Pain control in day surgery: SIAARTI Guidelines
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LINEE GUIDA SIAARTI
MINERVA ANESTESIOL 2004;70:5-24
Pain control in day surgery:
SIAARTI Guidelines
M. SOLCA
Coordinator of Clinical Organizational SIAARTI Recommendations for Anesthesia in Day Surgery
G. SAVOIA
Coordinator of Clinical Organizational SIAARTI Recommendations for Postoperative Pain Control
C. MATTIA
Coordinator of Clinical Organizational SIAARTI Recommendations for Pain Treatment in Day Surgery
F. AMBROSIO, G. BETTELLI , M. BERTI, L. BERTINI, D. CELLENO, F. COLUZZI,
G. FANELLI, G. FINCO, C. GIORGINI, F. GIUNTA, M. LORETO, E. MONDELLO,
F. PAOLETTI, F. PAOLICCHI, F. PETRINI, G. PITTONI, G. VARRASSI
mentation of combined techniques of local
P ain is one of the complications that most
often interfere with patient discharge after
interventions performed on a day surgery
anesthesia at the operating table, such as inci-
sion site infiltration (pre-incisional pre-emp-
basis. During the first postoperative hours, up tive analgesia) and intracavitary administration
to 40% of patients may experience moderate (intraperitoneal, intraarticular, intrafascial).
or severe pain, leading to delayed discharge or
unplanned overnight hospitalization.1 Organizational issues
Pain is affected by various factors, chiefly
by type, site and duration of surgery, type Just as in other phases, so too in postoper-
and quantity of drugs administered in the ative pain control the organizational compo-
perioperative period, anesthesia technique, nent is fundamental. Prompt patient discharge
previous analgesic treatment, sociocultural from the institution requires that the prob-
factors, sex, age and body mass index.2 lems be anticipated and the solutions identi-
The modern concept of perioperative med- fied and programmed a priori.
icine, defined as a system designed to ensure For this purpose, the following actions
the quality of healthcare services and aimed should be carried out:
at optimizing the delivery of services and — determine the characteristics of the
preventing complications, is ideally appli- expected pain in relation to the treated case
cable to the field of day surgery. Derived series;
from multimodal pain management strate-
gies and the association of several active prin- — define anesthesia treatment protocols
ciples, postoperative pain control should be suited to the case-mix of the institution;
conducted with the aim of involving the — define the pain assessment scales to be
entire day surgery team, starting from the used;
surgeon carrying out the operation. — define the patient information in order to
Not only does this approach respond to the facilitate pain monitoring as best as possible;
needs of the surgical component 3 but it also — provide tools for recording postopera-
contributes significantly to facilitating the imple- tive pain;
Vol. 70, N. 1-2 MINERVA ANESTESIOLOGICA 5LINEE GUIDA SIAARTI
— organize the modalities for the supply of The use of a multimodal postoperative
analgesics; treatment plan (level A) is recommended.
— draw up a rescue treatment plan to be The combined effects of NSAIDs and/or par-
instituted should the prescribed treatment acetamol, weak opiates (codeine, tramadol)
have only a partial effect; and local anesthetics administered and/or
— provide a telephone help line so the injected by various routes during the peri-
patient can contact the anesthesiologist-inten- operative phase (levels A-C, cf. appendices 1-
sive care physician if necessary. 2) should be exploited.
To permit rapid discharge, the possible use
of NSAIDs with a prevalent impact on COX-1
Practical set up of pain control and potent opioids at recommended thera-
treatment peutic doses should take into account poten-
tial adverse effects (gastric bleeding and/or
The fundamental points for good pain con- bleeding of the surgical wound site, NSAIDs-
trol are: induced renal damage, respiratory depres-
sion, delayed canalization, nausea, vomiting,
— adequate selection of drugs and admin- excessive sedation, difficulty in urinating,
istration times; pruritus induced by potent opioids, postop-
— regular control of the patient by staff erative hyperalgesia resulting from elimination
until discharge; of rapid half-life intraoperative opioids such
— provision of patient information and as alfentanil and remifentanil). Recent stud-
instructions appropriate with therapy; ies have shown the advantages in analgesic
— adequate involvement of the family phy- efficacy and reduced incidence of side effects
sician; of several NSAIDs with prevalent action on
— availability of a telephone help line at COX-2 or of drugs with selective action on
the institution where the intervention was COX-2 (COXIB) in injectable and oral for-
carried out. mulation for perioperative use (level B).
Clearly comprehensible written prescrip-
Underpinned by a rigorous analytic pro- tions should provide the patient with unitary
cess, the formulation of these evidence-based rescue doses, preferably as oral medication to
guidelines cover the most common treat- be used when pain is episodic and/or inci-
ments (based on the literature and expert dental.
opinion) and assign to each treatment an evi-
dence level based on its validated efficacy. Interface with technfiques
The 4 levels, as applied and developed by the of administered anesthesia
United States Preventive Services Task Force,
comprise: Within the context of multimodal periop-
— level A: evidence from important ran- erative analgesic strategies, the use of loco-
domized controlled studies, with meta-analy- regional anesthesia techniques (levels A-B) is
sis where possible; this level represents the strongly recommended.
standard on which treatment recommenda- When nerve blocks are used, discharge
tions should be based; should be permitted only after complete
— level B: evidence from one or more motor recovery and spontaneous micturition
well designed randomized controlled trials; without globus vesicalis (level B).
— level C: evidence from well designed When single or continuous peripheral
nonrandomized trials or analytic group or blocks are used, in case of residual motor
case-control studies, preferably multicenter block in a single limb, the patient should
studies or those conducted at various times; receive written procedures of protected dis-
— level D: opinions of recognized autho- charge. When single limb motor block per-
rity based on clinical experience, descriptive sists, all written procedures should be ensured
studies or expert committee reports. for protected discharge.
6 MINERVA ANESTESIOLOGICA Gennaio-Febbraio 2003LINEE GUIDA SIAARTI
Algometric data: methodology formed using reports that take into account
and criteria for use of data algometric data, complications and sudden
events.
The pain symptom should be included in Pain control should form an integral part of
the protocols of discharge criteria assessment the assessment form for user satisfaction and
in order to reduce the incidence of rehospital- of the process of validation and certification
ization for intractable pain at home (level A). of excellence of the day surgery treatment
It is also recommended that the pain assess- unit (level A). Specific audit processes should
ment methods are selected on the basis of also be carried out.
simplicity and ease of use in order to be clear-
ly documented and designed for home use
by patients and/or their family members when Training and updating
telephoning the reference team (level A).
Pain control should be a subject of training
and specific updating courses for medical
Relationship with the and nursing staff in the day hospital and in
primary care physician general for specialized personnel receiving
training in related disciplines.4
Given the importance of involving the The ABC acronym may help to remember
primary care physician in the day surgery the fundamental points of pain treatment in
process, it is also recommended that the infor- day surgery:
mation provided to the physician on treat- — assessment: systematic evaluation of
ment (type of operation and anesthesia, sum- pain as the 5th vital parameter;
mary of the course of the operation and any — balanced analgesia: prefer multimodal
complications) also includes details on anal- techniques with the association of nonopi-
gesic treatment instituted and medications oids, opioids and locoregional anesthesia;
prescribed for the postoperative period. — continuous audit: continuous verifica-
tion of patient satisfaction levels;
— discharge: discharge the patient with
Aspects of continuous improvement written instruction for home treatment of
in quality pain, including details on rescue doses;
— education: the education process of the
To ensure treatment efficacy and contin- staff (anesthetists, surgeons, nurses) should be
uous improvement in the quality of servic- continuous and also involve physicians in
es, periodic outcome reviews should be per- general medicine.
