Preemptive analgesia or balanced periemptive analgesia?

"Preemptive analgesia" means that analgesia given before the painful stimulus prevents or reduces subsequent pain. The concept of preemptive analgesia originates from basic science and experimental studies. However, in some clinical studies preemptive effect is not always present. The authors think that it happens for: differences among experimental models and clinical reality, wrong use of some pharmacological knowledges, some methodological errors in clinical research. The authors analyze these factors and review in a critical manner clinical studies on preemptive analgesia. In some operations, only one administration of an analgesic drug, before surgery, is not sufficient to produce an evident preemptive effect. Postoperative pain can be reduced making a pharmacological treatment before surgery, for the whole time of painful stimulus. For this reason, the term "preemptive analgesia", like "analgesia given before surgery" is not adequate. The authors suggest that the concept of prevention of postoperative pain is well defined by the term of "balanced periemptive analgesia"; it is a new approach that use many modalities of analgesia in different times to prevent and control painful stimulus for the whole time of its origin: before and/or during operation and, if necessary, in the postoperative period for the residual pain.     

Is single-shot epidural analgesia more effective than morphine patient-controlled analgesia for donor nephrectomy?

Objective

We compared single-shot epidural analgesia (20 mL 0.125% levobupivacaine and 3 mg diamorphine) followed by regular tramadol versus morphine patient-controlled analgesia (PCA) for postoperative pain following donor nephrectomy.

Methods

We retrospectively evaluated 12 patients who received single-shot epidural analgesia (SSE group) before anesthesia induction, followed by regular tramadol, and 14 patients who received morphine PCA (PCA group) for postoperative pain after donor nephrectomy. Postoperative pain scores were recorded at 0, 1, 12, 24, and 48 hours after nephrectomy. We also collected data regarding morphine consumption, additional analgesia, nausea, antiemetic use, time to oral intake, mobilization, and discharge.

Results

The 2 groups were similar for age, gender, body mass index, American Society of Anesthesiologists status, duration of surgery, laparoscopic/open nephrectomy ratio, and intra- and postoperative additional analgesia. There were no significant between-group differences in pain and nausea scores. The SSE group showed lower intra- and postoperative antiemetic use than the PCA group (25% vs 78.5% and 1 dose vs 2.5 doses, respectively; P < .05). The average time to oral fluid and solid food intake and for assisted mobilization were similar in the 2 groups. However, independent mobilization and hospital discharge were significantly sooner in the SSE group (34 hours vs. 47.4 hours; [P < .05] and 3.7 days vs 4.7 days [P < .05], respectively).

Conclusions

In this small pilot study, SSE with 20 mL 0.125% levobupivacaine and 3 mg diamorphine, followed by regular tramadol, provided postoperative analgesia similar to morphine PCA. However, patients in the SSE group used less antiemetic medication, were independently mobile earlier, and were discharged from the hospital earlier than patients in the PCA group.     

Acute transverse myelitis after thoracic epidural anesthesia and analgesia: Should anesthesia and analgesia be blamed?

A 63-year-old man developed acute transverse myelitis (ATM) with a rapid progression of sensory and motor deficits and autonomic dysfunction 2 days after chest surgery. Thoracic epidural anesthesia/analgesia (TEA) had been administered in this case. Since the temporal and spatial relationships between TEA and ATM are so close, one may easily mistake the TEA as the cause. Therefore, we discuss here the differential diagnoses for cord damage after TEA and the characteristics of ATM, and suggest that it is unlikely that TEA is the cause of ATM in this case.     

Pre-emptive analgesia with thoracic paravertebral blockade?

The concept of pre-emptive analgesia is based on the intuitiveidea that if pain is treated before the injury occurs, the nociceptivesystem will perceive less pain than if analgesia is given afterthe injury has already occurred. Pre-emptive analgesia wouldapply well to the situation of elective surgery, since in thissituation it is possible to control the series of events and,thus, it is possible to deliver effective analgesia before thestart of surgery. Animal and human volunteer studies have verified the conceptof pre-emptive analgesia. However, despite the use of     

Single dose spinal analgesia: Is it a good alternative to epidural analgesia in controlling labour pain?

ObjectivesRegional anaesthesia is considered the optimal technique for obstetric patients; nevertheless, the optimal method of regional anaesthesia for delivery remains to be determined. In our study we investigate the safety, efficacy and cost benefits of single-dose spinal analgesia in comparison with epidural analgesia during labour.Study designIn our study women in advanced labour were randomly allocated into two equal groups using a computer-generated randomization table, one group (spinal group = S group) were given 3.75 mg hyperbaric bupivacaine +25 μg fentanyl with 0.75 ml saline, the other group (Epidural group = E group) were given 4 ml bupivacaine with 4 ml saline and 1 ml (50 μg) fentanyl pain intensity was recorded by the parturient on a visual analogue scale. The quality of pain relief was also rated with a verbal score directly after delivery. Side effects, such as hypotension, Pruritus, sedation, nausea and motor block were noted. Obstetric parameters were followed and recorded, Apgar score were noted, and all the results were compared in the two groups.ResultsOnset of sensory block (detected by pin-prick test) was early (4.4 ± 1.5 min vs 12.5 ± 2.3 min, p < 0.001) and duration of sensory block was longer (120.4 ± 15.6 vs 103.2 ± 18.3 min, p < 0.001) in S group compared to E group, time to reach maximum dermatome level of sensory block (T₁₀) was shorter in S than E group (8.3 ± 2.4 min vs 22.4 ± 5.7 min, p < 0.001), two segment regression occur late in S group compared to E group(75.6 ± 12.5 min vs 66.3 ± 9.4 min, p < 0.001). Visual analogue scores after 5, 15, 30, 60, 90, 120 and 150 min were lower in S group compared to E group, all the previous result is statically significant (p < 0.001). 88% of the parturients in S group vs 60% in E group scored the analgesic quality as excellent, the mean duration of analgesia (Mean ± SD) was longer in S group compared to E group. 8% of parturients in S group vs 14% of parturients in E group had hypotension. Motor block, sedation and nausea were 2–6% in both groups. Pruritus was seen in 60% in E group vs 25% in spinal one. No caesarean section was performed. Vacuum extraction was done in 15% vs 25% among S group and E group respectively. Oxytocin augmentation was needed in 48% vs 62% of the parturients among S group and E group respectively. Faetal heart rate disturbances following the spinal block were seen in 2 cases. Apgar score were high and no neonate had Apgar score <7 in both group. The overall cost was lower in S group compared to E group.ConclusionsBased on the results of our study we concluded that single dose spinal analgesia is a good alternative to epidural analgesia in controlling labour pain i.e. spinal compared to epidural is more easy performed, faster, less expensive, and provide effective analgesia.