Postoperative Akutschmerztherapie - Neue Möglichkeiten der systemischen Analgesie

Zusammenfassung

Eine suffiziente Schmerztherapie hat nicht zuletzt aufgrund der Reduktion von Patientenmorbidität und Verbesserung des Patientenoutcomes einen hohen Stellenwert im Rahmen der perioperativen Betreuung von Patienten. Obwohl patientenkontrollierte Regionalanalgesieverfahren der entsprechend gesteuerten systemischen Analgesie mit Opioiden im Rahmen der Schmerztherapie überlegen sind, kann aus vielerlei Gründen die Anwendung des etwas weniger wirksamen Verfahrens notwendig werden (z.B. Patientenwunsch, bestimmte Kontraindikationen). Adjuvante Analgetika oder Ko-Analgetika können in Zukunft große Bedeutung für die Verbesserung der Analgesiequalität, der Reduktion des Opioidverbrauchs und - damit verbunden - einer möglichen Senkung opioidinduzierter Nebenwirkungen bekommen. Darüber hinaus können bestimmte Ko-Analgetika möglicherweise auch zur Reduktion einer opioidinduzierten Hyperalgesie und zu einer Vermeidung chronischer postoperativer Schmerzen beitragen. In der folgenden Übersichtsarbeit soll der Stellenwert einer systemischen Applikation von NMDA-Rezeptorantagonisten, Antikonvulsiva, Kortikosteroiden und Lokalanästhetika für den Einsatz in der postoperativen Schmerztherapie anhand der aktuellen Literatur diskutiert werden. Zusätzlich soll in diesem Rahmen ein orales opioidbasiertes Analgesiekonzept zur Behandlung von Schmerzen nach kurzen bis mittelangen Eingriffen vorgestellt werden.

Summary

Postoperative pain is now a critical focus of perioperative patient care. The current perioperative analgesic strategy is a „balanced-multimodal analgesia”. Cornerstones of this treatment approach are patient controlled neuraxial administration of local anesthetics and opioids or patient controlled intravenous administration of opioids. However, systemic opioids are limited by side effects. Thus, adjuvants like anticonvulsants, NMDA receptor antagonists, alpha-2 adrenergic agonists and other non-Opioid analgesics are considered to reduce pain and opioid requirements in the perioperative period. In the present review we discuss recent findings about the effectiveness of different systemic administered adjuvants including ketamine, lidocaine, gabapentin, pregabalin and corticosteroids for postoperative pain treatment. Furthermore a nurse based oral analgesic concept using controlled released Oxycodon for all postoperative patients without a patient controlled analgesia device will be introduced.

Adjuvante Analgetika - Ko-Analgetika - postoperativer Akutschmerz - opioidinduzierte Hyperalgesie (OIH) - chronischer Schmerz

adjuvants - co-analgesic - postoperative pain - opioid-induced hyperalgesia (OIH) - chronic pain

