses involved in nociception, thereby producing ing the intensity of postoperative scapular pain (27).
more effective perioperative analgesia with fewer side However, when bupivacaine was injected at the pre- peritoneal fascial plane during extraperitoneal laparo- In summary, local anesthetic wound infiltration and scopic hernia repair, it did not reduce postoperative peripheral nerve block techniques are simple, safe, pain (28). Local anesthetics can also be injected into and effective approaches to providing perioperative joint spaces to provide analgesia during and after analgesia in the ambulatory setting. Use of major neu- arthroscopic surgery (29). In a placebo-controlled ral blockade techniques involving the upper (e.g., in- study, intraarticular instillation of 30 mL of 0.5% bu- terscalene brachial plexus block) and lower (e.g., fem- pivacaine reduced the opioid requirements and facil- oral nerve block) extremities can facilitate an earlier itated early mobilization and discharge after knee ar- discharge after major shoulder and knee reconstruc- throscopy (30). A follow-up study (31) involving a tive procedures, respectively (46,47). The availability combination of intraarticular bupivacaine and sys- of newer local anesthetic drugs that are alleged to be temic ketorolac (60 mg IV or IM) further decreased associated with less toxicity and greater selectivity pain in the early postoperative recovery period. A with respect to sensory and motor blockade (e.g., ropi- wide variety of adjuvants has also been injected into vacaine and levobupivacaine) may further enhance the intraarticular space to decrease postarthroscopic the benefits of local anesthetic supplementation after pain, including morphine, ketorolac, triamcinolone, ambulatory surgery. The addition of adjuvants (e.g., and clonidine (32–35). Small-dose intraarticular mor- clonidine) can prolong the postoperative analgesia phine 1–3 mg, in combination with bupivacaine, produced by peripheral nerve blocks (48). Recent seems to provide the longest lasting and most cost- studies by Klein et al. (49,50) suggest that improved effective analgesia after knee arthroscopy (36,37). Al- pain control could also be achieved after major shoul- though administering the intraarticular morphine be- der and knee procedures by using a disposable, non- fore knee surgery was reported to provide a longer electronic catheter system for continuously infusing NON-OPIOID ANALGESICS AND POSTOPERATIVE PAIN local anesthetic solutions. However, additional studies be associated with similar visual analog pain scores to are needed to document the alleged advantages of fentanyl (1 ␮g/kg IV) (62). After gynecologic laparos- these newer local anesthetic drugs and techniques.
copy surgery (63), diclofenac decreased pain and an- Future studies are also needed to determine the opti- algesic requirements for 24 h postoperatively but had mal local anesthetic concentrations and infusion rates little effect on the recovery profile. Similarly, the ad- ministration of ketorolac during the perioperative pe-riod in outpatients undergoing laparoscopic cholecys-tectomy procedures (59) decreased postoperativeopioid requirements, but this contributed to only a marginal improvement in ventilatory function at 4 hr NSAIDs have long been used for treating nonsurgical pain syndromes because of their well known antiin- When diclofenac was administered preoperatively to flammatory, antipyretic, and analgesic properties.
pediatric patients, both the incidence of restlessness and However, with the introduction of parenteral prepa- crying and the postoperative opioid requirements were rations of NSAIDs (e.g., ketorolac and diclofenac), lower in the diclofenac-treated (versus acetaminophen- these drugs have become more popular in the man- treated) patients (64). Oral ketorolac (1 mg/kg) com- agement of pain associated with ambulatory surgery.
pared favorably to small-dose acetaminophen (10 mg/ NSAIDs block the synthesis of prostaglandins by in- kg) for bilateral myringotomy procedures in children, hibiting the enzyme cyclooxygenase (COX), thereby with the ketorolac-treated patients recording lower pain reducing the production of mediators of the acute scores and requiring less analgesic medication in the inflammatory response. By decreasing the inflamma- early postoperative period (65). In children undergoing tory response to surgical trauma, NSAIDs have been inguinal hernia repair (66), ketorolac (1 mg/kg IV) com- alleged to reduce peripheral nociception. However, pared favorably to caudal bupivacaine 0.2% with respect more recent studies also suggest that the central re- to pain control and postoperative side effects. In fact, the sponse to painful stimuli may be modulated by ketorolac-treated patients had an improved recovery NSAID-induced inhibition of prostaglandin synthesis profile, including less vomiting, shorter times to voiding and ambulation, and earlier discharge home. Further- Early reports suggested that NSAIDs possessed an- more, the intraoperative administration of ketorolac as algesic properties comparable to those of opioid anal- an adjuvant to general anesthesia in pediatric patients gesics (51–53) without opioid-related side effects provided postoperative analgesia comparable to mor- (54,55). When ketorolac was administered as an adju- phine (67). As expected, the ketorolac-treated patients vant to propofol/nitrous oxide anesthesia, its use was experienced less postoperative nausea and vomiting.
