domingo, 19 de enero de 2014

Analgesia pre-emptiva/Pre-emptive analgesia

Analgesia pre-emptiva: Tendencias y evidencias recientes

Pre-emptive analgesia: Recent trends and evidences.
Mishra AK, Afzal M, Mookerjee SS, Bandyopadhyay KH, Paul A.
Indian J Pain [serial online] 2013 [cited 2014 Jan 7];27:114-20.
Preemptive analgesia, initiated before the surgical procedure to prevent pain in the early postoperative period has the potential to be more effective than a similar analgesic treatment initiated after surgery. This article aims to review all the recent published evidences that assess the efficacy of this enigmatic concept. Materials and Methods: We reviewed original research articles, case-reports, meta-analyses, randomized control trials (RCTs), and reviews based on pain physiology for preemptive analgesia from Medline, Medscape, and PubMed from 1993 to 2013. A broad free-text search in English was undertaken with major keywords "Preemptive analgesia," "postoperative pain," "preoperative," and "preincisional". Results: Review of publications showed that intravenous (IV) nonsteroidal anti-inflammatory drugs (NSAIDs) are quite effective when used alone, as well as with low dose iv ketamine, preemptively to provide adequate postoperative analgesia. However, ketamine has a doubtful role as a standalone agent. Preemptive administration of LA at the incision site reduces postoperative pain, but achieves an analgesic effect similar to that of postincisional anesthetic infiltration as does intraperitoneal administration. Preemptive epidural analgesia has proved its efficacy in controlling perioperative immune function and pain in comparison to parenteral opioids. Gamma-amino butyric acid (GABA) analogues like gabapentin and pregabalin have great potential as preemptive analgesic with the added advantage of its anxiolytic effect. Conclusion: Multimodal approaches that address multiple sites along the pain pathway is necessary to treat pain adequately. However, we need to find an answer to the question of how to obtain the maximal clinical benefits with the use of preemptive analgesia.
Keywords: Central sensitization, preemptive analgesia, postoperative pain, surgery

Uso pre-emptivo de ketamina en dolor operatorio de apendicectomía

Preemptive use of ketamine on post operative pain of appendectomy.
Behdad A, Hosseinpour M, Khorasani P.
Korean J Pain. 2011 Sep;24(3):137-40. doi: 10.3344/kjp.2011.24.3.137. Epub 2011 Sep 6.
BACKGROUND:Although early reviews of clinical findings were mostly negative, there is still a widespread belief for the efficacy of preemptiveanalgesia among clinicians. In this study, we evaluated whether the preemptive use of ketamine decreases post operative pain in patients undergoing appendectomy. METHODS:In double-blind, randomized clinical trials, 80 adult male patients undergoing an operation for acute appendicitis were studied. Patients were randomly assigned to two groups. In the operating room, patients in the ketamine group received 0.5 mg/kg of ketamine IV 10 minutes before the surgical incision. In the control group, 0.5 mg/kg of normal saline was injected. The pain intensity was assessed at time 0 (immediately after arousal) and 4, 12, and 24 hours postoperatively using the 10 points visual analogue scale (VAS). RESULTS: Eighty patients (40 for both groups) were enrolled in this study. For all of the evaluated times, the VAS score was significantly lower in the ketamine group compared to the control. The interval time for the first analgesic request was 23.1 ± 6.7 minutes for the case group and 18.1 ± 7.3 minutes for the control (P = 0.02). The total number of pethidine injections in the first 24 hours postoperatively was 0.6 ± 0.6 for the case group and 2.0 ± 0.8 for the controls (P = 0.032). There were no drug side effects for the case group. CONCLUSIONS: A low dose of intravenously administered ketamine had a preemptive effect in reducing pain after appendectomy.
KEYWORDS: appendectomy, ketamine, pre-emptive analgesia

Influencia de la analgesia pre-emptiva sobre la analgesia postoperatoria y su evaluación objetiva
The influence of pre-emptive analgesia on postoperative analgesia and its objective evaluation.
Fricova J, et al.
Arch Med Sci. 2010 Oct;6(5):764-71. doi: 10.5114/aoms.2010.17093. Epub 2010 Oct 26.
INTRODUCTION: The evaluation of pain intensity is still a subject of research. Mostly psychological evaluations are used. We started to conduct biochemical evaluation in animal experiments. Now we present biochemical evaluation in postoperative pain in man. MATERIAL AND METHODS: In 67 patients herniotomy was done. For pre-emptive analgesia morphine and pethidine were used and the following indicators were measured: visual analogue scale (VAS), measurement of lipid spectra, saccharides and proteins, thioredoxin, super-oxide dismutase (SOD), glutathione peroxidase (GPx) and NAD(P)H-oxidase (NOX), and free radicals using electron paramagnetic resonance (EPR). Blood samples were taken and tested: before pre-medication and intervention, 4 h after and 24 h after intervention. RESULTS: Free radicals (FR) increased in individual samples during the postoperative course in pethidine and without pre-medication. After application of morphine the FR were insignificantly reduced. Statistically significant differences were found in albumin, prealbumin, apolipoprotein A, total cholesterol, atherosclerotic index, CRP, glucose, and thioredoxin (p ≤ 0.001). A greater difference was seen in VAS values between morphine and pethidine premedications (p ≤ 0.001). CONCLUSIONS: It was proved that the biochemical markers of lipid, protein and saccharide metabolisms and free radicals as well as singlet oxygen can serve as very good indicators of the intensity of pain and nociception. In patients it was proved that pre-emptive analgesia plays an important role in reducing the intensity of postoperative pain. From the three modalities of pre-emptive analgesia morphine represents the best solution.
KEYWORDS: VAS, morphin, objective evaluation, pethidin, postoperative pain, pre-emptive analgesia

Anestesiología y Medicina del Dolor
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