APPENDIX 1
Prediction of pain in relation to type of surgery
Pain arises in 4 body areas: operation; deep somatic pain that is well local-
— the skin: pain in the incision site is per- ized, stabbing and worsens with movement;
ceived as a sense of burning; — the viscera: dull and diffuse tenderness,
— the muscles: parietal peritoneum and crampy pain relieved by rest and associated
support structures of the viscera involved in the with signs of sympathetic hypertonous hyper-
Vol. 70, N. 1-2 MINERVA ANESTESIOLOGICA 7LINEE GUIDA SIAARTI
tension, tachycardia, nausea, vomiting, pallor, ations of the lower abdomen and the pelvis
anxiety; (except for bone tissue).
— the lower back: due to the constrained
position maintained on the operating table, Obstetrics-gynecology surgery
particularly severe in patients with lumbalgia, (examples)
sciatica.
Incisional pain is the type that most often — uterine cavity revision;
and for longer periods affects patients even — diagnostic operative hysteroscopy;
after laparotomy and arthroscopy.2 The — pick-up;
administration of local anesthetics to the site — FIVET;
of incision before the operation helps to — laparoscopy;
achieve better pain control.5 — others.
Orthopedics (examples) Problems related to surgery
— neurolysis;
Typical pain in obstetrics and gynecology
— arthroscopy; surgery is associated with spontaneous uterine
— tenorrhaphy; contraction and is caused by drugs adminis-
— de Querven; tered for this purpose. It is an exquisitely vis-
— removal of fixation devices; ceral pain. Nausea and vomiting are frequent;
— onychectomy; therefore, prophylactic measures are recom-
— fracture synthesis; mended.9
— others. Because no recommendations by scientif-
ic societies exist on the prevention and treat-
Problems related to surgery ment of PONV, the most efficacious treat-
Pain is an important problem, particularly ment according to evidence from authoritative
after the interventions and in relation to tour- studies 10, 11 includes:
niquet placement. The inflammatory compo- — 5-HT3 antagonists (5-hydroxytryptamine
nent is always very important. Severe pain 3 receptor);
can be predicted especially after shoulder — reduced use of protoxide during the
and knee surgery.6-8 intervention and administration of oxygen
during the postoperative period;
General surgery (examples) — metoclopramide 10 mg;
— hemorrhoids and anal fistula; — droperidol 0.5-0.75 mg;
— hernioplasty; — administration of dexamethasone 4 mg
— quadrantectomy; i.v. possibly during the preoperative phase;
— varices (stripping); — perioperative use of propofol;
— pilonidal cysts; — adequate hydration of the patient (25
— hemorrhoidectomy sphincterectomy; ml/kg);
— laparoscopy; — adequate pain treatment.
— skin lesion exeresis;
— others. ENT surgery (examples)
— myringotomy;
Problems related to surgery — tympanoplasty;
Pain after general surgery varies depending — septorhinoplasty;
on the type of intervention: it is greater after — nasal polyps;
operations of the upper abdomen, moder- — paranasal sinus lavage;
ate to severe and less prolonged after oper- — others.
8 MINERVA ANESTESIOLOGICA Gennaio-Febbraio 2003LINEE GUIDA SIAARTI
Problems related to surgery anesthetics and anti-inflammatory agents
associated with rescue doses of tramadol or
Several of these procedures, like septo-
codeine should be provided.
rhinoplasty, are particularly painful. It should
also be remembered that nausea, vomiting
and postoperative bleeding are frequent com- Urologic surgery (examples)
plications. Infiltration with a local anesthetic — bladder and prostate biopsy;
is always recommended in addition to the — prostate transuretiral resection;
administration of paracetamol and codeine or — lithotripsy;
paracetamol and tramadol. — varicocele;
— urethrotomy;
Eye surgery (examples) — circumcision;
— cataracts (faco); — hypospadias;
— trabeculectomy; — others.
— chalazion;
— pterigium; Problems related to surgery
— strabismus; In interventions on the penis, peripenile
— others. block with long-acting anesthetics is always
recommended; in interventions on varico-
Problems related to surgery cele, ileoinguinal nerve block is recommend-
ed. Except for interventions on the bladder
In minor operations like cataracts, pain and prostate, the administration of anti-inflam-
can be controlled by administering anti- matory agents may be recommended in asso-
inflammatory agents. In operations for strabis- ciation with weak opioids.
mus, besides pain, there is also a high inci-
dence of nausea and vomiting. Plastic surgery (examples)
Odontostomatology surgery (examples) — blepharoplasty;
— mastoplasty;
— dental extraction — liposuction;
— implants; — others.
— orthodontic treatment;
— others. Problems related to surgery
Problems related to surgery In liposuction and mastoplasty, pain treat-
ment should comprise drug associations pref-
The principal problems related to this area erably excluding NSAIDs due to problems
of surgery are pain and bleeding. Pain is of bleeding; in intervention with prior admin-
evoked by the inflammatory component that istration of local anesthetics good pain con-
is always present in these patients. Local trol can be provided.
APPENDIX 2
Medications and therapeutic regimens
Pharmacological treatment the necessity for multimodal therapy 12-14
Postoperative pain control, because of its especially in moderate to severe pain. The
particular characteristics, cannot always be association of different drugs allows better
achieved with single agent therapy; hence, pain control at lower drug doses:
Vol. 70, N. 1-2 MINERVA ANESTESIOLOGICA 9LINEE GUIDA SIAARTI
TABLE I.—Administration, duration and dose of FANS.
NSAIDs Route of administration Duration of action (h) dose/die
Ketoprofen os 6-8 300 mg
Naproxen 12 0.5-1 g
Ibuprofen 4-6 0.6 2-4 g
Piroxicam os 12 20-40 mg
Ketorolac os 5.1-5.4 60-90 mg
Paracetamol os 4-6 20 mg/kg every 6 h
— anti-inflammatory agents reduce the serotoninergic mechanisms of spinal inhibi-
somatic pain caused by surgical maneuvers tion of pain. The drug can be administered by
and limit the associated inflammatory reaction; the oral or rectal route. Its analgesic effect is
— local anesthetics inhibit the transmis- closely dose-dependent; at least 1 g every 6
sion of pain at the peripheral, central and h is needed in adult patients (Table I). If used
spinal levels; as the sole analgesic, the recommended dos-
— opioids block the transmission at the age is 1 g every 4 h (6 g over 24 h). But in
spinal and supraspinal level; they are useful cases of liver insufficiency, no more than 4 g
in somatic and visceral pain; over 24 h should be taken. Rectal administra-
— adjuvants increase the analgesic effect, tion has a slow and variable rate of absorp-
thus reducing both the need for the above- tion. In adults, the initial dose should be 2 g
mentioned drugs and the side effects they then 1 g every 6 h. The use of this route of
cause. administration is common in children (dosage
may vary from a minimum of 30 mg/kg to a
NSAIDS maximum of 60 mg/kg). When associated
with NSAIDs, thanks to its different mecha-
Nonsteroid anti-inflammatory drugs cause nism of action, it potentiates the effect and
a lower production of prostaglandins (at the duration of the analgesia.