associated with improved postoperative analgesia and When ketorolac or morphine are administered for pain patient comfort, which compared favorably to fenta- control in pediatric patients, ketorolac-induced analgesia nyl (55). Moreover, ketorolac was associated with a develops more slowly but is longer lasting compared decreased incidence of postoperative nausea and vomiting, and patients tolerated oral fluids and were Oral or rectal administration of NSAIDs can also be judged fit for discharge earlier than those receiving highly effective in the prophylactic management of opioid compounds. Other investigators have also re- pain after ambulatory surgery. For example, when ported that ketorolac provided similar postoperative oral naproxen was administered before laparoscopic pain relief to that of fentanyl but was associated with surgery, postoperative pain scores, opioid require- less nausea and somnolence and an earlier return of ments, and time to discharge were significantly re- bowel function after ambulatory surgery (56). Further- duced (69). Furthermore, premedication with oral ibu- more, it was recently reported that the administration profen (800 mg) was associated with superior of ketorolac (30 mg) at the incision site to supplement postoperative analgesia and less nausea compared local anesthesia resulted in significantly less postop- with fentanyl (75 ␮g IV) (70). However, the more erative pain, a better quality of recovery, and earlier important role for oral NSAIDs is in the postdischarge discharge compared with local anesthesia alone (57).
period. In a recent outpatient study involving the use However, when ketorolac was substituted for or com- of a multimodal analgesic technique consisting of al- bined with fentanyl during outpatient gynecologic fentanil, lidocaine, ketorolac, and paracetamol (71), and laparoscopic surgical procedures, the beneficial oral ibuprofen (800 mg every 8 h) was equianalgesic to effects of the NSAID were more variable (58 – 60).
paracetamol 800 mg plus codeine 60 mg (every 8 h) Use of shock-wave lithotripsy to evaluate the effect when administered during the first 72 h after dis- of NSAIDs on visceral pain, diclofenac produced only charge, and it resulted in better global patient satis- a marginal opioid-sparing effect (61). Furthermore, faction and less constipation than the opioid- when diclofenac (1 mg/kg IV) was administered be- containing oral analgesic. To achieve the optimal fore outpatient arthroscopic surgery, it was found to benefit of using NSAIDs in the perioperative period, NON-OPIOID ANALGESICS AND POSTOPERATIVE PAIN these compounds should be continued as prophylactic Korpela et al. (78) demonstrated that the opioid- analgesics for preventive pain management in the sparing effect of acetaminophen was strictly dose re- lated. The optimal dosing regimen for acetaminophenin children consists of a preoperative initial loadingdose of 40 mg/kg followed by a maintenance dose of 20 mg/kg every 6 – 8 h during the early postoperative In an effort to minimize the potential for operative-site bleeding complications, as well as gastrointestinal and An IV formulation of acetaminophen, known as renal damage, associated with the classical NSAIDs, propacetamol, has been administered to adults as an the more specific COX-2 inhibitors are being increas- alternative to ketorolac in the perioperative period ingly used as non-opioid adjuvants for minimizing (80,81). Propacetamol is a prodrug that is rapidly and pain during the perioperative period (Table 3). Early completely hydrolyzed by nonspecific plasma ester- studies evaluated the use of celecoxib and rofecoxib ases to form acetaminophen (also known as paraceta- for preventative analgesia when administered for oral mol). Although the future role of this non-opioid par- premedication (72–74). Rofecoxib (50 mg orally [PO]) enteral analgesic during the perioperative period is seems to produce more effective and sustained anal- yet to be determined, rectal acetaminophen (1.3 g) has gesia compared with celecoxib (200 mg PO) after sur- been successfully used as an adjuvant to NSAIDs and gery (72). Preliminary data suggest that celecoxib local anesthetics in adult outpatients as part of a mul- (200 mg PO) is equivalent to acetaminophen (2 g PO) timodal fast-tracking protocol (82).
when administered before outpatient otorhinolaryn-gology surgery (73). However, rofecoxib (50 mg PO) produced significantly more effective analgesia thanacetaminophen (2 g PO), and the pain relief was more Ketamine is a unique anesthetic with analgesic-like sustained in the postdischarge period (74). Premedi- properties which has been used for both the induction cation with rofecoxib also facilitated the recovery pro- and maintenance of anesthesia and as an analgesic cess by reducing postoperative pain and improving adjuvant during MAC (83). As a result of its well the quality of recovery from the patient’s perspective.
