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. 1991 Jul-Aug;64(4):351–374.

Current methods of controlling post-operative pain.

R S Sinatra 1
PMCID: PMC2589526  PMID: 1667560

Abstract

Until recently, the clinical significance of post-surgical pain and its undertreatment were for the most part unappreciated. Recognition that inadequate analgesia adversely affects the patient's cardiovascular, pulmonary, and emotional status has spurred development of new and highly effective methods of controlling pain. With the introduction of spinal opioid and patient-controlled analgesia (PCA) came the realization that, while such forms of therapy provided superior pain relief, they were not without their own unique and occasionally serious side effects. For this reason, both techniques are more safely provided by highly trained members of a dedicated acute/post-surgical pain service. Although spinal opioid (epidural, intrathecal) techniques are invasive and require patient cooperation, they have a high degree of safety in low-risk populations (ASA 1 and 2). The major therapeutic advantage of spinal opioids is their ability to prevent pain from being perceived. PCA permits patients to titrate intravenous opioids in proportion to their particular level of pain intensity. Although PCA provides effective pain "relief," the technique is incapable of preventing pain from being appreciated. A number of studies have observed that pain scores in patients successfully employing PCA were significantly higher than those noted in individuals treated with epidural opioids. Nevertheless, the control gained by self-administration, uniformity of analgesia, and low level of adverse results associated with PCA provides higher patient satisfaction and decreased sedation when compared with traditional intramuscular dosing. The effectiveness of PCA may be improved by adjusting for patient variables, utilizing opioids having rapid onset, the addition of a basal infusion, and supplementation with non-steroidal anti-inflammatory agents. Interpleural analgesia represents an important therapeutic option in patients sensitive to opioid-induced respiratory depression. The technique is more effective when local anesthetic solutions are continually infused. Analgesic efficacy may be further enhanced by the addition of "low-dose" PCA.

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Selected References

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  1. Abboud T. K., Moore M., Zhu J., Murakawa K., Minehart M., Longhitano M., Terrasi J., Klepper I. D., Choi Y., Kimball S. Epidural butorphanol or morphine for the relief of post-cesarean section pain: ventilatory responses to carbon dioxide. Anesth Analg. 1987 Sep;66(9):887–893. [PubMed] [Google Scholar]
  2. Bailey P. W., Smith B. E. Continuous epidural infusion of fentanyl for postoperative analgesia. Anaesthesia. 1980 Oct;35(10):1002–1006. doi: 10.1111/j.1365-2044.1980.tb05002.x. [DOI] [PubMed] [Google Scholar]
  3. Birnbach D. J., Johnson M. D., Arcario T., Datta S., Naulty J. S., Ostheimer G. W. Effect of diluent volume on analgesia produced by epidural fentanyl. Anesth Analg. 1989 Jun;68(6):808–810. [PubMed] [Google Scholar]
  4. Blackburn C. Respiratory arrest after epidural sufentanil. Anaesthesia. 1987 Jun;42(6):665–666. doi: 10.1111/j.1365-2044.1987.tb03098.x. [DOI] [PubMed] [Google Scholar]
  5. Bollish S. J., Collins C. L., Kirking D. M., Bartlett R. H. Efficacy of patient-controlled versus conventional analgesia for postoperative pain. Clin Pharm. 1985 Jan-Feb;4(1):48–52. [PubMed] [Google Scholar]