central and peripheral levels), thus contribut-
ing to the control of pain in minor interven- COX-2 INHIBITORS
tions, in association with weak opioids (tram-
adol, codeine) for major interventions, and COX-2 inhibitors were introduced to
they reduce the use of opioids by 30% to reduce the side effects of NSAIDs, while
40% for other types of interventions.13, 14 maintaining the same action. COX-2 inhibitors
However, the limits to NSAID administra- can reduce pain and inflammation, without
tion must always be considered (history of affecting platelet function, and reduce the
gastric bleeding for which gastroprotection is incidence of gastrointestinal side effects.15-17
necessary, coagulopathies, diagnosed NSAID The first 2 available drugs for single oral
hypersensitivity, concurrent use of other administration, celecoxib and rofecoxib
drugs acting on hemostasis, asthmatic bron- (Table II), seem to be as efficacious as clas-
chitis, latent renal insufficiency, hyperten- sic NSAIDs in inhibiting inflammation, while
sion, edema), since the extent of the adverse markedly reducing the incidence of gastric
events does not vary in relation to the route lesions endoscopically demonstrable in sub-
of administration. jects without previous gastric damage.18-20
NSAIDs should not be administered for This advantageous tolerability led the devel-
more than 5 consecutive days and never opment of a second generation of potent
above the recommended dosage since over- selective COX-2 inhibitors following celecox-
dosing leads to an increase in side effects ib and rofecoxib.
without an increase in efficacy. One agent of the new generation is pare-
Paracetamol inhibits the release of prosta- coxib, the first COX-2 selective inhibitor that
glandins in the spinal cord and affects the can be administrated by the intramuscular or
10 MINERVA ANESTESIOLOGICA Gennaio-Febbraio 2003LINEE GUIDA SIAARTI
TABLE II.—Dose and duration of action of COX-2 inhibitors.
COX-2 Dose (mg) Onset (min) Duration of action (h)
Celecoxib 400-600 (os) 45-60 12-24
Rofecoxib 50-75 (os) 30-50 12-24
Valdecoxib 40-80 (os) 30-40 24
Parecoxib 20-40 (e.v. or i.m.) 7-13 Over 12
endovenous route; it is a prodrug that is rap- less than 30 ml/min, whereas in patients with
idly converted into valdecoxib after injec- hepatic insufficiency the recommended dos-
tion. Preliminary clinical data on its good age is 50 mg every 12 h (Table III).
analgesic effect suggest the use of parecox- As with other morphine agents, the use of
ib in the treatment of postoperative pain.21 tramadol can cause nausea and vomiting.
The availability of a single drug in both inject- Generally, the incidence of these side effects
able and oral formulations allows the cor- can be reduced by avoiding elevated plas-
rect setting of a therapeutic regimen also for ma peaks and avoiding the use of bolus
home therapy. administrations; instead, continuous perfu-
sion and administration of the starting dose
TRAMADOL for at least 30 min is recommended.21
This central analgesic works mainly in 2
ways: action on µ receptors; inhibition of LOCAL ANESTHETICS
serotonin uptake and noradrenalin uptake The new generation local anesthetics
at the central level. (ropivacaine and levobupivacaine) have a
Given the agent’s marked affinity for µ lower affinity for the brain and the cardiac
receptors but reduced affinity for κ and δ muscle, making them less neurotoxic and
receptors, it may be classified as a partial cardiotoxic. They also have a good selectiv-
agonist. These properties may explain the ity for sensory and motor block (Table IV).
reduced incidence of respiratory depression,
dysphoria and paralytic ileus. It is metabolized ADJUVANTS
by the liver and chiefly excreted by the kid-
ney. The dosage should be reduced to 20 Clonidine causes membrane hyperpola-
mg/die in patients with creatinine clearance rization at the level of the posterior horn of
TABLE III.—Power, duration of action and dose of tramadol.
Drug Potency Duration (h) Maximum dose/die Starting dose
Tramadol 1/10 6 400-600 mg 2 mg/kg
(1-2 mg/kg/6 h)
Codeine 1/60 3-6 0.5 mg/kg/4 h
TABLE IV.—Onset and duration of action of local anesthetics.
Drug Onset Duration of action (min)
Lidocaine 2% Fast 60-120
Mepivacaine 2% Fast 90-180
Bupivacaine 0.5% Slow 120-240
Bupivacaine 0.125% Slow 120-240
Levobupivacaine 0.5% Intermediate 100-595
Ropivacaine 0.75% Intermediate 180-300
Ropivacaine 0.2% Intermediate
Vol. 70, N. 1-2 MINERVA ANESTESIOLOGICA 11LINEE GUIDA SIAARTI
TABLE V.—Administration of long-acting anesthetics with single nerve blocks.
Type of intervention Nerve block site
Inguinal hernia Ileohypogastric ileoinguinal
Circumcision Peripenile
Mesosalpinx Local infiltration
Shoulder arthroscopy Interscalene brachial plexus
Foot surgery Sciatic
Eye surgery Retrobulbar or peribulbar
Cholecystectomy or laparoscopic plastic surgery Incision infiltration
Elbow, wrist, hand Axillary brachial plexus
the spinal cord, potentiates the action of opi- sation, motor block sensation and sympa-
oids and has an intrinsic anesthetic action. thetic nerve block sensation), as is the admin-
Clonidine, because it binds to presynaptic istration of sequential peridural/subarach-
alpha-2 receptors, interferes with the sleep/ noid anesthesia which may lead to an elevat-
wake cycle, arterial pressure, heart rate and ed incidence of side effects. To enable rap-
nociception. In postoperative acute pain, id discharge, recovery of lower limb move-
clonidine may be used at a dose of 1 mcg/kg. ment is required; hence, local anesthetics
Generally, it is associated with local anes- are recommended that permit rapid recovery
thetics and opioids. of the motor block.
Peripheral nerve blocks: wound infiltra-
Routes of administration tion with local anesthetics are simple, safe
and efficacious techniques that provide pro-
For intraoperative analgesia during inter- longed intra- and postoperative analgesia
ventions that can be performed with gener- (Tables V, VI).
al anesthesia, the use of NSAIDs or COX-2 Nerve blocks offer several distinct advan-
selective inhibitors is recommended as is the tages:
use of potent opioids but at adequate doses — reduced need for intraoperative anes-
to avoid pharmacokinetically relevant waiting thetics and analgesics;
times during the postoperative period. — reduced need for postoperative opioid
Central or peripheral blocks allow the analgesics;
delivery of selective subarachnoid anesthesia — reduced recovery times (early mobil-
with local normobaric and/or hyperbaric ization, rapid discharge);
anesthetics; lipophilic opioids may be used — reduced postoperative incidence of nau-
with due caution (fentanil at a maximum sea and vomiting.
dose of 25 mcg and sufentanil at 5-10 γ; the The administration of long-acting anesthet-
use of low-dose morphine (LINEE GUIDA SIAARTI
TABLE VI.—Check list for patients receiving peripheral nerve blocks in day surgery.
Problem Action Assessment Discharge criteria
Risk of position injury Identify physical Check that skin is No signs of symptoms
associated with motor alterations that may integral and not associated with
paralysis affect positioning reddened position injuries
procedures.