known side-effect profile (Table 4), ketamine fell into More recently, a parenterally active COX-2 inhibi- disfavor in the anesthesia community in the early tor, parecoxib (20 – 40 mg IV), has been investigated as 1980s. However, the use of so-called small-dose ket- an alternative to ketorolac and diclofenac (75,76). Pare- amine (0.1– 0.2 mg/kg IV) techniques seems to be coxib is a prodrug with an active metabolite (valde- associated with a much less frequent incidence of coxib) and is similar both pharmacokinetically and adverse events and with greater patient and physician pharmacodynamically to celecoxib. Both preoperative acceptance (84). Recent studies have described the use (75) and postoperative (76) administration of this in- of ketamine in combination with propofol for MAC vestigational COX-2 drug seems to exert significant (85,86) and IV anesthesia (87). The administration of opioid-sparing effects, and these preliminary studies ketamine 4 –18 ␮g · kgϪ1 · minϪ1 in combination with suggest that it can improve the quality of recovery and propofol 30 –90 ␮g · kgϪ1 · minϪ1 can obviate the re- patient satisfaction with postoperative pain manage- spiratory depression produced by propofol/opioid ment. However, further comparative clinical studies combinations while producing positive mood effects are needed to define the optimal role of COX-2 inhib- after surgery, and it may even provide for an earlier recovery of cognitive function (85,86). In addition, asingle bolus dose of ketamine 0.1– 0.15 mg/kg duringsurgery has been reported to produce significant opioid-sparing effects after painful ambulatory sur- Of the nonopioid analgesics, acetaminophen is poten- gery procedures (88,89). However, the clinical signifi- tially one of the most useful, yet it is vastly underused cance of ketamine’s preemptive analgesic effects re- in the ambulatory setting. When administered in an appropriate oral or rectal dose, acetaminophen can bea very useful adjuvant during the perioperative period and compares favorably to the NSAIDs in children(77). Although Watcha et al. (65) reported minimal Nonpharmacologic “electroanalgesic” techniques (e.g., analgesic-sparing effects after a 10 mg/kg dose of transcutaneous electrical nerve stimulation [TENS], acetaminophen, Rusy et al. (77) found that a larger acupuncture-like TENS, and percutaneous neuromodu- dose (35 mg/kg per rectum) was as effective as ke- lation therapy) can also be used as adjuvants in the torolac 1 mg/kg IV in reducing pain after tonsillec- treatment of both acute and chronic pain in the ambula- tomy procedures and was associated with less post- tory setting (92). Given the inherent side effects pro- operative bleeding than the NSAID. More recently, duced by both opioid and non-opioid analgesics (Table NON-OPIOID ANALGESICS AND POSTOPERATIVE PAIN Table 3. Dosage Recommendations and Duration of Action of COX-2 Inhibitors
COX-2 ϭ cyclooxygenase-2; PO ϭ orally.
a Data on file with Pharmacia (Skokie, IL) and Merck (West Point, PA).
b IV prodrug of valdecoxib (the active analgesic compound).
results regarding the effect of TENS on the require- Table 4. Potential Side Effects of Opioid and Non-Opioid
ment for opioid analgesic medication and the quality of postoperative pain relief. Several studies suggest that the location, intensity, and frequency of electrical Respiratory and cardiovascular depression stimulation are all important factors influencing the efficacy of TENS (and acupuncture-like TENS) thera- pies (96 –98). Moreover, the clinical efficacy of electro- Pruritus and skin rashSedation and dizziness analgesic techniques remains controversial because of the potential sources of bias and difficulty in quanti- fying the inherent placebo effect of the therapy. Other nonpharmacologic approaches that have also been evaluated as potentially useful analgesic adjuvants in the perioperative period include cryoanalgesia, ultra- sound, laser, and even hypnosis (99 –101). However, Sympathomimetic effects (due to vasoconstrictors) additional well controlled clinical studies are needed to establish the benefits of these nonpharmacologic modalities on patient outcome after ambulatory Allergic reactions and bronchospasmHypertensionPedal edema As more extensive and painful surgical procedures (e.g., laparoscopic cholecystectomy, adrenalectomy, and nephrectomy, as well as prostatectomy, laminec- tomy, shoulder and knee reconstructions, and hyster- ectomy) are performed on an outpatient or short-stay basis, the use of multimodal perioperative analgesic regimens containing non-opioid analgesic therapies will probably assume an increasingly important role in facilitating the recovery process and improving pa- tient satisfaction (3). Optimizing pain management is necessary to maximize the benefits of ambulatory sur- gery for both patients and health care providers. Ad-ditional outcome studies are needed to validate the 4), it is possible that nonpharmacologic approaches will beneficial effects of these newer therapeutic ap- assume a more prominent role in the management of proaches with respect to important recovery variables pain after ambulatory surgery in the future.
