Abstract
Background and aims
The effect of postoperative pain relief on morbidity and hospital stay is reviewed.
Results
Beneficial effects of postoperative pain relief by patient-controlled analgesia (PCA) opioids on morbidity and hospital stay have not been documented. The clinical outcome effects of the 20%–30% opioid sparing by non-steroidal anti-inflammatory agents have not been defined, but recent data suggest hastened recovery in cholecystectomy and knee surgery. The effect of continuous epidural analgesia on morbidity and hospital stay remains controversial except for improved pulmonary outcome. However, existing randomised trials on continuous epidural analgesia have insufficient design due to predominantly opioid-based epidural analgesia and the lack of a revision of perioperative care programmes to take advantage of the beneficial physiological effects of balanced epidural analgesia.
Conclusion
The effects of pain relief on outcome remains debatable, despite beneficial effects of pathophysiological responses. Future outcome studies are required where optimised dynamic pain relief is integrated with a multimodal rehabilitation programme.
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References
Kehlet H (1997) Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 78:606–617
Kehlet H, Dahl JB (2003) Anaesthesia, surgery and challenges for postoperative recovery. Lancet 362:1921–1928
Walder B, Schafer M, Henzi I, Tramer MR (2001) Efficacy and safety of patient-controlled opioid analgesia for acute postoperative pain. A quantitative systematic review. Acta Anaesthesiol Scand 45:795–804
Beattie WS, Badner NH, Choi P (2001) Epidural analgesia reduces postoperative myocardial infarction: a meta-analysis. Anesth Analg 93:853–858
Ballantyne JC, Carr DB, deFerranti S, Suarez T, Lau J, Chalmers TC, Angelillo IF, Mosteller F (1998) The comparative effects of postoperative analgesic therapies on pulmonary outcome: cumulative meta-analyses of randomized, controlled trials. Anesth Analg 86:598–612
Kehlet H, Holte K (2001) Effect of postoperative analgesia on surgical outcome. Br J Anaesth 87:62–72
Holte K, Kehlet H (2003) Postoperative epidural analgesia and outcome—a research agenda. In: Tramèr MR (ed) Evidence-based resource in anaesthesia and analgesia, 2nd edn. BMJ Books, pp 175–183
Rodgers A, Walker N, Schug S, McKee A, Kehlet H, van Zundert A, Sage D, Futter M, Saville G, Clark T, MacMahon S (2000) Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ 321:1493–1497
Wilmore DW (2002) From Cuthbertson to fast-track surgery: 70 years of progress in reducing stress in surgical patients. Ann Surg 236:643–648
Kehlet H (1998) Modification of responses to surgery by neural blockade: clinical implications. In: Cousins MJ, Bridenbaugh PS (eds) Neural blockade in clinical anesthesia and management of pain, 3rd edn. Lippincott-Raven, Philadelphia, Pennsylvania, pp 129–175
Holte K, Kehlet H (2002) Epidural anaesthesia and analgesia – effects on surgical stress responses and implications for postoperative nutrition. Clin Nutr 21:199–206
Holte K, Kehlet H (2002) Perioperative single-dose glucocorticoids administration: pathophysiologic effects and clinical implications. J Am Coll Surg 195:694–748
Jorgensen H, Wetterslev J, Moiniche S, Dahl JB (2002) Epidural local anaesthetics versus opioid-based analgesic regimens on postoperative gastrointestinal paralysis, PONV and pain after abdominal surgery (Cochrane review). In: The Cochrane Library, Issue 1. Update Software, Oxford
Kehlet H, Rung GW, Callesen T (1996) Postoperative opioid-analgesia: time for a reconsideration? J Clin Anesth 8:441–445
Power I, Barrett S (1999) Analgesic agents for the postoperative period. Non-opioids. Surg Clin N Am 79:275–295