Set patient and limbs
in anatomically correct
position.
Rest and raise limbs
and give adequate
support.
Check for signs and
symptoms of position
injury.
Risk of inadequate Identify basal situation Vital signs of patient Tissue perfusion and
perfusion due to of tissue perfusion. are stable and wound perfusion
impaired local blood Check whether peripheral saturation stable or improved
supply preexisting conditions within expected range compared with
could predispose preoperative
patient to inadequate assessment
tissue perfusion.
Assess postoperative
tissue perfusion.
Monitor any adverse
or toxic reactions and
side effects.
Knowledge of possible Give clear instructions Patient expresses Patient demonstrates
gaps due to lack of on duration, functional his/her expectations to have correctly
information about recovery and possible about discharge and understood
discharge criteria symptoms correlated confirms importance prescriptions for
with nerve block. of treatment, therapy, discharge concerning
Give instructions on and prescribed pharmacological
drug prescriptions, activities treatment of pain,
care of wound site and rehabilitation process
use of devices (cast, and medications and
ice packs etc.), confirms
recovery of sensation comprehension of
and movement. instructions
Explain sequence of
expected events.
Explain necessary
home care treatment.
Assess home setting
and possible
difficulties (stairs,
access barriers etc.).
Assess response to
instructions.
ynamic viewpoint it would be better to ensure In the control of moderate-to-severe pain,
analgesic continuity by using multimodal pre- continuous and/or patient-controlled infu-
emptive analgesia (pre-incisional, intra-and sion of low-concentration anesthetics can be
postoperative).30 used with catheters placed at the level of the
Vol. 70, N. 1-2 MINERVA ANESTESIOLOGICA 13LINEE GUIDA SIAARTI
TABLE VII.—Administration of low-concentration local anesthetics in continuous infiltration and/or patient-
controlled infusion. Type of surgical intervention and sites of catheter placement.
Surgery Catheter site
Hand surgery Continuous block of brachial plexus by axillary route
Surgical wound
Shoulder surgery Continuous block of brachial plexus by interscalene route
Subacromial
Intraarticular
Foot surgery Continuous block of sciatic nerve
Breast surgery (mastoplasty, mastectomy) Surgical wound
Inguinal hernia Surgical wound (subcutaneous, subfascial)
Maxillofacial surgery Supraperiosteal
Obstetrics-gynecology surgery Surgical wound
nerve plexus or perineural 25, 26 or at the sur- than customary until the effect of the anes-
gical wound site (Table VII). thetic has worn off.
Postoperative analgesia Upper limb - pain treatment
Correct recovery room procedures include: The anesthetic effect of the peripheral
pain assessment (visual analogue scale, VAS), nerve block may last from 12 to 24 h. Start
planning of weak/strong rapid half-life opi- taking your prescribed pain medication at
oid titration and control of nausea and vom- the times indicated or before going to bed or
iting. before you start to feel pain, i.e. before the
Drug prescription for home use should effect of the anesthetic wears off.
include the use of: Take your prescribed medications at the
— full dose paracetamol at set hours; times prescribed even if you don’t feel any
— weak opioids at personalized doses pain.
(age, weight, physical condition). If you have been discharged with a small
As needed (VAS >5): pump that continues to administer the anes-
— NSAIDs or COX-2 selective inhibitor at thetic, loss of sensation and difficulty in mov-
full dose and set hours, checking for the ing may persist until the end of treatment.
absence of contraindications, also in combi-
nation with paracetamol. Upper limb - additional instructions
Oral administration is the preferred route An adult caretaker should remain with you
of delivery. at home to help you after the operation.
Remember that you won’t be able to use the
Discharge instructions operated limb for washing, dressing or eating.
for patients receiving single You may feel some numbness and have
or continuous nerve blocks changes in vision, hoarseness, a congested
nose and a red eye on the side of the oper-
Upper limb - Activities ation. These effects will disappear as the
anesthetic wears off.
The operated shoulder, arm or hand will be After the operation, you may experience
numb and weak after the operation. difficulty in breathing deeply until the anes-
It may not be possible to move your arm thetic wears off. This is caused by the effect
until the effect of the drug has worn off. of the anesthesia on the nerve controlling
Pay attention to how the arm and particu- the diaphragm (the muscle you use to
larly the elbow are positioned. Rest your arm breathe). You’ll feel better if you lie down
on 2 pillows or keep the brace on while and sleep with your head and upper part of
awake and while sleeping. the body resting on 2 or 3 pillows inclined at
Avoid contact with hot or cold objects. a 45° angle. This uncomfortable feeling will
Your ability to feel hot and cold may be less disappear as the anesthetic wears off.
14 MINERVA ANESTESIOLOGICA Gennaio-Febbraio 2003LINEE GUIDA SIAARTI
Instructions for emergency calls Keep the operated limb raised on pillows
Call your physician at this number … if for as long as possible.
you have problems or questions. Use ice packs to relieve the pain and to
Go to the emergency room of the nearest reduce the swelling. Put crushed ice cubes in
hospital or call ....... if you experience cough- a plastic bag wrapped in a towel and place it
ing, chest pain or trouble breathing even on the wound for 15 to 20 min every hour.
when sitting upright. These could be signs Do not sleep with the ice pack on the wound
of an event not associated with the anes- as this may cause skin damage.
thesia. Pay attention when going up and down
stairs. If there are access barriers to your
Discharge instructions for patients home, talk to your physician about this.
receiving single or continuous Do not drive a motor vehicle until your
peripheral nerve blocks treating physician has given you permission.
Lower limb - activities
Instructions for emergency calls
The operated leg may feel numb after the
operation. Call your physician at this number … if
You will have to use crutches for walking you have problems or questions.
because your leg may give out. Call your physician at this number … if
Do not rest the weight of your body on the you experience strong headaches.
operated leg until the effect of the anesthesia Go to the emergency room of the nearest
has worn off and/or for at least 24 h unless hospital or call … if you experience cough-
otherwise instructed by the operating surgeon. ing, chest pain or trouble breathing even
Avoid contact with hot or cold objects. when sitting upright. These could be signs of
Your ability to feel hot and cold may be less an event not associated with the anesthesia.
than customary until the effect of the anes-
thetic has worn off.
Conclusions
Lower limb - pain treatment
The anesthetic effect of the peripheral The prescriptions should be clear, include
nerve block may last from 12 to 24 h. Start preferably oral medications and a treatment
taking your prescribed pain medication at regimen with regular times and dosages, fol-
the times indicated or before going to bed or lowed by rescue dose of a second drug to be
before you start to feel pain, i.e. before the administered if the pain becomes intolerable
effect of the anesthetic wears off. (VAS >5 or intense pain on a simple verbal
Take your prescribed medications at the scale).
times prescribed even if you don’t feel any An initial basal treatment should be pre-
pain. scribed for the treatment of side effects
If you have been discharged with a small caused by the medications (nausea, vomiting,
pump that continues to administer the anes- drowsiness, etc.).
thetic, loss of sensation and difficulty in mov- Ideally, the patient should be motivated
ing may persist until the end of treatment. to contact the reference center: excessive
pain despite the assumption of basal medica-
Lower limb - additional instructions tion and 1 or 2 rescue doses, onset of intract-
able side effects, recurrence of signs of motor
An adult caretaker should remain with you block of the involved limbs, dislodgement
at home to help you after the operation. of peripheral catheters for continuous infu-
Remember that you will need to use crutch- sion of local anesthetics.