  6. Brismar B., Pettersson N., Tokics L., Strandberg A., Hedenstierna G. Postoperative analgesia with intrapleural administration of bupivacaine-adrenaline. Acta Anaesthesiol Scand. 1987 Aug;31(6):515–520. doi: 10.1111/j.1399-6576.1987.tb02613.x. [DOI] [PubMed] [Google Scholar]
  7. Bromage P. R., Camporesi E. M., Durant P. A., Nielsen C. H. Nonrespiratory side effects of epidural morphine. Anesth Analg. 1982 Jun;61(6):490–495. [PubMed] [Google Scholar]
  8. Bromage P. R., Camporesi E., Chestnut D. Epidural narcotics for postoperative analgesia. Anesth Analg. 1980 Jul;59(7):473–480. [PubMed] [Google Scholar]
  9. Burns J. W., Hodsman N. B., McLintock T. T., Gillies G. W., Kenny G. N., McArdle C. S. The influence of patient characteristics on the requirements for postoperative analgesia. A reassessment using patient-controlled analgesia. Anaesthesia. 1989 Jan;44(1):2–6. doi: 10.1111/j.1365-2044.1989.tb11086.x. [DOI] [PubMed] [Google Scholar]
  10. Cousins M. J., Mather L. E. Intrathecal and epidural administration of opioids. Anesthesiology. 1984 Sep;61(3):276–310. [PubMed] [Google Scholar]
  11. Cronin M., Redfern P. A., Utting J. E. Psychiatry and postoperative complaints in surgical patients. Br J Anaesth. 1973 Aug;45(8):879–886. doi: 10.1093/bja/45.8.879. [DOI] [PubMed] [Google Scholar]
  12. Duggan A. W., Hall J. G., Headley P. M. Suppression of transmission of nociceptive impulses by morphine: selective effects of morphine administered in the region of the substantia gelatinosa. Br J Pharmacol. 1977 Sep;61(1):65–76. [PMC free article] [PubMed] [Google Scholar]
  13. Duggan A. W., Johnson S. M., Morton C. R. Differing distributions of receptors for morphine and Met5-enkephalinamide in the dorsal horn of the cat. Brain Res. 1981 Dec 21;229(2):379–387. doi: 10.1016/0006-8993(81)91002-7. [DOI] [PubMed] [Google Scholar]
  14. Durrani Z., Winnie A. P., Ikuta P. Interpleural catheter analgesia for pancreatic pain. Anesth Analg. 1988 May;67(5):479–481. [PubMed] [Google Scholar]
  15. El-Baz N. M., Faber L. P., Jensik R. J. Continuous epidural infusion of morphine for treatment of pain after thoracic surgery: a new technique. Anesth Analg. 1984 Aug;63(8):757–764. [PubMed] [Google Scholar]
  16. Fischer R. L., Lubenow T. R., Liceaga A., McCarthy R. J., Ivankovich A. D. Comparison of continuous epidural infusion of fentanyl-bupivacaine and morphine-bupivacaine in management of postoperative pain. Anesth Analg. 1988 Jun;67(6):559–563. [PubMed] [Google Scholar]
  17. Glynn C. J., Mather L. E., Cousins M. J., Graham J. R., Wilson P. R. Peridural meperidine in humans: analgesic response, pharmacokinetics, and transmission into CSF. Anesthesiology. 1981 Nov;55(5):520–526. [PubMed] [Google Scholar]
  18. Gourlay G. K., Cherry D. A., Plummer J. L., Armstrong P. J., Cousins M. J. The influence of drug polarity on the absorption of opioid drugs into CSF and subsequent cephalad migration following lumbar epidural administration: application to morphine and pethidine. Pain. 1987 Dec;31(3):297–305. doi: 10.1016/0304-3959(87)90159-X. [DOI] [PubMed] [Google Scholar]
  19. Graves D. A., Arrigo J. M., Foster T. S., Baumann T. J., Batenhorst R. L. Relationship between plasma morphine concentrations and pharmacologic effects in postoperative patients using patient-controlled analgesia. Clin Pharm. 1985 Jan-Feb;4(1):41–47. [PubMed] [Google Scholar]
  20. Graves D. A., Foster T. S., Batenhorst R. L., Bennett R. L., Baumann T. J. Patient-controlled analgesia. Ann Intern Med. 1983 Sep;99(3):360–366. doi: 10.7326/0003-4819-99-3-360. [DOI] [PubMed] [Google Scholar]