Literaturverzeichnis

• 1 Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged.  Anesth Analg. 2003;  97 534-40
• 2 Pavlin DJ, Chen C, Penaloza DA, Polissar NL, Buckley FP. Pain as a factor complicating recovery and discharge after ambulatory surgery.  Anesth Analg. 2002;  95 627-34
• 3 Simanski C, Lefering R, Paffrath T, Riess P, Yucel N, Maegele M, Thusing C, Neugebauer E. Postoperative pain relief is an important factor for the patients' selection of a clinic. Results of an anonymous survey.  Schmerz. 2006;  20 327-33
• 4 Kehlet H. Effect of postoperative pain treatment on outcome-current status and future strategies.  Langenbecks Arch Surg. 2004;  389 244-9
• 5 Kehlet H, Holte K. Effect of postoperative analgesia on surgical outcome.  Br J Anaesth. 2001;  87 62-72
• 6 Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome.  Am J Surg. 2002;  183 630-41
• 7 Kehlet H, Werner M, Perkins F. Balanced analgesia: what is it and what are its advantages in postoperative pain?.  Drugs. 1999;  58 793-7
• 8 Nishimori M, Ballantyne JC, Low JH. Epidural pain relief versus systemic opioid-based pain relief for abdominal aortic surgery.  Cochrane Database Syst Rev. 2006;  3
• 9 Block BM, Liu SS, Rowlingson AJ, Cowan AR, Cowan Jr. JA, Wu CL. Efficacy of postoperative epidural analgesia: a meta-analysis.  Jama. 2003;  290 2455-63
• 10 Wu CL, Cohen SR, Richman JM, Rowlingson AJ, Courpas GE, Cheung K, Lin EE, Liu SS. Efficacy of postoperative patient-controlled and continuous infusion epidural analgesia versus intravenous patient-controlled analgesia with opioids: a meta-nalysis.  Anesthesiology. 2005;  103 1079-88 1109-10
• 11 Grass JA. Patient-controlled analgesia.  Anesth Analg. 2005;  101 44-61
• 12 Hudcova J, McNicol E, Quah C, Lau J, Carr DB. Patient controlled opioid analgesia versus conventional opioid analgesia for postoperative pain.  Cochrane Database Syst Rev. 2006; 
• 13 Romsing J, Moiniche S, Mathiesen O, Dahl JB. Reduction of opioid-related adverse events using opioid-sparing analgesia with COX-2 inhibitors lacks documentation: a systematic review.  Acta Anaesthesiol Scand. 2005;  49 133-42
• 14 Romsing J, Moiniche S, Dahl JB. Rectal and parenteral paracetamol, and paracetamol in combination with NSAIDs, for postoperative analgesia.  Br J Anaesth. 2002;  88 215-26
• 15 Dougherty PM, Palacek J, Paleckova V, Sorkin LS, Willis WD. The role of NMDA and non-NMDA excitatory amino acid receptors in the excitation of primate spinothalamic tract neurons by mechanical, chemical, thermal, and electrical stimuli.  Journal of Neuroscience. 1992;  12 3025-3041
• 16 Woolf CJ, Salter MW. Neuronal Plasticity: Increasing the gain in pain.  Science. 2000;  288 1765-1768
• 17 Pogatzki EM, Niemeier JS, Sorkin LS, Brennan TJ. Spinal glutamate receptor antagonists differentiate primary and secondary mechanical hyperalgesia caused by incision.  Pain. 2003;  105 97-107
• 18 Pogatzki EM, Zahn PK, Brennan TJ. Effect of pretreatment with intrathecal excitatory amino acid receptor antagonists on the development of pain behavior caused by plantar incision.  Anesthesiology. 2000;  93 489-96
• 19 Zahn PK, Pogatzki-Zahn EM, Brennan TJ. Spinal administration of MK-801 and NBQX demonstrates NMDA-independent dorsal horn sensitization in incisional pain.  Pain. 2005;  114 499-510
• 20 Zahn PK, Brennan TJ. Lack of effect of intrathecally administered N-methyl-D-aspartate receptor antagonists in a rat model for postoperative pain.  Anesthesiology. 1998;  88 143-56
• 21 Kock M De, Lavand'homme P, Waterloos H. Balanced analgesia' in the perioperative period: is there a place for ketamine?.  Pain. 2001;  92 373-80
• 22 Schmid RL, Sandler AN, Katz J. Use and efficacy of low-dose ketamine in the management of acute postoperative pain: a review of current techniques and outcomes.  Pain. 1999;  82 111-125
• 23 Elia N, Tramer MR. Ketamine and postoperative pain-a quantitative systematic review of randomised trials.  Pain. 2005;  113 61-70
• 24 Subramaniam K, Subramaniam B, Steinbrook RA. Ketamine as adjuvant analgesic to opioids: a quantitative and qualitative systematic review.  Anesth Analg. 2004;  99 482-95
• 25 Vandermeulen E. Systemic analgesia and co-analgesia.  Acta Anaesthesiol Belg. 2006;  57 113-20
• 26 Duedahl TH, Romsing J, Moiniche S, Dahl JB. A qualtitative systematic review of peri-operative detromethorphan in post-operative pain.  Acta Anaesthesiol Scand. 2006;  50 1-13