es or a brace for walking. Ask your physi- A controversial issue, and one that should
cian for advice on how to walk. be the object of future clinical trials, is the use
Vol. 70, N. 1-2 MINERVA ANESTESIOLOGICA 15LINEE GUIDA SIAARTI
of potent opioids at home. Such products tors, local peri-incisional anesthetics or single
include transdermal band-aids with low-dose central or peripheral blocks;
fentanil (25 mcg/h) and/or oral formulations — rescue dose: paracetamol/codeine or
of fast-releasing morphine for the treatment tramadol.
of incident pain following complex proce- 3) Strong/intense pain:
dures with high pain intensity. — Basal drug: local peri-incisional anes-
Based on the expected level of nocicep- thetics or single central or peripheral blocks
tion, a 3-tiered ladder can be envisaged: or peripheral locoregional blocks and contin-
1) Mild pain: uous peri-incisional anesthetics, NSAIDs,
COX-2 inhibitors;
— basal drug: paracetamol, local anesthet-
ics in cream form or for peri-incisional infil- — rescue dose: tramadol, the commission
proposes the potential use of fast-release oral
tration;
morphine and/or transdermal fentanil; min-
— rescue dose: tramadol. isterial authorization limits the prescription
2) Intermediate pain: of this agent for chronic oncologic and non-
— Basal drug: NSAIDs or COX-2 inhibi- oncologic pain only.
Bibliografia
1. Chung F. Recovery pattern and home redeness after 14. Kehlet H, Dahl JB. The value of multimodal or bal-
ambulatory surgery. Can J Anaesth 1996;43:1121-7. anced analgesia in postoperative pain treatment. Anesth
2. Carpenter R. Consensus statement on acute pain man- Analg 1993;77:1048-56.
agement. Reg Anesth 1996;21:152-6. 15. Rowbotham DJ. COX-2 selective inhibitors: clinical rel-
3. De Jong. Postoperative pain tratment in ambulatory evance in surgical and acute pain. Eur J Anesthesiol
surgery. Proceedings of the 5th International Association 2002;19 (Suppl 25):11-20.
on Ambulatory Surgery Congress, Boston, May 8th- 16. Stoltz R, Harris SI, Kuss ME, LeComte D, Talwalker S,
11th, 2003. Dhadda S et. al. Upper GI mucosal effects of parecox-
4. European Board of Anaesthesiology (Reanimation and ib sodium in healthy elderly subjects. Am J Gastro-
Intensive Care). Training guidelines in anaesthesia of enterol 2002;97:65-71.
the European Board of Anaesthesiology Reanimation 17. Noveck RJ, Laurent A, Kuss M. Parecoxib sodium does
and Intensive Care. Eur J Anaesthesiol 2001;18: 563-571. not impair platelet function in healthy elderly and non-
5. Harrop-Griffiths W, Picard J. Continuous regional anal- elderly individuals. Clin Drug Invest 2001;21:465-76.
gesia: can we afford not to use it? Anaesthesia 2001; 18. Lichtenstein DR, Wolfe MM. COX-2 selective NSAIDs:
56:299-301. new and improved? JAMA 2000;284:1297-9.
6. Horn E, Schroeder F, Wilhelm S. Wound infiltration 19. White PF. The role of non opioids analgesic techniques
and dreinage lavage with ropivacaine after major shoul- in the management of pain after ambulatory surgery.
der surgery. Anesth Analg 1999;89:1461-6. Anesth Analg 2002;94:577-85.
20. Korttila K. COX-2 selective inhibition: a new advance
7. Reuben S, Sklar J. Pain management in patient who in pain management. Chairman’s introduction Eur J
undergo outpatient artrhoscopic surgery of knee. J Anaesthesiol Suppl 2002;25:1-2.
Bone Joint Surg Am 2000;82:1755-66. 21. Moore RA, McQuay HJ. Single patient metanaliysis of
8. Rassmussen S, Larseen A, Thomsen ST. Intrarticular 3453 postoperative patients: oral tramadol vs placebo,
glucorticoid bupivacine and morphine reduces pain codeine and combination analgesic. Pain 1997;69:287-94.
inflammatory response and convalescence after arthros- 22. Klein S, Nielsen K, Greengrass R, Warner DS, Martin A,
copic meniscectomy. Pain 1998;78:131-4. Stelle SM. Ambulatory discharge after long acting
9. Joshi W, Reuben S, Kjlaru PR, Sklar J, Macrolek H. peripheral nerve blockade: 2382 blocks with ropiva-
Postoperative analgesia for outpatients arthroscopic caine. Anesth Analg 2002;94;65-70.
knee surgery with intrarticular clonidine and or mor- 23. Moiniche S, Kehlet H, Dahl JB. A qualitative and quan-
phine Anesth Analg 2000;90:1012-6. titative systemic review of prempitive analgesia for
10. Tramér MR. Systematic reviews in PONV therapy. In: postoperative pain relief. Anesthesiolgy 2002;96:725-41.
Tramér MR. Evidence based resource in anaesthesia 24. Rawal N, Axelsson K, Hylander J, Allvin R, Amilon A,
and analgesia. London: BMJ Books; 2000.p.157-78. Lidegran G et al. Postoperative patient-controlled local
11. Leslie JB. How can we best prevent or treat postoper- anesthetic administration at home. Anesth Analg 1998;
ative nausea and vomiting? Curr Opin Anaesthesiol 86:86-9.
2001;14:623-27. 25. Ilfeld BM, Morey TE, Enneking K. Continuous infracla-
12. Bisgaard T, Klarkov B, Rosenberg J, Kehlet H. vicular brachial plexus block for postoperative pain
Characteristics and prediction of early pain after lapar- control at home. Anesthesiology 2002;96:1297-304.
oscopic cholecystectomy. Pain 2001;90:261-9. 26. Rawal N, Allvin R, Axelsson K, Hallen J, Ekback G,
13. Crews JC. Multimodal pain management strategies for Ohlsson T et al. Patient-controlled regional analgesia
officed based ambulatory procedures. JAMA 2002;629-32. (PCRA) at home. Anesthesiology 2002;96:1290-6.
16 MINERVA ANESTESIOLOGICA Gennaio-Febbraio 2003LINEE GUIDA SIAARTI
Il controllo del dolore nel Day Surgery: Linee Guida SIAARTI
I l dolore è una delle complicanze che più frequen-
temente interferiscono con la dimissione del pazien-
te dopo interventi eseguiti in regime di day surgery.