(e.g., resumption of normal activities and return to Most studies suggest that TENS produces a 15%– work). Although many factors other than pain per se 30% decrease in the postoperative opioid requirement must be controlled to minimize postoperative morbid- (93). In addition to reporting that TENS reduces pain ity and facilitate the recovery process after ambulatory and the need for oral analgesics, Jensen et al. (94) surgery, pain remains a major concern of all patients reported a more rapid recovery of joint mobility after undergoing surgical procedures (102).
outpatient arthroscopic surgery. In reviewing the It is clear that the anesthetic technique can influence medical literature, Carroll et al. (95) found conflicting the analgesic requirement in the early postoperative NON-OPIOID ANALGESICS AND POSTOPERATIVE PAIN period. Although opioid analgesics will continue to 9. Li S, Coloma M, White PF, et al. Comparison of the costs and play an important role in the management of moder- recovery profiles of three anesthetic techniques for ambulatoryanorectal surgery. Anesthesiology 2000;93:1225–30.
ate to severe pain after surgery, the adjunctive use of 10. Ding Y, White PF. Post-herniorrhaphy pain in outpatients after nonopioid analgesics will probably assume a greater pre-incision ilioinguinal-hypogastric nerve block during mon- role in the future. Although opioid-free anesthesia itored anesthesia care. Can J Anaesth 1995;42:12–5.
may not yet be feasible for major intracavitary surgical 11. Hinkle AJ. Percutaneous inguinal block for the outpatient man- agement of post-herniorrhaphy pain in children. Anesthesiol- procedures, it is becoming increasingly popular for superficial procedures in the ambulatory or office- 12. Broadman LM, Hannallah RS, Belman AB, et al. Post- based setting (103–105). In addition to the local circumcision analgesia: a prospective evaluation of subcutane- anesthetics, NSAIDs, acetaminophen, and ketamine, ous ring block of the penis. Anesthesiology 1987;67:399 – 402.
13. Baram D, Smith C, Stinson S. Intraoperative topical etidocaine nonopioid drugs such as adenosine, ␤-blockers, ␣2- for reducing postoperative pain after laparoscopic tubal liga- agonists, and steroids have also been shown to be tion. J Reprod Med 1990;35:407–10.
potentially useful adjuvants during or after surgery 14. Ritchie ED, Tong D, Chung F, et al. Suprascapular nerve block for postoperative pain relief in arthroscopic shoulder surgery: (82,106 –112). Use of analgesic drug combinations with a new modality? Anesth Analg 1997;84:1306 –12.
differing mechanisms of action may provide additive 15. Tierney E, Lewis G, Hurtig JB, et al. Femoral nerve block with or even synergistic effects with respect to improving bupivacaine 0.25 per cent for postoperative analgesia after pain control and facilitating the recovery process. Fi- open knee surgery. Can J Anaesth 1987;34:455– 8.
16. Brown AR, Weiss R, Greenberg C, et al. Interscalene block for nally, safer, simpler, and less costly analgesic drug shoulder arthroscopy: comparison with general anesthesia. Ar- delivery systems are needed to provide for more cost- effective pain relief in the postdischarge period after 17. Casati A, Cappelleri G, Fanelli G, et al. Regional anaesthesia for outpatient knee arthroscopy: a randomized clinical compari-son of two different anaesthetic techniques. Acta Anaesthesiol In conclusion, “stress-free” anesthesia with minimal postoperative discomfort should be achievable for the 18. Woolf CJ, Chong MS. Preemptive analgesia: treating postop- majority of outpatients undergoing ambulatory surgi- erative pain by preventing the establishment of central sensi- cal procedures, with the appropriate use of multimo- tization. Anesth Analg 1993;77:362–79.
19. Ejlersen E, Andersen HB, Eliasen K, Mogensen T. A compari- dal analgesic techniques. The aim of the analgesic son between preincisional and postincisional lidocaine infiltra- technique should be not only to lower the pain scores, tion and postoperative pain. Anesth Analg 1992;74:495– 8.
but more importantly to facilitate earlier mobilization 20. Møiniche S, Kehlet H, Dahl JB. A qualitative and quantitative and rehabilitation by reducing complications after dis- systematic review of pre-emptive analgesia for postoperativepain relief: the role of timing of analgesia. Anesthesiology, In charge home. Recent evidence suggests that clinicians can more effectively prevent postoperative pain and 21. Tverskoy M, Cozacov C, Ayache M, et al. Postoperative pain improve the recovery profile after ambulatory surgery after inguinal herniorrhaphy with different types of anesthesia.