  21. Harrison D. M., Sinatra R., Morgese L., Chung J. H. Epidural narcotic and patient-controlled analgesia for post-cesarean section pain relief. Anesthesiology. 1988 Mar;68(3):454–457. doi: 10.1097/00000542-198803000-00025. [DOI] [PubMed] [Google Scholar]
  22. Kafer E. R., Brown J. T., Scott D., Findlay J. W., Butz R. F., Teeple E., Ghia J. N. Biphasic depression of ventilatory responses to CO2 following epidural morphine. Anesthesiology. 1983 May;58(5):418–427. doi: 10.1097/00000542-198305000-00005. [DOI] [PubMed] [Google Scholar]
  23. Kitahata L. M., Collins J. G. Spinal action of narcotic analgesics. Anesthesiology. 1981 Feb;54(2):153–163. doi: 10.1097/00000542-198102000-00010. [DOI] [PubMed] [Google Scholar]
  24. Lamotte C., Pert C. B., Snyder S. H. Opiate receptor binding in primate spinal cord: distribution and changes after dorsal root section. Brain Res. 1976 Aug 13;112(2):407–412. doi: 10.1016/0006-8993(76)90296-1. [DOI] [PubMed] [Google Scholar]
  25. Laurito C. E., Kirz L. I., VadeBoncouer T. R., Riegler F. X., Citron G. M., Segil L. J., Pelligrino D. A. Continuous infusion of interpleural bupivacaine maintains effective analgesia after cholecystectomy. Anesth Analg. 1991 Apr;72(4):516–521. doi: 10.1213/00000539-199104000-00017. [DOI] [PubMed] [Google Scholar]
  26. Leysen J. E., Gommeren W., Niemegeers C. J. [3H]Sufentanil, a superior ligand for mu-opiate receptors: binding properties and regional distribution in rat brain and spinal cord. Eur J Pharmacol. 1983 Feb 18;87(2-3):209–225. doi: 10.1016/0014-2999(83)90331-x. [DOI] [PubMed] [Google Scholar]
  27. Loper K. A., Ready L. B., Downey M., Sandler A. N., Nessly M., Rapp S., Badner N. Epidural and intravenous fentanyl infusions are clinically equivalent after knee surgery. Anesth Analg. 1990 Jan;70(1):72–75. doi: 10.1213/00000539-199001000-00012. [DOI] [PubMed] [Google Scholar]
  28. Loper K. A., Ready L. B. Epidural morphine after anterior cruciate ligament repair: a comparison with patient-controlled intravenous morphine. Anesth Analg. 1989 Mar;68(3):350–352. [PubMed] [Google Scholar]
  29. Marks R. M., Sachar E. J. Undertreatment of medical inpatients with narcotic analgesics. Ann Intern Med. 1973 Feb;78(2):173–181. doi: 10.7326/0003-4819-78-2-173. [DOI] [PubMed] [Google Scholar]
  30. McIlvaine W. B., Knox R. F., Fennessey P. V., Goldstein M. Continuous infusion of bupivacaine via intrapleural catheter for analgesia after thoracotomy in children. Anesthesiology. 1988 Aug;69(2):261–264. doi: 10.1097/00000542-198808000-00019. [DOI] [PubMed] [Google Scholar]
  31. Modig J., Paalzow L. A comparison of epidural morphine and epidural bupivacaine for postoperative pain relief. Acta Anaesthesiol Scand. 1981 Oct;25(5):437–441. doi: 10.1111/j.1399-6576.1981.tb01682.x. [DOI] [PubMed] [Google Scholar]
  32. Moore R. A., Bullingham R. E., McQuay H. J., Hand C. W., Aspel J. B., Allen M. C., Thomas D. Dural permeability to narcotics: in vitro determination and application to extradural administration. Br J Anaesth. 1982 Oct;54(10):1117–1128. doi: 10.1093/bja/54.10.1117. [DOI] [PubMed] [Google Scholar]
  33. Naulty J. S., Datta S., Ostheimer G. W., Johnson M. D., Burger G. A. Epidural fentanyl for postcesarean delivery pain management. Anesthesiology. 1985 Dec;63(6):694–698. doi: 10.1097/00000542-198512000-00025. [DOI] [PubMed] [Google Scholar]
  34. Nishio Y., Sinatra R. S., Kitahata L. M., Collins J. G. Spinal cord distribution of 3H-morphine after intrathecal administration: relationship to analgesia. Anesth Analg. 1989 Sep;69(3):323–327. [PubMed] [Google Scholar]
  35. Owen H., Plummer J. L., Armstrong I., Mather L. E., Cousins M. J. Variables of patient-controlled analgesia. 1. Bolus size. Anaesthesia. 1989 Jan;44(1):7–10. doi: 10.1111/j.1365-2044.1989.tb11087.x. [DOI] [PubMed] [Google Scholar]