— predisposti strumenti di registrazione del dolo-
re postoperatorio;
— organizzate le modalità di approvvigionamen-
Nelle prime ore del postoperatorio, un dolore di gra- to degli antidolorifici;
do medio o severo è presente in una percentuale — predisposto un trattamento rescue in caso di
variabile, fino al 40% dei pazienti e può essere cau- effetto parziale del trattamento prescritto;
sa di ritardata dimissione o di ricovero notturno non
— predisposto un canale di comunicazione che
pianificato 1.
consenta al paziente di mettersi in contatto con il
Il dolore è influenzato da diversi fattori, di cui i più
importanti sono tipo, sede e durata di intervento, medico anestesista rianimatore qualora necessario.
tipo e quantità dei farmaci somministrati nel periodo
perioperatorio nonché tecnica di anestesia praticata,
precedenti terapie analgesiche assunte, fattori socio- Impostazione pratica
culturali, sesso, età, indice di massa corporea 2. del trattamento del dolore
Il moderno concetto di medicina perioperatoria,
inteso come sistema organizzato per assicurare qua- I punti fondamentali per un buon controllo del
lità nel servizio durante l’iter assistenziale e finalizzato dolore sono:
all’ottimizzazione delle prestazioni e alla prevenzio- — scelta adeguata dei farmaci e dei loro tempi di
ne delle complicanze, trova proprio nella day sur- somministrazione;
gery il campo di applicazione ottimale. — regolare controllo del paziente da parte dello
Oltre a essere ispirato alla multimodalità nelle tec- staff fino alla dimissione;
niche analgesiche e nell’associazione di più principi
attivi, il trattamento del dolore postoperatorio dovreb- — fornire al paziente informazioni e istruzioni
be essere condotto con il coinvolgimento dell’intero adeguate sulla terapia;
team di day surgery, a partire dal chirurgo che esegue — adeguato coinvolgimento del medico di fami-
l’intervento. glia;
Tale coinvolgimento non solo risponde a precise — disponibilità di contatto telefonico con la strut-
esigenze della componente chirurgica 3, ma, soprat- tura ospedaliera che ha eseguito l’intervento.
tutto, contribuisce ad agevolare la realizzazione di
tecniche combinate che si avvalgono dell’uso di ane- La stesura di queste linee guida basate sull’eviden-
stetici locali al tavolo operatorio, quali l’infiltrazione za, è stata supportata da un rigoroso processo analiti-
della sede d’incisione (pre-incisional preemptive anal- co.
gesia) e la somministrazione intracavitaria (intraperi- Esse tengono conto di quelli che sono i trattamenti
toneale, intraarticolare, intrafasciale). maggiormente utilizzati (basandosi su quanto ripor-
tato in letteratura e sul parere di esperti nel settore)
e identificano ciascun trattamento con un livello di evi-
Aspetti organizzativi denza in base all’efficacia validata.
I livelli di evidenza sono 4, secondo quanto uti-
lizzato e sviluppato dalla United States Preventive
Come in tutte le altre fasi, anche per il controllo del
dolore postoperatorio, la componente organizzativa Services Task Force:
è fondamentale. La dimissione del paziente dalla — livello A: evidenza ottenuta da importanti stu-
struttura richiede che i problemi vengano anticipati e di randomizzati, controllati con eventuale meta-ana-
le soluzioni individuate e programmate a priori. lisi dove possibile, tale livello rappresenta lo stan-
dard sul quale dovrebbero essere basate le racco-
Allo scopo, è raccomandato che siano: mandazioni terapeutiche;
— individuate le caratteristiche del dolore atteso in — livello B: evidenza ottenuta da uno o più trial
funzione della casistica trattata; ben disegnati, randomizzati e controllati;
— definiti protocolli di trattamento antalgico — livello C: evidenza ottenuta da trial ben dise-
dimensionati sul case-mix della struttura; gnati non randomizzati o studi analitici di gruppo o
— definite le scale di valutazione del dolore che case-control, preferibilmente multicentrici o condot-
saranno utilizzate; ti in tempi diversi;
— definite le informazioni da fornire ai pazienti al — livello D: opinioni di autorità riconosciute basa-
riguardo, in modo da facilitare il più possibile il moni- te su esperienza clinica, studi descrittivi o report di
toraggio del sintomo; comitati di esperti.
Vol. 70, N. 1-2 MINERVA ANESTESIOLOGICA 17LINEE GUIDA SIAARTI
Si raccomanda l’utilizzo di un piano di trattamen- parenti nei contatti telefonici con il team di riferi-
to postoperatorio «multimodale» (livello A). Dovreb- mento (livello A).
bero esser sfruttati gli effetti combinati dei FANS e/o
del paracetamolo, degli oppiacei deboli (codeina,
tramadolo) e degli anestetici locali, somministrati e/o Rapporti con il medico di base
iniettati per più vie nel perioperatorio (livello A-C,
allegati 1, 2). Data l’importanza del coinvolgimento del medico
Si raccomanda che l’eventuale impiego intraope- di base nel processo di day surgery, è, inoltre, rac-
ratorio di FANS a prevalente impatto sulle COX-1 e di comandato che, tra le informazioni fornite a que-
oppiacei forti alle dosi terapeutiche consigliate tenga st’ultimo sul trattamento erogato (tipo di intervento e
conto dei potenziali effetti avversi (sanguinamento di anestesia praticata, sintesi del decorso ed even-
gastrico e/o al sito chirurgico, danno renale per i tuali complicanze), siano comprese anche quelle
FANS; depressione respiratoria, ritardi della canaliz- riguardanti il trattamento antalgico istituito e quello
zazione, nausea, vomito, eccessiva sedazione, diffi- prescritto per il postoperatorio.
coltà alla minzione, prurito per gli oppiacei forti; ipe-
ralgesia postoperatoria per gli oppiacei intraoperatori
a rapida emivita di eliminazione come alfentanil e Aspetti inerenti il miglioramento
remifentanil), ai fini di una rapida dimissione. Emerge, continuo della qualità
dalla recente letteratura, il ruolo vantaggioso, in ter-
mini di efficacia analgesica e di incidenza di effetti col- Allo scopo di garantire sia l’efficacia del tratta-
laterali, di alcuni FANS ad azione prevalente sulle mento sia il miglioramento continuo della qualità del-
COX-2 o di farmaci ad azione selettiva sulle COX-2 la prestazione, sono raccomandate periodiche revi-
(COXIB), iniettabili e per os, utilizzati perioperato- sioni dei risultati, sulla base di appositi report che
riamente (livello B). prendano in considerazione, accanto alle rilevazioni
Attraverso comprensibili prescrizioni scritte, algometriche, anche eventuali complicanze e impre-
dovrebbero essere fornite al paziente rescue dosi visti.
unitarie, preferibilmente assumibili per via orale, da Si raccomanda che il controllo del dolore sia par-
utilizzare in caso di dolore intervallare e/o incidente. te integrante delle schede di valutazione del grado di
soddisfazione del paziente e del processo di valida-
zione e certificazione di eccellenza delle unità di trat-
Aspetti d’interfaccia con le tecniche tamento di day-surgery (livello A). Si raccomanda
di anestesia praticate inoltre che vengano attivati specifici processi di audit.
Nel contesto di una analgesia multimodale perio-
peratoria, è fortemente raccomandato l’impiego del-
le tecniche di anestesia locoregionale (livello A-B). Formazione e aggiornamento specifici
Ove si impieghino blocchi centrali, è necessario
attendere, per la dimissione, un completo recupero Viene, infine, raccomandato che la materia sia
motorio e la minzione spontanea con assenza di glo- oggetto di formazione e aggiornamento specifici sia
bo vescicale (livello B). per il personale medico e infermieristico operante
Quando si utilizzino blocchi periferici singoli o nelle strutture di day surgery, sia, più in generale,
continui, in caso di blocco motorio residuo a un sin-
per il personale specialistico in formazione nelle disci-
golo arto, vanno consegnate al paziente procedure
pline coinvolte 4.
scritte di dimissione protetta.
