Elsevier

The Lancet

Volume 377, Issue 9784, 25 June–1 July 2011, Pages 2215-2225
The Lancet

Series
Treatment of acute postoperative pain

https://doi.org/10.1016/S0140-6736(11)60245-6Get rights and content

Summary

Although postoperative pain remains incompletely controlled in some settings, increased understanding of its mechanisms and the development of several therapeutic approaches have substantially improved pain control in past years. Advances in our understanding of the process of nociception have led to insight into gene-based pain therapy, the development of acute opioid-induced hyperalgesia, and persistent postsurgical pain. Use of specific analgesic techniques such as regional analgesia could improve patient outcomes. We also examine the development of new analgesic agents and treatment modalities and regimens for acute postoperative pain.

Introduction

The treatment of acute postoperative pain is an important health-care issue. Many advances have been made in our understanding of the process of nociception and innovations in both analgesic agents and techniques for provision of analgesia since the last Lancet review of the topic.1 Although there have been many developments in acute postoperative pain during the past decade, we provide the latest perspective on several key areas in the treatment of this form of pain.

Section snippets

Treatment of acute postoperative pain: how are we doing?

During the past two decades, the undertreatment of acute pain has been widely recognised as an important issue in health care. Researchers have estimated that only one in four surgical patients in the USA received adequate relief of acute pain.2 Acknowledgment of the widespread nature of acute postoperative pain led to the development of many medical societal guidelines and more notably of new regulatory standards (eg, Joint Commission on Accreditation of Healthcare Organizations) for the

Mechanisms

Although a comprehensive overview of the nociceptive processing of acute postoperative pain is beyond the scope of this report, there have been several recent developments in the study of the nociception of acute postoperative pain.17 Neurophysiological and pharmacological studies in recently developed animal models for postoperative pain have advanced our knowledge of the mechanisms of pain resulting from surgical incision and associated tissue injury.18, 19, 20, 21 These studies suggest that

Pathophysiological responses

Acute pain causes a wide range of pathophysiological responses, which are initiated when nociceptors are activated after tissue injury, resulting in a local inflammatory response and subsequent behavioural and physiological responses.1 After tissue injury, sympathoneural and neuroendocrine activation (along with uncontrolled pain) can ultimately lead to various potentially detrimental responses such as tachycardia, hypertension, hyperglycaemia, immunosuppression, decreased regional blood flow

Multimodal analgesia and adjuvant agents

The use of multimodal analgesia, a strategy that concurrently uses more than one class of analgesic agent or technique (table), has been advocated as a means to improve analgesia through either additive or synergistic effects while reducing opioid-related side-effects.65 Although there are many permutations by which analgesics can be combined, multimodal analgesia realistically can be defined as a combination of an opioid and non-opioid analgesic, with or without a regional anaesthetic block,

Advances

Although there have been many advances in the development of both analgesic agents and techniques since the previous review,1 we have only described those that have been used or are very close to being available in the clinical setting. The analgesic agents and techniques described in this section are at different stages of development and might or might not be approved for use, depending on the location of the practitioner.

Sustained-release or extended-release formulations of conventional agents

Although agents such as opioids or local anaesthetics can provide

Complementary and alternative modalities

Several complementary and alternative modalities for postoperative analgesia have been investigated to some extent, although the number of high-quality studies is low. Perioperative acupuncture might be a valuable adjunct for acute postoperative pain management, because a systematic review incorporating 15 randomised controlled trials noted a significant decrease in opioid consumption, risk of opioid-related side-effects (eg, nausea), and postoperative pain intensity at 8 and 72 h in the

Conclusion

Although postoperative pain remains incompletely controlled in some settings and the reasons why are not entirely clear, a comprehensive understanding of its mechanisms and the development of several therapeutic approaches have substantially improved pain control in past years. The use of more effective analgesic techniques (eg, regional analgesia) might be helpful not only for provision of superior analgesia, but also for improvement of conventional outcomes, particularly in high-risk patients

Search strategy and selection criteria

We searched Medline (between 2000, and July, 2010) and Embase (2000–11) using the search terms “acute pain” or “postoperative pain”, and limiting the field to “title/abstract”. Although we largely focused on reports published within the past 3 years, we did not exclude commonly referenced and highly regarded older publications. The reference lists of articles identified by this search strategy, several book chapters, and the authors' personal reference lists were also included. The reference

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