Anesth Analg 1990;70:29 –35.
by using a combination of preemptive multimodal 22. Jebeles J, Reilly J, Gutierrez J, et al. The effect of pre-incisional techniques involving both centrally and peripherally infiltration of tonsils with bupivacaine on the pain following acting analgesic drugs, as well as nonpharmacologic tonsillectomy under general anesthesia. Pain 1991;47:305– 8.
23. Ding Y, White PF. Post-herniorrhaphy pain in outpatients after pre-incision ilioinguinal-hypogastric nerve block during mon-itored anaesthesia care. Can J Anaesth 1995;42:12–5.
24. Sinclair R, Cassuto J, Hogstrom S, et al. Topical anesthesia with lidocaine aerosol in the control of postoperative pain. Anesthe-siology 1988;68:895–901.
1. Armitage EN. Postoperative pain-prevention or relief [editori- 25. Casey WF, Rice LJ, Hannallah RS, et al. A comparison between al]. Br J Anaesth 1989;63:136 – 8.
bupivacaine instillation versus ilioinguinal/iliohypogastric 2. Chung F, Ritchie E, Su J. Postoperative pain in ambulatory nerve block for postoperative analgesia following inguinal her- surgery. Anesth Analg 1997;85:808 –16.
niorrhaphy in children. Anesthesiology 1990;72:637–9.
3. White PF. Ambulatory anesthesia advances into the new mil- 26. Tree-Trakarn T, Pirayavaraporn S, Lertakyamee J. Topical an- lennium. Anesth Analg 2000;90:1234 –5.
algesia for relief of post-circumcision pain. Anesthesiology 4. Guignard B, Bossard AE, Coste C, et al. Acute opioid tolerance: intraoperative remifentanil increases postoperative pain and 27. Narchi P, Benhamou D, Fernandez H. Intraperitoneal local morphine requirement. Anesthesiology 2000;93:409 –17.
anaesthetic for shoulder pain after day-case laparoscopy. Lan- 5. Eriksson H, Tenhunen A, Korttila K. Balanced analgesia im- proves recovery and outcome after outpatient tubal ligation.
28. Saff GN, Marks RA, Kuroda M, et al. Analgesic effect of bu- Acta Anaesthesiol Scand 1996;40:151–5.
pivacaine on extraperitoneal laparoscopic hernia repair.
6. Michaloliakou C, Chung F, Sharma S. Preoperative multimo- dal analgesia facilitates recovery after ambulatory laparoscopic 29. Dahl MR, Dasta JF, Zuelzer W, McSweeney TD. Lidocaine local cholecystectomy. Anesth Analg 1996;82:44 –51.
anesthesia for arthroscopic knee surgery. Anesth Analg 1990; 7. Vloka JD, Hadzic A, Mulcare R, et al. Femoral and genitofem- oral nerve blocks versus spinal anesthesia for outpatients un- 30. Smith I, Van Hemelrijck J, White PF, Shively R. Effects of local dergoing long saphenous vein stripping surgery. Anesth anesthesia on recovery after outpatient arthroscopy. Anesth 8. Song D, Greilich NB, White PF, et al. Recovery profiles and 31. Smith I, Shively RA, White PF. Effects of ketorolac and bupiv- costs of anesthesia for outpatient unilateral inguinal hernior- acaine on recovery after outpatient arthroscopy. Anesth Analg rhaphy. Anesth Analg 2000;91:876 – 81.
NON-OPIOID ANALGESICS AND POSTOPERATIVE PAIN 32. Stein C, Comisel K, Haimerl E, et al. Analgesic effect of intra- 52. O’Hara DA, Fragen RJ, Kinzer M, et al. Ketorolac articular morphine after arthroscopic knee surgery. N Engl tromethamine as compared with morphine sulfate for the treatment of postoperative pain. Clin Pharmacol Ther 1987;41: 33. Reuben S, Connelly NR. Postoperative analgesia for outpatient arthroscopic knee surgery with intraarticular bupivacaine and 53. Powell H, Smallman JMB, Morgan M. Comparison of intra- ketorolac. Anesth Analg 1995;80:1154 –7.
muscular ketorolac and morphine in pain control after lapa- 34. Wang JJ, Ho ST, Lee SC, et al. Intraarticular triamcinolone rotomy. Anaesthesia 1990;45:538 – 42.
acetonide for pain control after arthroscopic knee surgery.
54. Murray AW, Brockway MS, Kenny GNC. Comparison of the cardiorespiratory effects of ketorolac and alfentanil during 35. Reuben SS, Connelly NR. Postoperative analgesia for outpa- propofol anaesthesia. Br J Anaesth 1989;63:601–3.
tient arthroscopic knee surgery with intraarticular clonidine.
55. Ding Y, White PF. Comparative effects of ketorolac, dezocine, and fentanyl as adjuvants during outpatient anesthesia.