Nei confronti della permanenza del blocco moto- L’ABC che segue può essere un modo utile per
rio a un singolo arto, vanno assicurate tutte le pro- ricordare i punti fondamentali del trattamento del
cedure scritte di dimissione protetta. dolore in day surgery:
— assessment: valutare sistematicamente il dolore
quale «quinto parametro vitale»;
Dati algometrici: metodologia e criteri — balanced analgesia: preferire tecniche di anal-
di utilizzazione dei dati gesia multimodale, che prevedano l’associazione di
non oppioidi, oppioidi e anestesia locoregionale;
È fortemente raccomandato l’inserimento del sin- — continuous audit: verificare costantemente il
tomo dolore nei protocolli di valutazione dei criteri di livello di soddisfazione del paziente;
dimissibilità, allo scopo primario di ridurre l’inciden- — dimissione: dimettere il paziente con istruzioni
za di riospedalizzazioni motivate da dolore non trat- scritte per il trattamento domiciliare del dolore, com-
tabile a domicilio (livello A). presa l’indicazione delle rescue doses;
Si raccomanda che le metodiche di misura del — educazione: il processo di educazione dello
dolore vengano scelte sulla base della semplicità e staff (anestesisti, chirurghi, infermieri) deve essere
praticità d’uso, allo scopo di essere chiaramente docu- continuo e deve coinvolgere anche i medici di medi-
mentabili e utilizzabili a domicilio dai pazienti e/o cina generale.
18 MINERVA ANESTESIOLOGICA Gennaio-Febbraio 2004LINEE GUIDA SIAARTI
ALLEGATO 1
Previsione del dolore in funzione della tipologia chirurgica
Il dolore proviene da 4 siti fondamentali: Problematiche legate alla chirurgia
— cute: dolore nella sede dell’incisione avvertito
come bruciore; Il dolore dopo chirurgia generale varia in manie-
— muscoli, peritoneo parietale e strutture di sup- ra abbastanza netta a seconda della sede dell’inter-
porto dei visceri interessati dall’intervento: dolore di vento: è maggiore per interventi sull’addome supe-
tipo somatico profondo ben localizzato, pungente, riore, è moderato grave e meno duraturo negli inter-
aggravato dai movimenti; venti del basso addome e della pelvi (non compren-
— visceri: dolorabilità sorda e diffusa, crampifor- denti il tessuto osseo).
me attenuata dal riposo e associata a segni di iperto-
no simpatico ipertensione, tachicardia, nausea, vomi- Chirurgia ostetrico-ginecologica (esempi di inter-
to, pallore, ansia; vento)
— dolore in sede dorso lombare: dovuto alla posi-
zione obbligata sul letto operatorio, particolarmente — revisioni cavità uterina;
accentuato nei pazienti già affetti da lombalgia, scia- — isteroscopie operative diagnostiche;
talgia. — pick-up;
Il dolore incisionale è quello che, più spesso, e per — FIVET;
più tempo, impegna il paziente anche dopo procedu- — laparoscopia;
re laparo e artroscopiche 2. La somministrazione di
— altri.
anestetici locali prima dell’intervento in sede di incisione
aiuta a ottenere un miglior controllo del dolore 5.
Problematiche legate alla chirurgia
Ortopedia (esempi di intervento) Il dolore caratteristico nella chirurgia ginecologica
e ostetrica è quello legato alla contrazione uterina
— neurolisi; spontanea e determinata dai farmaci somministrati
— artroscopia; all’uopo. È un dolore, quindi, strettamente viscerale.
— tenorrafie; Inoltre, è frequente l’incidenza di nausea e vomito,
— de Querven; pertanto si consiglia la loro prevenzione 9.
— rimozione di mezzi di sintesi; In assenza di raccomandazioni di società scienti-
— onicectomia; fiche per la prevenzione e il trattamento della nausea
e del vomito postoperatorio, sulla base dell’evidenza
— sintesi di fratture; di autorevoli lavori scientifici a riguardo 10, 11, i trat-
— altri. tamenti più efficaci risultano essere:
— antagonisti della 5-HT3 (recettore 3 della 5-
Problematiche relative alla chirurgia idrossitriptamina);
— riduzione dell’utilizzo del protossido durante
Il dolore è importante soprattutto dopo l’inter- l’intervento e somministrazione di ossigeno nel posto-
vento anche in relazione al posizionamento del toru- peratorio;
niquet. La componente infiammatoria è sempre mol- — metoclopramide 10 mg;
to importante. Un dolore severo può essere previsto
soprattutto dopo chirurgia della spalla e del ginoc- — droperidolo 0,5-0,75 mg;
chio 6-8. — somministrazione di desametasone 4 mg e.v.,
possibilmente nel preoperatorio;
— impiego perioperatorio del propofol;
Chirurgia generale (esempi di intervento)
— adeguata idratazione del paziente (25 ml/kg);
— emorroidi e fistola anale; — adeguato trattamento del dolore.
— ernioplastica;
— quadrantectomia; Chirurgia ORL (esempi di intervento)
— varici (stripping); — miringotomia;
— cisti pilonidali; — timpanoplastica;
— emorroidectomie sfinterotomia; — settorinoplastica;
— laparoscopie; — poliposi nasale;
— exeresi di lesioni cutanee; — lavaggio dei seni paranasali;
— altri. — altri.
Vol. 70, N. 1-2 MINERVA ANESTESIOLOGICA 19LINEE GUIDA SIAARTI
Problematiche legate alla chirurgia Prevedere la somministrazione di anestetici locali
e anti-infiammatori associati a rescue dose di trama-
Alcune di queste procedure come la settorinoplastica dolo o codeina.
sono particolarmente dolorose inoltre, deve essere
ricordato che, in questi pazienti, sono frequenti com-
plicanze di nausea vomito e sanguinamento postope- Chirurgia urologica (esempi di intervento)
ratorio. È sempre consigliata l’infiltrazione con ane- — biopsia vescicale e prostatica;
stetico locale, oltre che la somministrazione di para-
cetamolo e codeina o paracetamolo e tramadolo. — resezione transuretrale della prostata;
— litotrissia;
— varicocele;
Chirurgia oculistica (esempi di intervento)
— uretrotomie;
— cataratta (faco); — circoncisione;
— trabeculectomia; — ipospadia;
— calazio; — altri.
— pterigio;
— strabismo; Problematiche legate alla chirurgia
— altri. Negli interventi sul pene è sempre consigliata l’e-
secuzione del blocco peripenieno con anestetici a
Problematiche legate alla chirurgia lunga durata; negli interventi di varicocele è consi-
Negli interventi minori, come la cataratta, la sinto- gliato il blocco del nervo ileoinguinale
matologia dolorosa può essere controllata semplice- A esclusione degli interventi su vescica e prostata;
mente somministrando degli anti-infiammatori. Negli la somministrazione di anti-infiammatori può essere
interventi di strabismo, oltre al dolore, deve essere consigliata in associazione a oppioidi minori.
tenuta presente l’alta incidenza di nausea e vomito.
Chirurgia plastica (esempi di intervento)
Chirurgia odontostomatologica (esempi di inter- — blefaro-plastiche;
vento) — mastoplastiche;
— estrazioni dentarie; — liposuzioni;
— impianti; — altri.
