Journal of Pain & Palliative Care Pharmacotherapy. 2014;28:314–315. ISSN: 1536-0288 print / 1536-0539 online DOI: 10.3109/15360288.2014.941137
EUROPEAN PERSPECTIVES ON PAIN AND PALLIATIVE CARE
Pain Management Discussion Forum: Prevention of Chronic Postoperative Pain Harald Breivik AB STRACT A case of a 35-year-old woman scheduled for removal of a painful breast tumor is discussed. Ways to reduce risk of chronic pain developing postoperatively are described. Preoperative medications, nerve blocks, local anesthetics, and postoperative epidural pharmacotherapy are described. This report is adapted from paineurope 2014; Issue 1, ©Haymarket Medical Publications Ltd., and is presented with permission. paineurope is provided as a service to pain management by Mundipharma International, Ltd., and is distributed free of charge to health care professionals in Europe. Archival issues can be accessed via the Web site: http://www.paineurope.com, at which European health professionals can register online to receive copies of the quarterly publication. KEYWORDS anesthetic, chronic, dexamethasone, dextromethadone, epidural, ketamine, local, pain, postoperative, pregabalin, prevention
A 35-year-old woman is scheduled for removal of a painful (possibly infected) breast tumor. She has a history of migraine headaches, has endometriosis, and had several episodes of nonspecific low back pain lasting several months each time. She is due to receive chemotherapy soon after removal of her breast tumor. She is nervous, having catastrophizing thoughts about not surviving surgery and about already having metastasis, and she has been told that there is a real risk of having chronic and difficult-to-treat pain after her surgery.
What should we do to reduce her risk of developing chronic pain after this operation?
RESPONSE This patient has most of the well-documented risk factors for persistent neuropathic-type pain after breast surgery, chronic postoperative pain (CPP)1–4 :
• Pain in the surgical area • Chronic pain conditions not related to the area of surgery • Extreme stress and nervousness about the outcome of the operation, with catastrophizing thoughts • Requires chemotherapy and possibly radiation therapy after removal of the breast tumor
Harald Breivik, MD, DMSc, FRCA, is Emeritus Professor of Anesthesiology, University of Oslo, Oslo, Norway. This report is adapted from paineurope 2014; Issue 1, ©Haymarket Medical Publications Ltd., and is presented with permission. paineurope is provided as a service to pain management by Mundipharma International, Ltd., and is distributed free of charge to health care professionals in Europe. Archival issues can be accessed via the Web site: http://www.paineurope.com, at which European health professionals can register online to receive copies of the quarterly publication. Address correspondence to: Dr. Harald Brievik, Division of Anesthesiology and Intensive Care, Rikshospitalet University Hospital, 0027 Oslo, Norway (Email: [email protected]
This patient needs all the measures we can offer her that are documented to have at least some effect on the risk of developing CPP: before surgery, a thorough explanation of the approach to pain management is important for alleviating her severe anxiety. I would give her pregabalin 300 mg before surgery 314
EUROPEAN PERSPECTIVES ON PAIN AND PALLIATIVE CARE
and continue with 150 mg twice daily after surgery and for the next 2 weeks. I would offer paravertebral blocks of thoracics 1 to 5 using lidocaine 20 mg per mL with adrenaline 5 μg per mL, 5 mL at each level (four levels), making sure the blocks are placed on the correct side. An even better alternative is a high thoracic epidural anesthesia, which can be continued as epidural analgesia after surgery for as long as necessary, using bupivacaine 1 mg per mL plus fentanyl 2 μg per mL and adrenaline 2 μg per mL at 5 to 10 mL per hour. With paravertebral and epidural blocks, she does not need a general anesthetic. But for her comfort and because of her hypervigilant state of mind, I would give her ketamine after she is asleep with 70% nitrous oxide, as both reduce the risk of CPP. For induction of anesthesia, I would give a bolus of lidocaine 100 mg intravenously (IV), which also reduces risk of CPP, before the induction agents, maintaining general anesthesia with nitrous oxide 70% in the inhaled gas mixture. I would give her one bolus of ketamine 500 μg per kg after induction and two more boluses during surgical anesthesia. I might even consider an IV infusion of ketamine at 2 μg per kg per minute for the day of surgery and the next two postoperative days. At the start of surgery, I would give her dexamethasone 16 mg IV. Dexamethasone 16 mg prevents postoperative nausea, reduces the risk of CPP, and is a potent analgesic with duration of action of up to 72 hours. I would consider with the surgeon the increased risk of chronic pain if an axillary lymph node dissection is performed, as compared with sentinel node biopsy,2,3 and discuss the importance of keeping the surgery as “atraumatic” as possible. After surgery, I would keep her pain-free, preferably by means of an epidural infusion of local anesthetic plus fentanyl and adrenaline (see above), for at least 2 days. If this approach is not possible, I would
give her appropriate pharmacotherapy with multimodal analgesia using paracetamol 1g IV three times daily, ketorolac 30 mg IV twice daily, and IV patientcontrolled analgesia with morphine or oxycodone as required to maintain a visual analogue scale (VAS) score (0–10) below 3 to 4 while moving the shoulder and arm on the operated side, although methadone may be preferable, given as a 20 mg IV bolus at the start of surgery, with an immediate postoperative booster bolus dose of 2–3 mg IV, as necessary. Dextromethadone in racemic methadone tablets is an Nmethyl-D-aspartate (NMDA) antagonist, which may be the reason why methadone has a superior effect on neuropathic pain compared with pure mu-opioidreceptor agonists such as morphine. The many drugs proposed here may seem like “overkill.” But please remember that approximately 30–50% of patients like her have CPP 5 years after tumor removal.1,4 This patient has more significant risk factors for CPP than the “average” breast cancer patient. Severe CPP could destroy her quality of life for the remainder of her life. It is therefore vitally important for her that we do everything that has some evidence for effectiveness in reducing the risk of CPP. I have seen too many sad cases of such patients being neglected as a result of physicians’ lack of knowledge or experience with CPP. Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.
REFERENCES  Rashiq S, Dick BD. Can J Anesth. 2013 Nov 2 [Epub ahead of print].  Haroutiunian S, Nikolajsen L, et al. Pain. 2013;154:95–102.  Kehlet H, Jensen TS, Woolf CJ. Lancet. 2006;367:1618–1625.  Sipil¨a R, Estlander AM, et al. Br J Cancer. 2012;107:1459–1466.
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