36. Khoury GF, Chen ACN, Garland DE, Stein C. Intraarticular 56. Wong HY, Carpenter RL, Kopacz DJ, et al. A randomized morphine, bupivacaine, and morphine/bupivacaine for pain double-blind evaluation of ketorolac tromethamine for postop- control after knee videoarthroscopy. Anesthesiology 1992;77: erative analgesia in ambulatory surgery patients. Anesthesiol- 37. Reuben SS, Sklar J, El-Mansouri M. The preemptive analgesic 57. Coloma M, White PF, Huber PJ, et al. The effect of ketorolac on effect of intraarticular bupivacaine morphine after ambulatory recovery after anorectal surgery: IV versus local administra- arthroscopic knee surgery. Anesth Analg 2001;92:923– 6.
tion. Anesth Analg 2000;90:1107–10.
38. Thomas DFM, Lambert WG, Williams KL. The direct perfusion 58. Ding Y, Fredman B, White PF. Use of ketorolac and fentanyl of surgical wounds with local anaesthetic solution: an ap- during outpatient gynecological surgery. Anesth Analg 1993; proach to postoperative pain? Ann R Coll Surg Engl 1983;65: 59. Liu J, Ding Y, White PF, et al. Effects of ketorolac on postop- 39. Gibbs P, Purushotam A, Auld C, Cuschieri RJ. Continuous erative analgesia and ventilatory function after laparoscopic wound perfusion with bupivacaine for postoperative wound cholecystectomy. Anesth Analg 1993;76:1061– 6.
60. Ramirez-Ruiz M, Smith I, White PF. Use of analgesics during 40. Levack ID, Holmes JD, Robertson GS. Abdominal wound per- propofol sedation: a comparison of ketorolac, dezocine, and fusion for the relief of postoperative pain. Br J Anaesth 1986; fentanyl. J Clin Anesth 1995;7:481–5.
61. Fredman B, Jedeikin R, Olsfanger D, Aronheim M. The opioid- 41. Rawal N, Axelsson K, Hylander J, et al. Postoperative patient- sparing effect of diclofenac sodium in outpatient extracorpo- controlled local anesthetic administration at home. Anesth real shock wave lithotripsy (ESWL). J Clin Anesth 1993;5: 42. Fredman B, Zohar E, Tarabykin A, et al. Bupivacaine wound 62. McLoughlin C, McKinney MS, Fee JPH, Boules Z. Diclofenac instillation via an electronic patient-controlled analgesia device for day-care arthroscopy surgery: comparison with standardopioid therapy. Br J Anaesth 1990;65:620 –3.
and a double-catheter system does not decrease postoperative 63. Gillberg LE, Harsten AS, Stahl LB. Preoperative diclofenac pain or opioid requirements after major abdominal surgery.
sodium reduces post-laparoscopy pain. Can J Anaesth 1993;40: 43. Cameron AEP, Cross FW. Pain and morbility after inguinal 64. Baer GA, Rorarius MGF, Kolehmainen S, Seliu S. The effect of herniorrhaphy: ineffectiveness of subcutaneous bupivacaine.
paracetamol or diclofenac administered before operation on postoperative pain and behaviour after adenoidectomy in 44. Yndgaard S, Holst P, Bjerre-Jepsen K, et al. Subcutaneously small children. Anaesthesia 1992;47:1078 – 80.
versus subfascially administered lidocaine in pain treatment 65. Watcha MF, Ramirez-Ruiz M, White PF, et al. Perioperative after inguinal herniotomy. Anesth Analg 1994;79:324 –7.
effects of oral ketorolac and acetaminophen in children under- 45. Kehlet H, Dahl JB. The value of “multimodal” or “balanced going bilateral myringotomy. Can J Anaesth 1992;39:649 –54.
analgesia” in postoperative pain treatment. Anesth Analg 66. Splinter WM, Reid CW, Roberts DJ, Bass J. Reducing pain after inguinal hernia repair in children: caudal anesthesia versus 46. Klein SM, Greengrass RA, Steele SM, et al. A comparison of ketorolac tromethamine. Anesthesiology 1997;87:542– 6.
0.5% bupivacaine, 0.5% ropivacaine, and 0.75% ropivacaine for 67. Watcha MF, Jones MB, Lagueruela RG, et al. Comparison of interscalene brachial plexus block. Anesth Analg 1998;87: ketorolac and morphine as adjuvants during pediatric surgery.
47. Mulroy MF, Larkin KL, Batra MS, et al. Femoral nerve block 68. Maunuksela EL, Kokki H, Bullingham RES. Comparison of IV with 0.25% or 0.5% bupivacaine improves postoperative anal- ketorolac with morphine for postoperative pain in children.
gesia following outpatient arthroscopic anterior cruciate liga- Clin Pharmacol Ther 1992;52:436 – 43.
ment repair. Reg Anesth Pain Med 2001;26:24 –9.