— trattamenti ortodontici;
— altri. Problematiche legate alla chirurgia
Problematiche legate alla chirurgia Per liposuzioni e mastoplastiche la terapia del
dolore deve comprendere associazioni di farmaci,
I problemi correlati a questa chirurgia sono il dolo- escludendo preferibilmente i FANS per problemi di
re e il sanguinamento. sanguinamento; inoltre, l’esecuzione degli interven-
Il dolore è evocato dalla componente infiammatoria ti previa somministrazione di anestesia locale deter-
sempre presente in questi pazienti mina un buon controllo del dolore.
ALLEGATO 2
Farmaci utilizzabili e schemi terapeutici
Trattamento farmacologico — gli anti-infiammatori determinano una riduzio-
ne del dolore somatico da trauma chirurgico e con-
Il controllo del dolore postoperatorio, per le sue tengono la reazione infiammatoria legata allo stesso;
caratteristiche particolari, non può essere sempre
ottenuto con una terapia monofarmacologica. È neces- — gli anestetici locali impediscono la trasmissione
sario, quindi, soprattutto nel dolore di intensità media del dolore a livello periferico e centrale, spinale;
e/o severa, utilizzare una «terapia multimodale» 12-14; — gli oppioidi impediscono la trasmissione a livel-
l’associazione di diversi farmaci permette di ottene- lo spinale e sovraspinale; sono utili, inoltre, sia nel
re un miglior controllo del dolore con dosi ridotte dolore somatico che viscerale;
degli stessi farmaci: — gli adiuvanti rinforzano l’analgesia e riducono,
20 MINERVA ANESTESIOLOGICA Gennaio-Febbraio 2004LINEE GUIDA SIAARTI
quindi, il consumo dei suddetti farmaci e gli effetti col- cedenti lesioni gastriche 18-20. Questa vantaggiosa
laterali degli stessi. tollerabilità ha promosso lo sviluppo di una seconda
generazione di potenti e selettivi COX-2 inibitori, suc-
FANS cessivi al celecoxib e al rofecoxib.
Alla nuova generazione appartiene il parecoxib
I farmaci anti-infiammatori non steroidei determi- (Tabella II), il primo inibitore selettivo delle COX-2
nano una minore produzione a livello centrale e peri- somministrabile per via intramuscolare ed endove-
ferico di prostaglandine, contribuendo così a con- nosa, un profarmaco che viene convertito in breve
trollare la sintomatologia dolorosa per interventi di lie- tempo dopo l’iniezione nel valdecoxib. Dati clinici
ve intensità, in associazione agli oppioidi deboli (tra- preliminari di buona efficacia antalgica suggeriscono
madolo, codeina) per interventi di moderata intensità l’uso del parecoxib nel dolore post-operatorio 21, la
e diminuendo il consumo di oppioidi del 30-40% per disponibilità di un unico farmaco, in formulazione
gli altri tipi di interventi 13, 14. sia iniettabile che orale, permette di impostare cor-
Tuttavia i limiti alla somministrazione di FANS rettamente lo schema terapeutico, anche successiva-
devono sempre essere rispettati (anamnesi positiva mente a domicilio.
per gastropatie in cui sono indispensabili misure di
gastroprotezione, coagulopatie, ipersensibilità accer-
tata ai FANS, impiego simultaneo di altri farmaci atti- TRAMADOLO
vi sull’emostasi, bronchite asmatica, insufficienza È un analgesico di tipo centrale che agisce princi-
renale latente, ipertensione, edema), poiché l’entità palmente in 2 maniere:
degli effetti avversi non varia in funzione della via di — azione sui recettori µ;
somministrazione.
— inibizione della ricaptazione della serotonina
I FANS non dovrebbero essere somministrati per
e della noradrenalina a livello centrale.
più di 5 giorni di fila ma, soprattutto non oltre il
dosaggio consigliato, poiché a un iperdosaggio si Ha una affinità spiccata per i recettori µ ma ridot-
accompagna solo un aumento degli effetti collatera- ta per κ e δ, potrebbe essere classificato come un
li e non un aumento dell’efficacia. agonista parziale; ciò spiega la ridotta incidenza di
Il paracetamolo inibisce il rilascio di prostaglandi- depressione respiratoria, disforia, ileo paralitico. Viene
ne nel midollo spinale e influisce sui meccanismi metabolizzato per via epatica ed escreto, per la mag-
serotoninergici dell’inibizione spinale del dolore. Può gior parte, attraverso il rene. Il dosaggio dovrebbe
essere somministrato per via orale e rettale. Il suo essere ridotto a 200 mg die in pazienti con creatini-
effetto sul dolore è strettamente dose dipendente e na clearance inferiore a 30 ml/min mentre, in pazien-
sono necessari almeno 1 g ogni 6 h per i pazienti ti affetti da insufficienza epatica, il dosaggio consigliato
adulti (Tabella I). Se viene utilizzato come unico anal- è di 50 mg ogni 12 h. Come per altri morfinici, l’uso
gesico è consigliata la somministrazione di 1 g ogni del tramadolo può comportare nausea e vomito: in
4 h (6 g nelle 24 h), ma se c’è insufficienza epatica, genere, si riesce a ridurre l’incidenza di questi effet-
è bene non superare la dose di 4 g nelle 24 h. La ti collaterali, evitando elevati picchi plasmatici e la
somministrazione per via rettale ha un assorbimento somministrazione in boli, e preferendo la perfusione
lento e variabile, la dose iniziale nell’adulto deve continua e somministrando in almeno 30 min la dose
essere 2 g seguita da 1 g ogni 6 h. L’utilizzo di que- di carico iniziale 21.
sta via di somministrazione è frequente nei bambini
(il dosaggio può variare da un minimo di 30 mg/kg ANESTETICI LOCALI
a 60 mg/kg). Quando viene associato ai FANS, grazie
al differente meccanismo d’azione, potenzia l’effetto Gli anestetici locali di nuova generazione (ropi-
e la durata dell’analgesia. vacaina e levobupivacaina) hanno un’affinità minore
per l’encefalo e il muscolo cardiaco, per cui sono
COX-2 INIBITORI meno neurotossici e cardiotossici, presentano, inol-
tre, una buona selettività del blocco sensitivo e di
Nell’intento di ridurre gli effetti collaterali da FANS, quello motorio (Tabella IV).
mantenendone inalterata l’attività, sono stati intro-
dotti i COX2 inhibitors. Tali farmaci sono in grado di ADIUVANTI
ridurre il dolore e l’infiammazione senza influire sul-
la funzione piastrinica e con bassa incidenza di effet- La clonidina determina una iperpolarizzazione di
ti collaterali gastrointestinali 15-17. membrana a livello del corno posteriore del midollo
I primi 2 farmaci disponibili, utilizzabili con la sola spinale e svolge un’azione di potenziamento degli
somministrazione orale – celecoxib e rofecoxib oppioidi, oltre a un’azione anestetica intrinseca. La clo-
(Tabella II), sembrano essere efficaci quanto i FANS nidina legandosi ai recettori α2 presinaptici interferisce
classici nel sopprimere l’infiammazione, pur ridu- con il ritmo sonno veglia, con la pressione arteriosa,
cendo notevolmente l’incidenza di lesioni gastriche con la frequenza cardiaca e con la nocicezione. Nel
endoscopicamente dimostrabili, in soggetti senza pre- dolore acuto postoperatorio la clonidina può essere
Vol. 70, N. 1-2 MINERVA ANESTESIOLOGICA 21Puoi anche leggere
