Effect of postoperative analgesia on major postoperative complications: a systematic update of the evidence.
ABSTRACT Few individual clinical trials have had sufficient subject numbers to definitively determine the effects of postoperative analgesia on major outcomes.
We systematically searched the Medline and the Cochrane Library databases for the past decade and focused on meta-analyses and large, randomized, controlled trials.
Eighteen meta-analyses, 10 systematic reviews, 8 additional randomized, controlled trials, and 2 observational database articles were identified for review or comment. Epidural analgesia with local anesthetics has the greatest theoretical potential to affect major outcomes and has been the most thoroughly investigated technique. The majority of evidence favors an ability of epidural analgesia to reduce postoperative cardiovascular and pulmonary complications only after major vascular surgery or in high-risk patients. This finding may become irrelevant because of rapid conversion of major surgery to minimally invasive techniques (e.g., endoluminal abdominal aortic repair) that carry less risk of complications. There is also consistent evidence that epidural analgesia with local anesthetics is associated with faster resolution of postoperative ileus after major abdominal surgery. Again, this finding may also become irrelevant with the adoption of laparoscopic techniques and multimodal fast-track programs for abdominal surgery. There is no current evidence that perineural analgesia, continuous wound catheters using local anesthetics, IV patient-controlled analgesia with opioids, or addition of multimodal systemic analgesics have any clinically significant beneficial effect on postoperative complications.
Overall, there is insufficient evidence to confirm or deny the ability of postoperative analgesic techniques to affect major postoperative mortality or morbidity. This is primarily due to typically insufficient subject numbers to detect differences in currently low incidences of postoperative complications.
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ABSTRACT: Nearly 60% of the Dutch population undergoing surgery is aged 65years and over. Older patients are at increased risk of developing perioperative complications (e.g., myocardial infarction, pneumonia, or delirium), which may lead to a prolonged hospital stay or death. Preoperative risk stratification calculates a patient’s risk by evaluating the presence and extent of frailty, pathophysiological risk factors, type of surgery, and the results of (additional) testing. Type of anesthesia, fluid management, and pain management affect outcome of surgery. Recent developments focus on multimodal perioperative care of the older patient, using minimally invasive surgery, postoperative anesthesiology rounds, and early geriatric consultation. Fast 60% der niederländischen Bevölkerung, die sich einer Operation unterziehen, sind 65Jahre und älter. Diese Patienten haben ein erhöhtes Risiko, perioperative Komplikationen zu entwickeln (z.B. Myokardinfarkt, Pneumonie oder Delirium), die zu einem verlängerten Krakenhausaufenthalt oder Tod führen können. Im Rahmen einer präoperativen Risikostratifizierung werden das Vorhandensein und Ausmaß von Frailty, pathophysiologische Risikofaktoren, die Art des chirurgischen Verfahrens sowie die Ergebnisse (zusätzlicher) Untersuchungen bewertet. Die Anästhesieform, das Flüssigkeits- und Schmerzmanagement beeinflussen das Operationsergebnis. Neuere Entwicklungen fokussieren auf eine multimodale perioperative Versorgung des älteren Patienten. Dazu gehören minimal-invasive Operationsmethoden, postoperative anästhesiologische Visiten und eine frühe geriatrische Konsultation. KeywordsPerioperative procedures–Risk assessment–Health status–Postoperative complications–Geriatrics SchlüsselwörterPerioperative Verfahren–Risikobewertung–Gesundheitsstatus–Postoperative Komplikationen–GeriatrieZeitschrift für Gerontologie + Geriatrie 04/2012; 44(3):187-191. · 0.61 Impact Factor
Article: Prediction of postoperative pain: a systematic review of predictive experimental pain studies.[show abstract] [hide abstract]
ABSTRACT: Quantitative testing of a patient's basal pain perception before surgery has the potential to be of clinical value if it can accurately predict the magnitude of pain and requirement of analgesics after surgery. This review includes 14 studies that have investigated the correlation between preoperative responses to experimental pain stimuli and clinical postoperative pain and demonstrates that the preoperative pain tests may predict 4-54% of the variance in postoperative pain experience depending on the stimulation methods and the test paradigm used. The predictive strength is much higher than previously reported for single factor analyses of demographics and psychologic factors. In addition, some of these studies indicate that an increase in preoperative pain sensitivity is associated with a high probability of development of sustained postsurgical pain.Anesthesiology 06/2010; 112(6):1494-502. · 5.36 Impact Factor
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ABSTRACT: Objective. To compare Visual Analogue Scale (VAS) scores with overall postoperative pain medication requirements including cumulative dose and patterns of medication utilization and to determine whether VAS scores predict pain medication utilization. Methods. VAS scores and pain medication data were collected from participants in a randomized trial of the utility of phenazopyridine for improved pain control following gynecologic surgery. Results. The mean age of the 219 participants was 54 (range19 to 94). We did not detect any association between VAS and pain medication utilization for patient-controlled anesthesia (PCA) or RN administered (intravenous or oral) medications. We also did not detect any association between the number of VAS scores recorded and mean pain scores. Conclusion. Postoperative VAS scores do not predict pain medication use in catheterized women inpatients following gynecologic surgery. Increased pain severity, as reflected by higher VAS scores, is not associated with an increase in pain assessment. Our findings suggest that VAS scores are of limited utility for optimal pain control. Alternative or complimentary methods may improve pain management.Pain research and treatment. 01/2011; 2011:987468.