Preventive analgesia for postoperative pain control: a broader concept
Local and Regional Anesthesia
Preventive analgesia for postoperative pain control: a broader concept
Sukanya Mitra 1 3
Alan David Kaye 3 5
Richard D Urman 3 4
0 Yale College , New Haven
1 Department of Anesthesia and intensive Care, Government Medical College and Hospital , Chandigarh, india
2 Department of Anesthesiology, Yale University School of Medicine , New Haven, CT , USA
3 erika Schermer
4 Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and w omen's Hospital , Boston, MA , USA
5 Department of Anesthesiology, Louisiana State University School of Medicine , New Orleans, LA , USA
6 School of Liberal Arts and Science, University of Connecticut , Storrs, CT , USA
: Pain from surgical procedures occurs as a consequence of tissue trauma and may result in physical, cognitive, and emotional discomfort. Almost a century ago, researchers first described a possible relationship between intraoperative tissue damage and an intensification of acute pain and long-term postoperative pain, now referred to as central sensitization. Nociceptor activation is mediated by chemicals that are released in response to cellular or tissue damage. Pre-emptive analgesia is an important concept in understanding treatment strategies for postoperative analgesia. Pre-emptive analgesia focuses on postoperative pain control and the prevention of central sensitization and chronic neuropathic pain by providing analgesia administered preoperatively but not after surgical incision. Additional research in pre-emptive analgesia is warranted to better determine good outcome measurements and a better appreciation with regard to treatment optimization. Preventive analgesia reduces postoperative pain and consumption of analgesics, and this appears to be the most effective means of decreasing postoperative pain. Preventive analgesia, which includes multimodal preoperative and postoperative analgesic therapies, results in decreased postoperative pain and less postoperative consumption of analgesics.
Nalini v adivelu1; preventive analgesia; central sensitization; chronic pain; pre-emptive analgesia
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Introduction
There has been much confusion and controversy regarding the terms pre-emptive
analgesia and preventive analgesia. While the aim of both is to decrease
postoperative pain while decreasing the consumption of analgesics after surgery and reduction
of long-term pain sensitization, this review attempts to clarify and differentiate these
two concepts. Recent understandings in pre-emptive analgesia have defined it as an
intervention given before incision or surgery, given that it is more effective than the
same treatment administered after incision or surgery.1,2 It is important to remember
the timing of pre-emptive analgesia in that it is an antinociceptive treatment given prior
to incision or surgery. This helps to prevent the development of altered processing of
afferent input, which would otherwise amplify postoperative pain.3 Almost a century
ago, Crile4 first described a possible relationship between intraoperative tissue damage
and an intensification of acute pain and long-term postoperative pain, which is now
referred to as central sensitization. He advocated a multimodal approach, including
drugs and use of regional blocks with local anesthetics, in addition to general anesthesia.
His rationale was to prevent intraoperative nociception with what we now call
preemptive analgesia; lack of such intervention can lead to changes in the central nervous
system during surgery and formation of painful scars. Wall
first proposed the concept of pre-emptive preoperative
analgesia in 1988.5 Pre-emptive analgesia given before incision
and surgery focuses on managing perioperative pain, as well
as conferring neuroprotective properties.6
The concept of pre-emptive analgesia is based on advances
and research in the basic science of pain and evidence-based
clinical research. It has now been refined and evolved to a
broader concept that surgical incision alone is not the trigger
for central sensitization.7 Other factors, such as preoperative
pain and additional painful noxious intraoperative inputs
such as retraction, as well as postoperative inflammatory
processes, related peripheral and central neuromodulators,
and ectopic neural activity8 can all cause an intensification
of acute pain and long-term postoperative pain as a result of
central sensitization. At present, there are several multimodal
strategies covering the perioperative period that can help
//www lsue more appropriate term because it encompasses all
periop:s an erative efforts to decrease postoperative pain and decrease
tthp rseo consumption of analgesics. Preventive analgesia could be
frodm ropF provided by a number of means, including no treatment at
ed all, placebo treatment, or multimodal treatment that can be
lona given to decrease postoperative pain and reduce analgesic
odw consumption. This treat (...truncated)