• 27 Angst MS, Clark JD. Opioid-induced hyperalgesia: a qualitative systematic review.  Anesthesiology. 2006;  104 570-87
• 28 Carroll IR, Angst MS, Clark JD. Management of perioperative pain in patients chronically consuming opioids.  Reg Anesth Pain Med. 2004;  29 576-91
• 29 Koppert W. Opioid-induced analgesia and hyperalgesia.  Schmerz. 2005;  19 386-90 392-4
• 30 Laulin JP, Maurette P, Corcuff JB, Rivat C, Chauvin M, Simonnet G. The role of ketamine in preventing fentanyl-induced hyperalgesia and subsequent acute morphine tolerance.  Anesth Analg. 2002;  94 1263-9
• 31 Koppert W, Sittl R, Scheuber K, Alsheimer M, Schmelz M, Schuttler J. Differential modulation of remifentanil-induced analgesia and postinfusion hyperalgesia by S-ketamine and clonidine in humans.  Anesthesiology. 2003;  99 152-9
• 32 Koppert W. Opioid-induced hyperalgesia. Pathophysiology and clinical relevance.  Anaesthesist. 2004;  53 455-66
• 33 Hansen EG, Duedahl TH, Romsing J, Hilsted KL, Dahl JB. Intra-operative remifentanil might influence pain levels in the immediate post-operative period after major abdominal surgery.  Acta Anaesthesiol Scand. 2005;  49 1464-70
• 34 Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention.  Lancet. 2006;  367 1618-25
• 36 Eisenach JC. Treating and preventing chronic pain: a view from the spinal cord-Bonica Lecture, ASRA Annual Meeting, 2005.  Reg Anesth Pain Med. 2006;  31 146-51
• 37 McCartney CJ, Sinha A, Katz J. A qualitative systematic review of the role of N-methyl-D-aspartate receptor antagonists in preventive analgesia.  Anesth Analg. 2004;  98 1385-400
• 38 Lavand'homme P. Perioperative pain.  Curr Opin Anaesthesiol. 2006;  19 556-561
• 39 Lavand'homme P, Kock M De, Waterloos H. Intraoperative epidural analgesia combined with ketamine provides effective preventive analgesia in patients undergoing major digestive surgery.  Anesthesiology. 2005;  103 813-20
• 40 Buvanendran A, Kroin JS, Kerns JM, Nagalla SN, Tuman KJ. Characterization of a new animal model for evaluation of persistent postthoracotomy pain.  Anesth Analg. 2004;  99 1453-60
• 41 Field MJ, Holloman EF, McCleary S, Hughes J, Singh L. Evaluation of gabapentin and S-(+)-3-isobutylgaba in a rat model of postoperative pain.  J Pharmacol Exp Ther. 1997;  282 1242-6
• 42 Gilron I. Review article: the role of anticonvulsant drugs in postoperative pain management: a bench-to-bedside perspective.  Can J Anaesth. 2006;  53 562-71
• 43 Kaneko M, Mestre C, Sanchez EH, Hammond DL. Intrathecally administered gabapentin inhibits formalin-evoked nociception and the expression of Fos-like immunoreactivity in the spinal cord of the rat.  J Pharmacol Exp Ther. 2000;  292 743-51
• 44 Smiley MM, Lu Y, Vera-Portocarrero LP, Zidan A, Westlund KN. Intrathecal gabapentin enhances the analgesic effects of subtherapeutic dose morphine in a rat experimental pancreatitis model.  Anesthesiology. 2004;  101 759-65
• 45 Sills GJ. The mechanisms of action of gabapentin and pregabalin.  Curr Opin Pharmacol. 2006;  6 108-13
• 46 Dahl JB, Mathiesen O, Moiniche S. Protective premedication': an option with gabapentin and related drugs? A review of gabapentin and pregabalin in in the treatment of post-operative pain.  Acta Anaesthesiol Scand. 2004;  48 1130-6
• 47 Ho KY, Gan TJ, Habib AS. Gabapentin and postoperative pain - a systematic review of randomized controlled trials.  Pain. 2006; 
• 48 Hurley RW, Cohen SP, Williams KA, Rowlingson AJ, Wu CL. The analgesic effects of perioperative gabapentin on postoperative pain: a meta-analysis.  Reg Anesth Pain Med. 2006;  31 237-47
• 49 Seib RK, Paul JE. Preoperative gabapentin for postoperative analgesia: a meta-analysis.  Can J Anaesth. 2006;  53 461-9
• 50 Turan A, Kaya G, Karamanlioglu B, Pamukcu Z, Apfel CC. Effect of oral gabapentin on postoperative epidural analgesia.  Br J Anaesth. 2006;  96 242-6
• 51 Dierking G, Duedahl TH, Rasmussen ML, Fomsgaard JS, Moiniche S, Romsing J, Dahl JB. Effects of gabapentin on postoperative morphine consumption and pain after abdominal hysterectomy: a randomized, double-blind trial.  Acta Anaesthesiol Scand. 2004;  48 322-7
• 52 Fassoulaki A, Patris K, Sarantopoulos C, Hogan Q. The analgesic effect of gabapentin and mexiletine after breast surgery for cancer.  Anesth Analg. 2002;  95 985-91
