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      Eficacia y complicaciones de las técnicas analgésicas para el tratamiento del dolor agudo postoperatorio moderado a intenso Translated title: Efficacy and complications of analgesic techniques for the treatment of moderate to severe postoperative acute pain

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          Abstract

          RESUMEN Introducción: A pesar de los esfuerzos y la evidencia disponible, el dolor agudo postoperatorio (DAP) moderado a intenso continúa teniendo una prevalencia elevada en nuestro medio. Como parte de una estrategia de analgesia balanceada o multimodal, las técnicas de analgesia regional ofrecen un adecuado control analgésico con menores efectos indeseables (que el uso exclusivo de opioides), aunque no están exentas de complicaciones y no son aplicables a todas las cirugías. El objetivo de este trabajo fue valorar la eficacia de las técnicas analgésicas para el tratamiento del DAP moderado a intenso, la incidencia de complicaciones asociadas a estas técnicas y la relación entre DAP y el antecedente de dolor crónico. Pacientes y métodos: Estudio retrospectivo que incluyó 728 pacientes en los que se indicaron técnicas analgésicas, como analgesia epidural, analgesia perineural continua y analgesia controlada por el paciente (PCA) con morfina intravenosa, para el tratamiento del DAP moderado a intenso entre octubre del 2018 y octubre del 2020. Los pacientes fueron valorados por la Unidad de Dolor Agudo Postoperatorio (UDAP) a las 24 y 48 horas, se registró el dolor con la ENV (Escala Numérica Verbal), la presencia de reacciones adversas y/o complicaciones, empleo de analgesia multimodal y consumo de morfina en equivalentes intravenosos. Los niveles de dolor se clasificaron en leve (ENV: 0-3), moderado (ENV: 4-6) e intenso (ENV mayor o igual a 7). Resultados: Cerca del 60 % de los pacientes presentaron dolor leve a las 24 horas y del 70 % a las 48 horas. Un 71,8 % de los portadores de analgésica continua epidural presentaron dolor leve el primer día y un 83 % al segundo. Las cirugías con niveles más altos de dolor moderado e intenso fueron la cirugía espinal en la que se empleó la PCA de morfina y la artroplastia de rodilla en que se utilizó analgesia a través de bloqueo femoral continuo. El consumo de morfina registrado en las PCA fue de 25,8 mg (DE: 18,4) a las 24 horas y de 18,6 mg (DE: 14,6) a las 48 horas. No hubo complicaciones graves asociadas a ninguna de las técnicas, excepto las retiradas accidentales de catéteres epidurales (3,6 %). En los bloqueos periféricos continuos, las retiradas accidentales (13 %) y las fugas pericatéter (6,4 %) fueron las complicaciones más frecuentes. Hubo una relación significativa entre el antecedente de dolor crónico y la intensidad de dolor postoperatorio (p = 0,000). Conclusiones: Las técnicas analgésicas evaluadas para el manejo del DAP moderado e intenso, se consideran eficaces. La analgesia epidural torácica fue la técnica más eficaz con los porcentajes más altos de dolor leve a las 24 y 48 horas. Los pacientes con antecedente de dolor crónico presentaron porcentajes más altos de dolor moderado e intenso a las 24 y 48 horas.

          Translated abstract

          ABSTRACT Introduction: Despite the efforts and the available evidence, moderate to severe acute postoperative pain (APP) continues to have a high prevalence in our setting. As part of a balanced or multimodal analgesia strategy, regional analgesia techniques offer adequate analgesic control with fewer undesirable effects (that the exclusive use of opioids), although they are not free of complications and do not apply to all surgeries. This study aimed to assess the efficacy of analgesic techniques for the treatment of moderate to intense APP, the incidence of complications associated with these techniques, and the relationship between APP and the presence of chronic pain. Patients and methods: This retrospective study included 728 patients in which analgesic techniques such as epidural analgesia, continuous perineural analgesia, and morphine Patient Controlled Analgesia (PCA) were indicated to treat moderate to severe APP between October 2018 and October 2020. The patients were evaluated by the APP service at 24 and 48 hours, the pain was recorded with the NRS (Numerical Rating Scale), and the study also registered the presence of adverse reactions and/or complications, the use of multimodal analgesia, and the consumption of morphine in equivalent intravenous doses. Pain levels were classified as mild (NRS: 0-3), moderate (NRS: 4-6) and intense (NRS greater than or equal to 7). Results: Approximately 60 % of all patients presented mild pain at 24 hours and 70 % at 48. Epidural analgesia in abdominal surgery presented 71.8 % mild pain on the first day and 83 % on the second. The surgeries with the highest levels of moderate and severe pain were spinal surgery using morphine PCA and knee replacement with continuous femoral nerve block. The morphine consumption recorded in the PCA was 25.8 mg (SD 18.4) at 24 hours and 18.6 mg (SD: 14.6) at 48 hours. There were no serious complications associated with any of the techniques, except for accidental removal of epidural catheters (3.6 %). In continuous peripheral nerve blocks, accidental withdrawals (13 %), and leakage from the catheter insertion site (6.4 %) were the most frequent complications. There was a significant relationship between chronic pain and pain intensity (p = 0.000). Conclusions: Analgesic techniques for the management of APP, achieve better analgesic levels with few complications. The role of effective and safe thoracic epidural analgesia in open abdominal surgery stands out. Patients with a history of chronic pain had higher percentages of moderate and severe pain at 24 and 48 hours.

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          Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council.

