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DI-106 A protocol for the selection of analgesic mixture drugs according to pain intensity in a postoperative pain unit
  1. E Zamora Ferrer1,
  2. M Heredia Benito1,
  3. T Sánchez Casanueva2,
  4. JC Valenzuela Gámez3,
  5. P Nieto-Sandoval Martín de la Torre3
  1. 1H. G. La Mancha Centro, Pharmacy, Alcazar de San Juan, Spain
  2. 2H. G. Tomelloso, Pharmacy, Tomelloso, Spain
  3. 3H. G. La Mancha Centro, Pharmacy, Alcázar de San Juan, Spain


Background The intensity of postoperative pain depends on the type of surgical procedure. However, it can be a problem finding the optimal treatment.

Purpose To improve medical analgesics prescription according to pain intensity, considering warnings and main drug interactions.

Materials and methods We did a bibliographic review from January 2004 to August 2013 in several databases (PubMed, Micromedex, Cochrane, etc.) and scientific journals.

Results We designed a postoperative analgesia protocol based on a pain severity prediction according to the type of surgical procedure performed.

For surgical procedures associated with mild-moderate pain:

Intravenous infusion in 100 ml physiological saline at 2 ml/h for 50 h:

Type 1: tramadol 6 mg/ml

Type 1-RI (renal impairment): tramadol 4 mg/ml

Type 2: metamizole 120 mg/ml

Type 3: ketorolac 1.8 mg/ml

Type 3-RI: ketorolac 1.2 mg/ml

Type 4: tramadol 6 mg/ml + metamizole 120 mg/ml

Type 4-RI: tramadol 4 mg/ml + metamizole 120 mg/ml

Type 5: tramadol 6 mg/ml + ketorolac 1.8 mg/mlType 5-RI: tramadol 4 mg/ml + ketorolac 1.2 mg/ml

For surgical procedures associated with severe pain:

Intravenous infusion in 100 ml physiological saline at 2 ml/h for 50 h:

Type 1: morphine 0.3 mg/ml + droperidol 0.025 mg/ml

Type 2: morphine 1 mg/ml PCA (patient-controlled analgesia)

Type 3: morphine 0.3 mg/ml + metamizole 120 mg/ml

Type 4: morphine 0.3 mg/ml + dexketoprofen 3 mg/ml

Epidural infusion in 250 ml physiological saline at 5 ml/h for 50 h:

Type 1: bupivacaine 0.1%

Type 2: bupivacaine 0.1% + fentanyl 2 mcg/ml

Concomitant analgesia: Paracetamol IV 1 g/6 h (dose adjustment in liver disease) and metamizole IV 2 g/6–8 h or dexketoprofen IV 50 mg/8 h (depending on the type of protocol).

General recommendations: To prescribe gastroprotective drugs with non-steroidal anti-inflammatory drugs and antiemetic drugs in nausea or vomiting.

Avoid use of intravenous ketorolac or dexketoprofen for more than 2 days.

Rescue analgesia: Morphine IV 0.05 mg/kg/4 h or pethidine IV 25–100 mg/4 h.

Neuropathic pain: Amitriptyline, pregabalin or duloxetine.

Conclusions An analgesics protocol has a role in guiding medical prescriptions and an impact on rational drug use. It contributes to identifying patients who could benefit from a specific drug combination and minimises possible drug side effects.

No conflict of interest.

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