Acute Pain Service and multimodal therapy for postsurgical pain control: evaluation of protocol efficacy.

AIM: The institution of a postoperative Acute Pain Control Service is mandatory to improve the control of pain induced by surgical injury. Treatment of postoperative pain may be achieved using a combination of analgesic agents and techniques, reducing the incidence of side effects owing to the lower doses of the individual drugs. In 1997 we established an Acute Pain Service (APS) at the San Raffaele Hospital in Milan. The aim of this study was to assess the efficacy and safety of our APS both in terms of treatment protocols and organisational issues. METHODS: In this prospective observational study we included 592 patients undergoing abdominal, gynecological, or orthopedic surgery with severe expected pain. According to general guidelines on pain treatment, the patients were assigned to different treatment protocols based on the kind of operation. All protocols were based on the multimodal therapy, with the association of nonsteroidal anti-inflammatory drugs (NSAIDS), opioids and regional anesthesia techniques. During the first 48 h of the postoperative period we recorded vital signs, level of pain and occurrence of any side effect. RESULTS: Our analgesic protocols proved to be effective and safe (low incidence of side effects) for every surgery. The incidence of postoperative nausea and vomiting was higher in patients receiving patient-controlled morphine than that with continuous epidural or nerve block. After lower abdominal surgery, pain at movement at 24 h was significantly lower in the epidural group than in the Patient Control Analgesia group. Nausea and vomiting, numbness and paresthesias at the lower limbs were higher in gynecological patients. A larger percentage of orthopedic patients in the epidural group reported numbness and paresthesias at the lower limbs in comparison with patients receiving continuous peripheral nerve block. CONCLUSION: In agreement with previous literature, this study confirmed that a multimodal approach to pain treatment provides an adequate control of postoperative pain, minimizing side effects.

[Systemic analgesia after peripheral block]. / Analgesia sistemica dopo il blocco periferico.

Over the past few years, increasing emphasis has been placed on the need to improve the management of acute pain. Despite a growing trend in acute pain management, many difficulties are still present for the treatment of postoperative pain. Loco-regional techniques together with an effective pain management should accelerate rehabilitation, decrease risk of postoperative complications and speed return to normal activities. A multimodal approach should be used for a reduction of pharmacological side effects, improving pain reduction. The association between NSAIDs and opioids permits reduction of full dose opioids with better pain relief and less side effects. If NSAIDs are contraindicated, acetaminophen is an alternative, though considered by someone to be an NSAID It's action is believed to result from inhibition of prostaglandin synthesis within the central nervous system. It doesn't cause gastrointestinal ulceration or bleeding, but we have to note that large amounts may lead to hepatic necrosis. Newer NSAIDs (COX-2 inhibitors), affect mainly COX-2, and appear to be associated with less adverse effect. Rofecoxib showed a reduction of morphine consuming after spinal fusion and has been admitted by FDA for the treatment of post operative pain. Newer methods of pain relief, as patient controlled analgesia (PCA), can provide excellent and safe pain relief. When high-tech options such as PCA are used, patients need a management by an anesthesiologist-based acute pain service (APS), allowing a better pain relief with less side effects compared to patients supervised by less experienced medical staff.

Cervical plexus anesthesia for carotid endarterectomy: comparison of ropivacaine and mepivacaine.

PURPOSE: To evaluate the effectiveness of cervical plexus block performed with ropivacaine 0.75% or 1%, or mepivacaine 2%. METHODS: In a prospective, randomized, double-blind study, 60 patients received deep cervical plexus block with 0.2 ml x kg(-1) divided among C2-C4 injections using ropivacaine 0.75% and 1% or mepivacaine 2%. A blinded observer recorded loss of pin-prick sensation every minute in the C2-C4 dermatomes until readiness for surgery. Then, a superficial cervical block was performed with 0.15 ml x kg(-1) lidocaine 1%. The need for intraoperative supplemental analgesia and degree of pain and time of first postoperative pain medication were also recorded. RESULTS: General anesthesia was not required to complete surgery in any case. No differences in the need for intraoperative supplemental analgesia was observed (7, 6, and 9 patients with ropivacaine 0.75% and 1% or mepivacaine 2%, respectively). Readiness to surgery required 15 (10-25) min with ropivacaine 0.75%, 18 (8-20) min with ropivacaine 1%, and 15 (5-20) min with mepivacaine 2% (P = NS); while patients asked for first postoperative pain medication after 10 (4-13) hr and 9 (6.5 - 11) hr with ropivacaine 0.75% and 1% compared with 5 (0-8) hr with mepivacaine 2% (P<0.05). CONCLUSION: Ropivacaine 0.75% or 1% are appropriate choices when performing cervical plexus anesthesia for carotid endarterectomy, providing nerve block characteristics similar to those of mepivacaine 2%, but with the advantage of longer postoperative pain relief.