  36. Pert C. B., Kuhar M. J., Snyder S. H. Autoradiograhic localization of the opiate receptor in rat brain. Life Sci. 1975 Jun 15;16(12):1849–1853. doi: 10.1016/0024-3205(75)90289-1. [DOI] [PubMed] [Google Scholar]
  37. Rawal N., Arnér S., Gustafsson L. L., Allvin R. Present state of extradural and intrathecal opioid analgesia in Sweden. A nationwide follow-up survey. Br J Anaesth. 1987 Jun;59(6):791–799. doi: 10.1093/bja/59.6.791. [DOI] [PubMed] [Google Scholar]
  38. Rawal N., Schött U., Dahlström B., Inturrisi C. E., Tandon B., Sjöstrand U., Wennhager M. Influence of naloxone infusion on analgesia and respiratory depression following epidural morphine. Anesthesiology. 1986 Feb;64(2):194–201. doi: 10.1097/00000542-198602000-00011. [DOI] [PubMed] [Google Scholar]
  39. Rawal N., Sjöstrand U. H., Dahlström B., Nydahl P. A., Ostelius J. Epidural morphine for postoperative pain relief: a comparative study with intramuscular narcotic and intercostal nerve block. Anesth Analg. 1982 Feb;61(2):93–98. [PubMed] [Google Scholar]
  40. Rawal N., Sjöstrand U., Christoffersson E., Dahlström B., Arvill A., Rydman H. Comparison of intramuscular and epidural morphine for postoperative analgesia in the grossly obese: influence on postoperative ambulation and pulmonary function. Anesth Analg. 1984 Jun;63(6):583–592. [PubMed] [Google Scholar]
  41. Ready L. B., Chadwick H. S., Ross B. Age predicts effective epidural morphine dose after abdominal hysterectomy. Anesth Analg. 1987 Dec;66(12):1215–1218. [PubMed] [Google Scholar]
  42. Ready L. B., Oden R., Chadwick H. S., Benedetti C., Rooke G. A., Caplan R., Wild L. M. Development of an anesthesiology-based postoperative pain management service. Anesthesiology. 1988 Jan;68(1):100–106. doi: 10.1097/00000542-198801000-00016. [DOI] [PubMed] [Google Scholar]
  43. Rosen M. A., Dailey P. A., Hughes S. C., Leicht C. H., Shnider S. M., Jackson C. E., Baker B. W., Cheek D. B., O'Connor D. E. Epidural sufentanil for postoperative analgesia after cesarean section. Anesthesiology. 1988 Mar;68(3):448–454. doi: 10.1097/00000542-198803000-00024. [DOI] [PubMed] [Google Scholar]
  44. Rosenberg P. H., Scheinin B. M., Lepäntalo M. J., Lindfors O. Continuous intrapleural infusion of bupivacaine for analgesia after thoracotomy. Anesthesiology. 1987 Nov;67(5):811–813. doi: 10.1097/00000542-198711000-00034. [DOI] [PubMed] [Google Scholar]
  45. Schmauss C., Yaksh T. L. In vivo studies on spinal opiate receptor systems mediating antinociception. II. Pharmacological profiles suggesting a differential association of mu, delta and kappa receptors with visceral chemical and cutaneous thermal stimuli in the rat. J Pharmacol Exp Ther. 1984 Jan;228(1):1–12. [PubMed] [Google Scholar]
  46. Sinatra R. S., Goldstein R., Sevarino F. B. The clinical effectiveness of epidural bupivacaine, bupivacaine with lidocaine, and bupivacaine with fentanyl for labor analgesia. J Clin Anesth. 1991 May-Jun;3(3):219–215. doi: 10.1016/0952-8180(91)90164-i. [DOI] [PubMed] [Google Scholar]
  47. Sinatra R. S., Lodge K., Sibert K., Chung K. S., Chung J. H., Parker A., Jr, Harrison D. M. A comparison of morphine, meperidine, and oxymorphone as utilized in patient-controlled analgesia following cesarean delivery. Anesthesiology. 1989 Apr;70(4):585–590. doi: 10.1097/00000542-198904000-00005. [DOI] [PubMed] [Google Scholar]
  48. Sinatra R. S., Lodge K., Sibert K., Chung K. S., Chung J. H., Parker A., Jr, Harrison D. M. A comparison of morphine, meperidine, and oxymorphone as utilized in patient-controlled analgesia following cesarean delivery. Anesthesiology. 1989 Apr;70(4):585–590. doi: 10.1097/00000542-198904000-00005. [DOI] [PubMed] [Google Scholar]
