Articles: postoperative.
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Postoperative pain can intensify the sympathoadrenergic reaction, which is commonly seen after surgery, and thus possibly pave the way for certain complications, such as coronary ischemia, bronchopneumonia, intestinal stasis, thromboembolism, infection, sepsis, and metabolic disturbances. Investigations of cardiovascular, respiratory, gastrointestinal, metabolic, and immunologic function indicate that high-quality pain relief can diminish postoperative organ impairment and failure. Some aspects of the improvements attributed to the quality of analgesia, such as prevention of tachycardia and hypertension, attenuation of hyperglycemia and catabolism, improvement of gastrointestinal motility and cellular immunity cannot be definitely distinguished from the effects of sympathetic blockade due to epidural analgesia with local anesthetics, however. ⋯ Some studies indicate that better analgesia is advantageous for the patient, especially with respect to postoperative complications, hospital stay, long-term well being, and costs. In other clinical trials incorporating more patients, however, this hypothesis had to be rejected. At present, therefore, we cannot state that effective pain relief influences postoperative morbidity and mortality.
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At present, intramuscular application of opioids given on request is the most widespread form of postoperative analgesia. This method is widely recognized as often being inadequate, however. As advanced techniques of pain management, such as patient-controlled analgesia, are not generally available, the question arises as to whether non-opioid analgesics should routinely be used in order to improve this situation. ⋯ Despite these results, it must be borne in mind that most studies have been carried out on patients of ASA groups I and II and that conclusions drawn from the literature are not necessarily representative for the elderly and for patients with organ failure. Alternative substances have received relatively little attention. Of these, the pyrazolone derivative, metamizol, may well prove to be of value for patients in whom the use of NSAIDS is contraindicated or relatively ineffective such as after biliary tract surgery.
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Postoperative pain arises largely from distension and sectioning of nerve fibers, which generate a short-lasting but enormous afferent impulse barrage. This causes a long-lasting enlargement of receptive fields and an increase in excitability of dorsal horn neurons sending their axons up to the brain. ⋯ Prostaglandins in the spinal cord facilitate the synaptic transmission from nociceptive afferents. Nonsteroidal anti-inflammatory drugs (NSAIDs) produce relief from postoperative pain by blocking the formation of prostaglandins in the spinal cord, thus abolishing the facilitatory effect of these compounds.
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Many studies investigated patient-controlled analgesia (PCA) in the postoperative period in recovery rooms under anaesthesiologic monitoring but reports on the advantages and indications of PCA in surgical wards are scarce. The aim of this prospective study therefore was to investigate PCA as a routine technique in surgical wards. In particular we were interested in safety and in the efficacy of analgesia. ⋯ We conclude that PCA with piritramide is a safe technique when performed under routine conditions on surgical wards. However, standardized monitoring is mandatory. PCA leads to effective analgesia and consequently to greater comfort of surgical patients in the postoperative period. These conclusions hold only for patients with ASA status I-II who have undergone operations of the types listed above.
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Animal experiments have unequivocally demonstrated peripheral antinociceptive effects of opioids in inflamed tissue. Exogenous mu-, delta- und kappa-agonists can produce such effects. Opioid receptors are present on peripheral terminals of primary afferent neurons and their endogenous ligands are produced and contained in resident immune cells within the inflamed tissue. ⋯ A small number of clinical studies has examined the peripheral analgesic effects of opioids. Their results are equivocal so far. In view of the predominant role of the inflammatory process in the manifestation of peripheral opioid effects, the postoperative situation seems to be particularly worthwhile to study.