69. Comfort VK, Code WE, Rooney ME, Yip RW. Naproxen pre- 48. Casati A, Magistris L, Fanelli G, et al. Small-dose clonidine medication reduces postoperative tubal ligation pain. Can J prolongs postoperative analgesia after sciatic-femoral nerve block with 0.75% ropivacaine for foot surgery. Anesth Analg 70. Rosenblum M, Weller RS, Conard PL, et al. Ibuprofen provides longer lasting analgesia than fentanyl after laparoscopic sur- 49. Klein SM, Grant SA, Greengrass RA, et al. Interscalene brachial 71. Raeder JC, Steine S, Vatsgar TT. Oral ibuprofen versus parac- plexus block with a continuous catheter system and a dispos- etamol plus codeine for analgesia after ambulatory surgery.
able infusion pump. Anesth Analg 2000;91:1473– 8.
50. Klein SM, Greengrass RA, Grant SA, et al. Ambulatory surgery 72. Reuben SS, Connelly NR. Postoperative analgesic effects of for multi-ligament knee reconstruction with continuous dual celecoxib or rofecoxib after spinal fusion surgery. Anesth catheter peripheral nerve blockade. Can J Anaesth 2001;48: 73. White PF, Klein KW, Issioui T, Coloma M. A prospective, 51. Yee JP, Koshiver JE, Allbon C, et al. Comparison of intramus- randomized, double-blinded, placebo-controlled trial to eval- cular ketorolac tromethamine and morphine sulphate for an- uate the analgesic efficacy and safety of a single oral dose of algesia of pain after major surgery. Pharmacotherapy 1986;6: acetaminophen and celecoxib for postoperative pain relief in outpatients undergoing ENT surgery [abstract]. Anesth Analg NON-OPIOID ANALGESICS AND POSTOPERATIVE PAIN 94. Jensen JE, Conn RR, Hazelrigg G, Hewett JE. The use of trans- 74. Issioui T, Klein KW, White PF, et al. Analgesic efficacy of cutaneous neural stimulation and isokinetic testing in arthro- rofecoxib alone or in combination with acetaminophen in the scopic knee surgery. Am J Sports Med 1985;13:27–33.
ambulatory setting [abstract]. Anesthesiology 2001;94:A35.
95. Carroll D, Tramer M, McQuay H, et al. Randomization is 75. Desjardins PJ, Grossman EH, Kuss ME, et al. The injectable important in studies with pain outcomes: systematic review of cyclooxygenase-2-specific inhibitor parecoxib sodium has an- transcutaneous electrical nerve stimulation in acute postoper- algesic efficacy when administered preoperatively. Anesth ative pain. Br J Anaesth 1996;77:798 – 803.
96. Wang B, Tang J, White PF, et al. Effect of the intensity of 76. Tang J, Chen X, White PF, et al. Abstract effect of parecoxib, a transcutaneous acupoint electrical stimulation on the postop- new cyclooxygenase-2 inhibitor on the postoperative analgesia erative analgesic requirement. Anesth Analg 1997;85:406 –13.
requirement. Anesth Analg 2001;92:S270.
97. Chen L, Tang J, White PF, et al. The effect of the location of 77. Rusy LM, Houck CS, Sullivan LJ, et al. A double-blind evalu- transcutaneous electrical nerve stimulation on postoperative ation of ketorolac tromethamine versus acetaminophen in pe-diatric tonsillectomy: analgesia and bleeding. Anesth Analg opioid analgesic requirement: acupoint versus nonacupoint stimulation. Anesth Analg 1998;87:1129 –34.
78. Korpela R, Korvenoja P, Meretoja OA. Morphine-sparing effect 98. Hamza MA, White PF, Ahmed HE, Ghoname EA. Effect of the of acetaminophen in pediatric day-case surgery. Anesthesiol- frequency of transcutaneous electrical nerve stimulation on the postoperative opioid analgesic requirement and recovery pro- 79. Birmingham PK, Tobin MJ, Fisher DM, et al. Initial and sub- file. Anesthesiology 1999;91:1232– 8.
sequent dosing of rectal acetaminophen in children: a 24-hour 99. Tovar EA, Roethe RA, Weissig MD, et al. One-day admission pharmacokinetic study of new dose recommendations. Anes- for lung lobectomy: an incidental result of a clinical pathway.