  49. Sinatra R. S., Sevarino F. B., Chung J. H., Graf G., Paige D., Takla V., Silverman D. G. Comparison of epidurally administered sufentanil, morphine, and sufentanil-morphine combination for postoperative analgesia. Anesth Analg. 1991 Apr;72(4):522–527. doi: 10.1213/00000539-199104000-00018. [DOI] [PubMed] [Google Scholar]
  50. Steinstra R., van Poorten F. Immediate respiratory arrest after caudal epidural sufentanil. Anesthesiology. 1989 Dec;71(6):993–994. doi: 10.1097/00000542-198912000-00030. [DOI] [PubMed] [Google Scholar]
  51. Symreng T., Gomez M. N., Johnson B., Rossi N. P., Chiang C. K. Intrapleural bupivacaine--technical considerations and intraoperative use. J Cardiothorac Anesth. 1989 Apr;3(2):139–143. doi: 10.1016/s0888-6296(89)92258-8. [DOI] [PubMed] [Google Scholar]
  52. Tung A. S., Yaksh T. L. In vivo evidence for multiple opiate receptors mediating analgesia in the rat spinal cord. Brain Res. 1982 Sep 9;247(1):75–83. doi: 10.1016/0006-8993(82)91029-0. [DOI] [PubMed] [Google Scholar]
  53. Van der Auwera D., Verborgh C., Camu F. Analgesic and cardiorespiratory effects of epidural sufentanil and morphine in humans. Anesth Analg. 1987 Oct;66(10):999–1003. [PubMed] [Google Scholar]
  54. Wang J. K., Nauss L. A., Thomas J. E. Pain relief by intrathecally applied morphine in man. Anesthesiology. 1979 Feb;50(2):149–151. doi: 10.1097/00000542-197902000-00013. [DOI] [PubMed] [Google Scholar]
  55. Welchew E. A., Thornton J. A. Continuous thoracic epidural fentanyl. A comparison of epidural fentanyl with intramuscular papaveretum for postoperative pain. Anaesthesia. 1982 Mar;37(3):309–316. doi: 10.1111/j.1365-2044.1982.tb01105.x. [DOI] [PubMed] [Google Scholar]
  56. Wells D. G., Davies G. Profound central nervous system depression from epidural fentanyl for extracorporeal shock wave lithotripsy. Anesthesiology. 1987 Dec;67(6):991–992. doi: 10.1097/00000542-198712000-00022. [DOI] [PubMed] [Google Scholar]
  57. White P. F. Mishaps with patient-controlled analgesia. Anesthesiology. 1987 Jan;66(1):81–83. doi: 10.1097/00000542-198701000-00018. [DOI] [PubMed] [Google Scholar]
  58. Wittels B., Scott D. T., Sinatra R. S. Exogenous opioids in human breast milk and acute neonatal neurobehavior: a preliminary study. Anesthesiology. 1990 Nov;73(5):864–869. doi: 10.1097/00000542-199011000-00012. [DOI] [PubMed] [Google Scholar]
  59. Yaksh T. L. Analgetic actions of intrathecal opiates in cat and primate. Brain Res. 1978 Sep 15;153(1):205–210. doi: 10.1016/0006-8993(78)91146-0. [DOI] [PubMed] [Google Scholar]
  60. Yaksh T. L., Rudy T. A. Analgesia mediated by a direct spinal action of narcotics. Science. 1976 Jun 25;192(4246):1357–1358. doi: 10.1126/science.1273597. [DOI] [PubMed] [Google Scholar]
  61. Yamaguchi H., Watanabe S., Motokawa K., Ishizawa Y. Intrathecal morphine dose-response data for pain relief after cholecystectomy. Anesth Analg. 1990 Feb;70(2):168–171. doi: 10.1213/00000539-199002000-00006. [DOI] [PubMed] [Google Scholar]
  62. Yeager M. P., Glass D. D., Neff R. K., Brinck-Johnsen T. Epidural anesthesia and analgesia in high-risk surgical patients. Anesthesiology. 1987 Jun;66(6):729–736. doi: 10.1097/00000542-198706000-00004. [DOI] [PubMed] [Google Scholar]
  63. van den Hoogen R. H., Colpaert F. C. Epidural and subcutaneous morphine, meperidine (pethidine), fentanyl and sufentanil in the rat: analgesia and other in vivo pharmacologic effects. Anesthesiology. 1987 Feb;66(2):186–194. doi: 10.1097/00000542-198702000-00013. [DOI] [PubMed] [Google Scholar]

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