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      The role of regional analgesia in personalized postoperative pain management

      review-article

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          Abstract

          Pain management plays a fundamental role in enhanced recovery after surgery pathways. The concept of multimodal analgesia in providing a balanced and effective approach to perioperative pain management is widely accepted and practiced, with regional anesthesia playing a pivotal role. Nerve block techniques can be utilized to achieve the goals of enhanced recovery, whether it be the resolution of ileus or time to mobilization. However, the recent expansion in the number and types of nerve block approaches can be daunting for general anesthesiologists. Which is the most appropriate regional technique to choose, and what skills and infrastructure are required for its implementation? A multidisciplinary team-based approach for defining the goals is essential, based on each patient's needs, and incorporating patient, surgical, and social factors. This review provides a framework for a personalized approach to postoperative pain management with an emphasis on regional anesthesia techniques.

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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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            Postoperative pulmonary complications.

            Postoperative pulmonary complications (PPCs) are common, costly, and increase patient mortality. Changes to the respiratory system occur immediately on induction of general anaesthesia: respiratory drive and muscle function are altered, lung volumes reduced, and atelectasis develops in > 75% of patients receiving a neuromuscular blocking drug. The respiratory system may take 6 weeks to return to its preoperative state after general anaesthesia for major surgery. Risk factors for PPC development are numerous, and clinicians should be aware of non-modifiable and modifiable factors in order to recognize those at risk and optimize their care. Many validated risk prediction models are described. These have been useful for improving our understanding of PPC development, but there remains inadequate consensus for them to be useful clinically. Preventative measures include preoperative optimization of co-morbidities, smoking cessation, and correction of anaemia, in addition to intraoperative protective ventilation strategies and appropriate management of neuromuscular blocking drugs. Protective ventilation includes low tidal volumes, which must be calculated according to the patient's ideal body weight. Further evidence for the most beneficial level of PEEP is required, and on-going randomized trials will hopefully provide more information. When PEEP is used, it may be useful to precede this with a recruitment manoeuvre if atelectasis is suspected. For high-risk patients, surgical time should be minimized. After surgery, nasogastric tubes should be avoided and analgesia optimized. A postoperative mobilization, chest physiotherapy, and oral hygiene bundle reduces PPCs.
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              Postoperative Multimodal Analgesia Pain Management With Nonopioid Analgesics and Techniques: A Review.

              Amid the current opioid epidemic in the United States, the enhanced recovery after surgery pathway (ERAS) has emerged as one of the best strategies to improve the value and quality of surgical care and has been increasingly adopted for a broad range of complex surgical procedures. The goal of this article was to outline important components of opioid-sparing analgesic regimens.
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                Author and article information

                Journal
                Korean J Anesthesiol
                Korean J Anesthesiol
                KJA
                Korean Journal of Anesthesiology
                Korean Society of Anesthesiologists
                2005-6419
                2005-7563
                October 2020
                5 August 2020
                : 73
                : 5
                : 363-371
                Affiliations
                [1 ]Department of Anesthesiology and Perioperative Care, University of British Columbia, Vancouver General Hospital, BC, Canada
                [2 ]Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
                [3 ]Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
                Author notes
                Corresponding author: Edward R. Mariano, M.D., M.A.S. Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, 3801 Miranda Avenue (112A), Palo Alto, CA 94304, USA Tel: +1-650-849-0254 Fax: +1-650-852-3423 Email: emariano@ 123456stanford.edu
                Author information
                http://orcid.org/0000-0001-9015-8757
                http://orcid.org/0000-0003-0693-8545
                http://orcid.org/0000-0003-2735-248X
                Article
                kja-20323
                10.4097/kja.20323
                7533178
                32752602
                9d87f408-4939-4422-ace8-aef99eea62f5
                Copyright © The Korean Society of Anesthesiologists, 2020

                This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 20 June 2020
                : 13 July 2020
                : 15 July 2020
                Categories
                Review Article

                Anesthesiology & Pain management
                acute pain,enhanced recovery,multimodal analgesia,nerve block,opioid,pain management,persistent postsurgical pain,personalized medicine,postoperative pain,regional anesthesia

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