Buvanendran A, Kroin JS, Tuman KJ, Lubenow TR, Elmofty D, Moric M, Rosenberg AG (2003) Effects of perioperative administration of a selective cyclooxygenase 2 inhibitor on pain management and recovery of function after knee replacement. A randomised controlled trial. JAMA 290:2411–2418
Gan TJ, Joshi GP, Viscusi E, Cheung RY, Dutsch W, Fort JD, Chen C (2004) Preoperative parenteral parecoxib and follow up oral valdecoxib reduces length of stay and improve quality of patient recovery after laparoscopic cholecystectomy surgery. Anesth Analg (in press)
Bisgaard T, Klarskov B, Kehlet H, Rosenberg J (2003) Preoperative dexamethasone improves surgical outcome after laparoscopic cholecystectomy. A randomized double-blind placebo-controlled trial. Ann Surg 238:651–660
Sauerland S, Nagelschmidt M, Malmann P, Neugebauer EA (2000) Risks and benefits of preoperative high-dose methylprednisolone in surgical patients: a systematic review. Drug Saf 23:449–461
Henzi I, Walder B, Tramèr MR (2000) Dexamethasone for the prevention of postoperative nausea and vomiting: a quantitative systematic review. Anesth Analg 90:186–194
Park WY, Thompson JS, Lee KK (2001) Effect of epidural anesthesia and analgesia on perioperative outcome: a randomized, controlled Veterans Affairs cooperative study. Ann Surg 234:560–569
Norris EJ, Beattie C, Perler BA, Martinez EA, Meinert CL, Anderson GF, Grass JA, Sakima NT, Gorman R, Achuff SC, Martin BK, Minken SL, Williams GM, Traystman RJ (2001) Double-masked randomized trial comparing alternate combinations of intraoperative anesthesia and postoperative analgesia in abdominal aortic surgery. Anesthesiology 95:1054–1067
Rigg JR, Jamrozik K, Myles PS, Silbert BS, Peyton PJ, Parsons RW, Collins KS, MASTER Anaesthesia Trial Study Group. Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial. Lancet 359:1276–1282
Peyton PJ, Myles PS, Silbert BS, Rigg JA, Jamrozik K, Parsons R (2003) Perioperative epidural analgesia and outcome after major abdominal surgery in high-risk patients. Anesth Analg 96:548–554
de Leon-Casasola OA (2003) When it comes to outcome, we need to define what a perioperative epidural technique is. Anesth Analg 96:315–318
Kehlet H, Wilmore DW (2002) Multimodal strategies to improve surgical outcome. Am J Surg 183:630–641
Holte K, Sharrock NE, Kehlet H (2002) Pathophysiology and clinical implications of perioperative fluid excess. Br J Anaesth 89:622–632
Brandstrup B, Tønnesen H, Beier-Holgersen R, Hjortsø E, Ørding H, Lindorff-Larsen K, Rasmussen MS, Lanng C, Wallin L, the Danish Study Group on Perioperative Fluid Therapy (Iversen LH, Gramkow CS, Okholm M, Blemmer T, Svendsen P-E, Rottensten HH, Thage B, Riis J, Jeppesen IS, Teilum D, Christensen AM, Graungaard B, Pott F) (2003) Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens. A randomized assessor-blinded multicenter trial. Ann Surg 238:641–648
Carli F, Mayo N, Klubien K, Schricker T, Trudel J, Belliveau P (2002) Epidural analgesia enhances functional exercise capacity and health-related quality of life after colonic surgery: results of a randomized trial. Anesthesiology 97:540–549
Perkins FM, Kehlet H (2000) Chronic pain as an outcome of surgery. A review of predictive factors. Anesthesiology 93:1123–1133
Macrae WA (2001) Chronic pain after surgery. Br J Anaesth 87:88–98
Acknowledgement
This work was supported by a grant from the Danish Research Council (22-01-0160).
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Kehlet, H. Effect of postoperative pain treatment on outcome—current status and future strategies. Langenbecks Arch Surg 389, 244–249 (2004). https://doi.org/10.1007/s00423-004-0460-4
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DOI: https://doi.org/10.1007/s00423-004-0460-4