80. Varrassi G, Marinangeli F, Agro F, et al. A double-blinded 100. Hashish I, Hai HK, Harvey W, et al. Reduction of postopera- evaluation of propacetamol versus ketorolac in combination tive pain and swelling by ultrasound treatment: a placebo with patient-controlled analgesia morphine: analgesic efficacy and tolerability after gynecologic surgery. Anesth Analg 1999; 101. Gam AN, Thorsen H, Lonnberg F. The effect of low-level laser therapy on musculoskeletal pain: a meta-analysis. Pain 1993; 81. Zhou TJ, Tang J, White PF. Propacetamol versus ketorolac for treatment of acute postoperative pain after total hip or knee 102. Macario A, Weinger M, Carney S, Kim A. Which clinical an- replacement. Anesth Analg 2001;92:1569 –75.
esthesia outcomes are important to avoid? The perspective of 82. Coloma M, Chiu JW, White PF, Armbruster SC. The use of patients. Anesth Analg 1999;89:652– 8.
esmolol as an alternative to remifentanil during desflurane 103. Tang J, Chen L, White PF, et al. Use of propofol for office-based anesthesia for fast-track outpatient gynecologic laparoscopic anesthesia: effect of nitrous oxide on recovery profile. J Clin surgery. Anesth Analg 2001;92:352–7.
83. White PF, Way WL, Trevor AJ. Ketamine: its pharmacology and therapeutic uses. Anesthesiology 1982;56:119 –36.
104. Tang J, Chen L, White PF, et al. Recovery profile, costs, and 84. Kohrs R, Durieux ME. Ketamine: teaching an old drug new patient satisfaction with propofol and sevoflurane for fast- tricks. Anesth Analg 1998;87:1186 –93.
track office-based anesthesia. Anesthesiology 1999;91:253– 61.
85. Badrinath S, Avramov MN, Shadrick M, et al. The use of 105. Tang J, White PF, Wender RH, et al. Fast-track office-based ketamine-propofol combination during monitored anesthesia anesthesia: a comparison of propofol versus desflurane with care. Anesth Analg 2000;90:858 – 62.
antiemetic prophylaxis in spontaneously breathing patients.
86. Mortero RF, Clark LD, Tolan MM, et al. The effects of small- dose ketamine on propofol sedation: respiration, postoperative 106. Za´rate E, Sa´ Reˆgo M, White PF, et al. Comparison of adenosine mood, perception, cognition, and pain. Anesth Analg 2001;92: and remifentanil infusions as adjuvants to desflurane anesthe- sia. Anesthesiology 1999;90:956 – 63.
87. Blakeley KR, Klein KW, White PF, et al. A total IV anesthetic 107. Smith I, Van Hemelrijck J, White PF. Efficacy of esmolol versus technique for outpatient facial laser resurfacing. Anesth Analg alfentanil as a supplement to propofol-nitrous oxide anesthe- sia. Anesth Analg 1991;73:540 – 6.
88. Suzuki M, Tsueda K, Lansing PS, et al. Small-dose ketamine 108. Segal IS, Jarvis DJ, Duncan SR, et al. Clinical efficacy of oral- enhances morphine-induced analgesia after outpatient sur- transdermal clonidine combinations during the perioperative gery. Anesth Analg 1999;89:98 –103.
period. Anesthesiology 1991;74:220 –5.
89. Menigaux C, Fletcher D, Dupont X, et al. The benefits of 109. Singelyn FJ, Gouverneur JM, Robert A. A minimum dose of intraoperative small-dose ketamine on postoperative pain after clonidine added to mepivacaine prolongs the duration of an- anterior cruciate ligament repair. Anesth Analg 2000;90: esthesia and analgesia after axillary brachial plexus block.
90. Adam F, Libier M, Oszustowicz T, et al. Preoperative small- 110. Campagni MA, Howie MB, White PF, McSweeney TD. Com- dose ketamine has no preemptive analgesic effect in patientsundergoing total mastectomy. Anesth Analg 1999;89:444 –7.
parative effects of oral clonidine and IV esmolol in attenuating 91. Dahl V, Ernoe PE, Steen T, et al. Does ketamine have preemp- the hemodynamic response to epinephrine injection. J Clin tive effects in women undergoing abdominal hysterectomy procedures? Anesth Analg 2000;90:1419 –22.
111. Aasboe V, Raeder JC, Groegaard B. Betamethasone reduces 92. White PF, Li S, Chiu JW. Electroanalgesia: its role in acute and postoperative pain and nausea after ambulatory surgery.
chronic pain management. Anesth Analg 2001;92:505–13.
93. Tyler E, Caldwell C, Ghia JN. Transcutaneous electrical nerve 112. Coloma M, Duffy LL, White PF, et al. Dexamethasone facili- stimulation: an alternative approach to the management of tates discharge after outpatient anorectal surgery. Anesth postoperative pain. Anesth Analg 1982;61:449 –56.

Source: http://anesthesia-education.com/pearls/pain.pdf