          Most patients who undergo surgical procedures experience acute postoperative pain, but evidence suggests that less than half report adequate postoperative pain relief. Many preoperative, intraoperative, and postoperative interventions and management strategies are available for reducing and managing postoperative pain. The American Pain Society, with input from the American Society of Anesthesiologists, commissioned an interdisciplinary expert panel to develop a clinical practice guideline to promote evidence-based, effective, and safer postoperative pain management in children and adults. The guideline was subsequently approved by the American Society for Regional Anesthesia. As part of the guideline development process, a systematic review was commissioned on various aspects related to various interventions and management strategies for postoperative pain. After a review of the evidence, the expert panel formulated recommendations that addressed various aspects of postoperative pain management, including preoperative education, perioperative pain management planning, use of different pharmacological and nonpharmacological modalities, organizational policies, and transition to outpatient care. The recommendations are based on the underlying premise that optimal management begins in the preoperative period with an assessment of the patient and development of a plan of care tailored to the individual and the surgical procedure involved. The panel found that evidence supports the use of multimodal regimens in many situations, although the exact components of effective multimodal care will vary depending on the patient, setting, and surgical procedure. Although these guidelines are based on a systematic review of the evidence on management of postoperative pain, the panel identified numerous research gaps. Of 32 recommendations, 4 were assessed as being supported by high-quality evidence, and 11 (in the areas of patient education and perioperative planning, patient assessment, organizational structures and policies, and transitioning to outpatient care) were made on the basis of low-quality evidence.
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            Poorly controlled postoperative pain: prevalence, consequences, and prevention

            Tong Gan (2017)
            This review provides an overview of the clinical issue of poorly controlled postoperative pain and therapeutic approaches that may help to address this common unresolved health-care challenge. Postoperative pain is not adequately managed in greater than 80% of patients in the US, although rates vary depending on such factors as type of surgery performed, analgesic/anesthetic intervention used, and time elapsed after surgery. Poorly controlled acute postoperative pain is associated with increased morbidity, functional and quality-of-life impairment, delayed recovery time, prolonged duration of opioid use, and higher health-care costs. In addition, the presence and intensity of acute pain during or after surgery is predictive of the development of chronic pain. More effective analgesic/anesthetic measures in the perioperative period are needed to prevent the progression to persistent pain. Although clinical findings are inconsistent, some studies of local anesthetics and nonopioid analgesics have suggested potential benefits as preventive interventions. Conventional opioids remain the standard of care for the management of acute postoperative pain; however, the risk of opioid-related adverse events can limit optimal dosing for analgesia, leading to poorly controlled acute postoperative pain. Several new opioids have been developed that modulate μ-receptor activity by selectively engaging intracellular pathways associated with analgesia and not those associated with adverse events, creating a wider therapeutic window than unselective conventional opioids. In clinical studies, oliceridine (TRV130), a novel μ-receptor G-protein pathway-selective modulator, produced rapid postoperative analgesia with reduced prevalence of adverse events versus morphine.
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              Pain intensity on the first day after surgery: a prospective cohort study comparing 179 surgical procedures.

              Severe pain after surgery remains a major problem, occurring in 20-40% of patients. Despite numerous published studies, the degree of pain following many types of surgery in everyday clinical practice is unknown. To improve postoperative pain therapy and develop procedure-specific, optimized pain-treatment protocols, types of surgery that may result in severe postoperative pain in everyday practice must first be identified. This study considered 115,775 patients from 578 surgical wards in 105 German hospitals. A total of 70,764 patients met the inclusion criteria. On the first postoperative day, patients were asked to rate their worst pain intensity since surgery (numeric rating scale, 0-10). All surgical procedures were assigned to 529 well-defined groups. When a group contained fewer than 20 patients, the data were excluded from analysis. Finally, 50,523 patients from 179 surgical groups were compared. The 40 procedures with the highest pain scores (median numeric rating scale, 6-7) included 22 orthopedic/trauma procedures on the extremities. Patients reported high pain scores after many "minor" surgical procedures, including appendectomy, cholecystectomy, hemorrhoidectomy, and tonsillectomy, which ranked among the 25 procedures with highest pain intensities. A number of "major" abdominal surgeries resulted in comparatively low pain scores, often because of sufficient epidural analgesia. Several common minor- to medium-level surgical procedures, including some with laparoscopic approaches, resulted in unexpectedly high levels of postoperative pain. To reduce the number of patients suffering from severe pain, patients undergoing so-called minor surgery should be monitored more closely, and postsurgical pain treatment needs to comply with existing procedure-specific pain-treatment recommendations.
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                Author and article information

                Journal
                dolor
                Revista de la Sociedad Española del Dolor
                Rev. Soc. Esp. Dolor
                Inspira Network Group, S.L (Madrid, Madrid, Spain )
                1134-8046
                October 2021
                : 28
                : 5
                : 264-275
                Affiliations
                [3] Lleida orgnameHospital Universitario Arnau de Vilanova orgdiv1Unidad del Dolor España
                [2] Lleida orgnameHospital Universitario Arnau de Vilanova orgdiv1Servicio de Anestesiología, Reanimación y Unidad del Dolor España
                [1] Lleida orgnameHospital Universitario Arnau de Vilanova orgdiv1Servicio de Anestesiología y Reanimación España
                Article
                S1134-80462021000600005 S1134-8046(21)02800500005
                10.20986/resed.2021.3942/2021
                84867178-4a38-47f9-87bb-d19e04eb5c58

                This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

                History
                : 03 December 2021
                : 12 September 2021
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 45, Pages: 12
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                SciELO Spain

                Categories
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                postoperative pain,complicaciones,consumo de opioides,analgesia postoperatoria,dolor crónico preoperatorio,dolor postoperatorio,Dolor agudo,complications,opioid consumption,postoperative analgesia,preoperative chronic pain,Acute pain

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