Multimodal analgesia techniques and postoperative rehabilitation

The concept of multimodal analgesia involves the use of different classes of analgesics and different sites of analgesic administration to provide superior dynamic pain relief with reduced analgesic-related side effects. Although multimodal analgesia techniques have assumed increasing importance in the management of perioperative pain, it has become increasingly apparent that postoperative outcome may not be improved. Nevertheless, the integration of multimodal analgesia techniques with a multimodal and multidisciplinary rehabilitation program may enhance recovery, reduce hospital stay, and facilitate early convalescence.     

Patient-controlled interscalene analgesia versus patient-controlled intravenous analgesia in postoperative analgesia after upper extremity surgery

The effectiveness of patient-controlled interscalene analgesia (PCISA) and patient-controlled intravenous analgesia (PCIVA) in the management of postoperative pain in 36 patients was studied. The general anesthetic technique was standardized. After surgery, all patients received 2 mg intravenous morphine. The patients were then randomized to receive either PCISA or PCIVA. The PCISA group received an interscalene block with 20 ml of 1% lidocaine. A catheter was introduced within the interscalene sheath and 20 min after the initial block, patients received a continuous infusion of 0.125 bupivacaine at rate of 4 ml/h supplemented by a bolus dose of 3 ml with a 15-min lockout time. PCIVA was given as a 1 mg morphine bolus and a 7-min lockout time. Pain relief was regularly assessed using a visual analog scale. Side effects and patient satisfaction were noted. The study period ended 48 h after the operation. Pain relief was significantly better controlled in the PCISA group 6, 12, 24, and 30 h after the operation (P<0.05). At 36, 42, and 48 h, no significant difference in pain score between the two groups was observed. Patient satisfaction was greater in the PCISA group (P<0.05). Vomiting and pruritus were observed more frequently in the PCIVA group (P<0.05). No major complications occurred in any of the study patients. The use of the PCISA technique was uncomplicated and provided better pain relief than PCIVA in postoperative analgesia.     

Lower extremity blocks for analgesia

A large proportion of patients undergoing surgery do not receive adequate postoperative analgesia.[1] Postoperative pain is the leading cause of unplanned hospital admissions after ambulatory surgery and a major source of dissatisfaction with perioperative outcome. [2] The establishment of acute pain services in major institutions both in the United States and overseas has had a major effect on postoperative comfort and patient satisfaction. [3 and 4] Most acute pain services primarily use intravenous patient-controlled analgesia (PCA) or patient-controlled epidural infusion; however, advances in neuronal blockade offer an unprecedented range of effective and surgery site–specific analgesic options. Using long-acting local anesthetics, peripheral nerve blocks can be used to provide an excellent anesthesia and postoperative analgesia. Additionally, a catheter for continuous infusion of local anesthetics can be inserted perineurally to extend the analgesia beyond the duration of the single-shot blocks. This review will discuss the advantages and limitations of various nerve block techniques when used for postoperative pain management for several common surgical indications. Copyright 2002, Elsevier Science (USA). All rights reserved.     

Upper extremity replantation

The most important determinants of the functional ability of an amputated part are proper patient selection and the recognition of vascular compromise. Ideally, a well-performed anastomosis should need no pharmacologic assistance, but the ideal is often the exception. The authors present an empirical approach to use of anticoagulation medication.     

Epidural analgesia for postoperative pain

Epidural analgesia provides superior analgesia compared with other postoperative analgesic techniques. Additionally, perioperative epidural analgesia confers physiologic benefits, which may potentially decrease perioperative complications and improve postoperative outcome. However, there are many variables (eg, choice of analgesics, catheter-incision congruency, and duration of analgesia) that may influence the efficacy of epidural analgesia. In addition, the use of epidural analgesia should be evaluated on an individual basis because there are risks associated with this technique.     

Ropivacaine for postoperative epidural analgesia

Ropivacaine is a long-acting local anesthetic that has lower toxicity than bupivacaine and causes less motor block when given via the epidural route in low concentrations. This makes it a potentially useful drug for postoperative epidural analgesia. Studies with epidural infusions of plain ropivacaine for 24 to 72 hours have shown that a large proportion of patients (up to 50%) required supplemental analgesics or were withdrawn from the study because of inadequate analgesia. This is not surprising and is consistent with earlier experience with bupivacaine because clinical experience shows more rapid segmental regression with ropivacaine than bupivacaine; however, when combined with fentanyl (2 to 4 μg/mL), ropivacaine 0.2% provides a similar quality of analgesia to bupivacaine (0.1% to 0.2%) with fentanyl (2 to 4 μg/mL), although there are few direct comparisons. The use of patient-controlled epidural analgesia with ropivacaine also is effective provided it is combined with an opioid. Initial studies with levobupivacaine show a similar need for admixture with adjuvants (eg, fentanyl) for effective postoperative analgesia. The incidence of motor block in the lower limbs is low with thoracic epidural infusions, and no difference has been consistently shown between ropivacaine and bupivacaine. There is evidence, however, that with lumbar epidural infusions, less motor block occurs in patients receiving ropivacaine than similar concentrations of bupivacaine. Acute toxicity is highly unusual in the postoperative setting. Both ropivacaine and bupivacaine show no significant increase in free plasma levels during prolonged (up to 72 hours) epidural infusion. There is a theoretical advantage of ropivacaine, and possibly levobupivacaine, in the circumstance of massive epidural overdose because of more rapid block regression than bupivacaine and less systemic toxicity. Copyright © 2001 by W.B. Saunders Company     

Epidural ketamine for postoperative analgesia

Thirty-four patients of ASA physical status I or II scheduled for gall bladder surgery were studied in a comparative prospective trial to evaluate the efficacy of epidural and intramuscular ketamine for postoperative pain relief. They were divided randomly into three groups. Group I (11 patients) received 30 mg intramuscular ketamine. Group II (10 patients) and Group III (13 patients) received 10 and 30 mg ketamine in 10 ml saline respectively, through epidural catheters. Pain was evaluated every two hours for the first 24 hours post-operatively by using a linear analogue pain scale from 0-10. Ketamine was given on the patient's request and whenever the pain score exceeded three. Ketamine produced analgesia in all patients studied. The reduction of pain score after two and four hours in Group I and III was significant when compared to Group II. Seven patients (54 per cent) in Group III did not require further analgesia after the initial injection. However, following 10 mg epidural ketamine or 30 mg IM ketamine, post-operative pain was more frequent. Four patients who received epidural ketamine complained of transient burning pain in the back during injection. No patient developed respiratory depression, psychic disturbance, cardiovascular instability, bladder dysfunction or neurologic deficit. It is concluded that 30 mg epidural ketamine is a safe and effective method for postoperative analgesia.