Section 2: Pain Management
Recent Advances in Multimodal Analgesia

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Acetaminophen

Oral acetaminophen has been used for several decades and believed to have a central role of action in analgesia because of its antipyretic properties and confers several mild analgesia antiinflammatory properties.3 Paracetamol, an intravenous (IV) formulation of acetaminophen, became available in 2002 and has been studied in Europe. Göröcs and colleagues4 administered a single dose of 1 g of IV paracetamol (Perfalgan) before the termination of surgery and observed high patient satisfaction and

NSAIDs

The use of NSAID in the perioperative period has been well established taking into consideration the adverse effects of bleeding. The utility of cyclooxygenase 2 inhibitors in this scenario has been demonstrated to be a benefit.1, 2 A randomized, double-blind, placebo-controlled study comparing celecoxib, 200 mg, with placebo in 37 patients undergoing major plastic surgery demonstrated the ability of celecoxib to reduce VAS and postoperative morphine consumption. More importantly, the treatment

Anticonvulsants

The use of adjunct agents to treat pain includes the use of anticonvulsants such as gabapentin and pregabalin. Clarke and colleagues22 studied the effects of varying doses of gabapentin given preoperatively and postoperatively in addition to femoral/sciatic nerve blocks and celecoxib in 36 patients undergoing total knee arthroplasty. When administered preoperatively and postoperatively, gabapentin decreased morphine consumption on postoperative days (PODs) 2 to 4 and increased the amount of

TRPV1 agonist: capsaicin

Capsaicin, the active component of chili peppers, selectively stimulates unmyelinated C fiber afferent neurons and causes the release of substance P. After initial depolarization, continued release of substance P in the presence of capsaicin leads to the depletion of substance P and subsequent decrease in C fiber activation. Capsaicin is a nonnarcotic that acts at TRPV1 receptor as an agonist peripherally. It does not affect the A delta and A alpha fibers. Capsaicin causes calcium-dependent

N-methyl-d-aspartate receptor antagonists

N-methyl-d-aspartate (NMDA) receptor antagonists, including ketamine and memantine, have been studied as adjuncts for acute and chronic pain management. Ketamine has options for routes of administration, including IV or IN. Remérand and colleagues33 demonstrated that an IV bolus at the beginning of surgery followed by a 24-hour infusion decreased morphine consumption in patients undergoing total hip arthroplasty. Also, in patients receiving ketamine, the incidence of chronic pain was decreased.

α2 Agonists

Use of α2 agonists as an analgesia adjunct has gained interest with clonidine and dexmedetomidine. Central and peripheral stimulation of the α2 receptors is believed to be the basic mechanism behind analgesia. The role of clonidine in neuraxial blockade has been described by several studies. Recently, Lena and colleagues38 compared a clonidine/morphine spinal plus remifentanil infusion with a sufentanil infusion for analgesia in 83 patients undergoing open heart surgery. The clonidine/morphine

Dual-acting agent: tapentadol

Tapentadol is a novel central-acting analgesic with duel mode of action.41 It has analgesic action via the μ opioid receptor and norepinephrine reuptake inhibition. Combining both effects in a single molecule eliminates the potential for drug-drug interactions inherent in multiple drug therapy. The analgesic effects of tapentadol are independent of metabolic activation with minimal metabolites. Having limited protein binding, no active metabolites, and no significant microsomal enzyme induction

Transdermal Fentanyl

The use of patient-controlled delivery has led to the development of other modalities that allow patient control in the delivery of opioid medications. Transdermal delivery systems, such as IONSYS, allow demand dosing of fentanyl at a predetermined interval. The fentanyl hydrochloride iontophoretic transdermal system (ITS) is a patient-controlled approach to analgesic delivery that may avoid some of the problems associated with IV PCA. Fentanyl ITS is a compact, needleless, self-contained

Summary

Acute postoperative pain is a predictable response. Recent research has demonstrated that untreated acute postoperative pain can lead to chronic persistent pain. It is imperative that the health care provider managing acute postoperative pain understand the various options such as multimodal analgesia so that acute pain can be treated and development of chronic pain from surgery prevented.

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      The factors that are associated with greater pain intensity are the type of approach and surgical procedure (Esteve et al., 2011), surgical specialty (higher in Traumatology and Gynecology) and sex (higher prevalence in women) (El-Aqoul et al., 2018; Moreno-Monsiváis et al., 2014), although this association has been related to the different proportion of men and women in these specialties (El-Aqoul et al., 2018); age (greater intensity in patients under 65) (Esteve et al., 2011; Navarro-García et al., 2011), educational levels and economic income (greater demand for, and consumption of, analgesics in higher incomes) and higher preoperative anxiety (greater pain intensity and higher consumption of analgesics) (Navarro-García et al., 2011). The prevention and control of APP is essential, not only to avoid unnecessary suffering, but to reduce postoperative morbidity, recovery time, hospital stay and associated costs (Kehlet & Wilmore, 2008; Young & Buvanendran, 2012). Therefore, an effective treatment of pain, in addition to reducing costs, improves the quality of care, reduces secondary complications and provides greater comfort.

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