• 53 Fassoulaki A, Stamatakis E, Petropoulos G, Siafaka I, Hassiakos D, Sarantopoulos C. Gabapentin attenuates late but not acute pain after abdominal hysterectomy.  Eur J Anaesthesiol. 2006;  23 136-41
• 54 Kehlet H. Perioperative analgesia to prevent chronic postmastectomy pain.  Anesth Analg. 2006;  103 494-5
• 55 Menigaux C, Adam F, Guignard B, Sessler DI, Chauvin M. Preoperative gabapentin decreases anxiety and improves early functional recovery from knee surgery.  Anesth Analg. 2005;  100 1394-9
• 56 Hill CM, Balkenohl M, Thomas DW, Walker R, Mathe H, Murray G. Pregabalin in patients with postoperative dental pain.  Eur J Pain. 2001;  5 119-24
• 57 Rowbotham DJ. Gabapentin: a new drug for postoperative pain?.  Br J Anaesth. 2006;  96 152-5
• 58 Pandey CK, Navkar DV, Giri PJ, Raza M, Behari S, Singh RB, Singh U, Singh PK. Evaluation of the optimal preemptive dose of gabapentin for postoperative pain relief after lumbar diskectomy: a randomized, double-blind, placebo-controlled study.  J Neurosurg Anesthesiol. 2005;  17 65-8
• 59 Bisgaard T, Klarskov B, Kehlet H, Rosenberg J. Preoperative dexamethasone improves surgical outcome after laparoscopic cholecystectomy: a randomized double-blind placebo-controlled trial.  Ann Surg. 2003;  238 651-60
• 60 Karst M, Kegel T, Lukas A. Effect of celecoxib and dexamethasone on postoperative pain after lumbar disc surgery.  Neurosurgery. 2003;  53 336-337
• 61 Afman CE, Welge JA, Steward DL. Steroids for post-tonsillectomy pain reduction: meta-analysis of randomized controlled trials.  Otolaryngol Head Neck Surg. 2006;  134 181-6
• 62 Romundstad L, Breivik H, Niemi G. Methylprednisolone intravenously 1 day after surgery has sustained analgesic and opioid-sparing effects.  Acta Anaesthesiol Scand. 2004;  48 1223-1231
• 63 Romundstad L, Breivik H, Roald H. Methylprednisolone reduces pain, emesis, and fatigue after breast augmentation surgery: a single-dose, randomized, parallel-group study with methylprednisolone 125 mg, parecoxib 40 mg, and placebo.  Anesth Analg. 2006;  102 418-425
• 64 Aanonsen LM, Lei S, Wilcox GL. Excitatory amino acid receptors and nociceptive neurotransmission in rat spinal cord.  Pain. 1990;  42 309-321
• 65 Sauerland S, Nagelschmidt M, Mallmann P, Neugebauer EA. Risks and benefits of preoperative high dose methylprednisolone in surgical patients: a systematic review.  Drug Saf. 2000;  23 449-61
• 66 Cassuto J, Wallin G, Hogstrom S, Faxen A, Rimback G. Inhibition of postoperative pain by continuous low-dose intravenous infusion of lidocaine.  Anesth Analg. 1985;  64 971-4
• 67 Groudine SB, Fisher HA, Kaufman RP, Jr., Patel MK, Wilkins LJ, Mehta SA, Lumb PD. Intravenous lidocaine speeds the return of bowel function, decreases postoperative pain, and shortens hospital stay in patients undergoing radical retropubic prostatectomy.  Anesth Analg. 1998;  86 235-9
• 68 Koppert W, Weigand M, Neumann F, Sittl R, Schuettler J, Schmelz M, Hering W. Perioperative intravenous lidocaine has preventive effects on postoperative pain and morphine consumption after major abdominal surgery.  Anesth Analg. 2004;  98 1050-5
• 69 Stiehl M. Controlled release oxycodone-a new option in the treatment of severe and very severe pain. Review of studies on neuropathic, physical activity-related and postoperative pain.  MMW Fortschr Med. 2004;  146 61-9
• 70 Cheville A, Chen A, Oster G, McGarry L, Narcessian E. A randomized trial controlled-release oxycodone during inpatient rehabilitation following unilateral total knee arthroplasty.  J. Bone Joint Surg. Am. 2001;  83 572-576
• 71 Kampe S, Warm M, Kaufmann J, Hundegger S, Mellinghoff H, Kiencke P. Clinical efficacy of controlled release oxycodone 20 mg administered on a 12-n dosing schedule on the management of postopeative pain after breast surgery for cancer.  Curr. Med. Res. Opin. 2004;  20 199-202
• 72 Ginsberg B, Sinatra RS, Adler LJ, Crews JC, Hord AH, Laurito CE, Ashburn MA. Conversion to oral controlled-release oxycodone from intravenous opioid analgesic in the postoperative setting.  Pain Med. 2003;  4 31-8
• 73 Gimbel JS, Ahdieh H. The Efficacy and safety of oral immediate-release oxymorphone for postsurgical pain.  Anesthesia and Analgesia. 2004;  99 1472-1477
• 74 Kalso E. Oxycodone.  Journal of Pain and Symptom Management. 2005;  55 S47-S56