Anesth Prog 39:142-145 1992
Postoperative Pain Control for Dental and Oral Surgery Richard V. Gregg, MD Department of Anesthesia, University of Cincinnati Medical Center Cincinnati, Ohio
level of analgesia or anesthesia and perhaps to maintain some analgesia in the postoperative period. On an outpatient basis, patients frequently need to have some mental function for getting home even though they have transportation arranged. They usually still have effective local anesthesia; without a pain stimulus, the side effects of opioids tend to be far more predominant. For those circumstances, frequently ultrashort-acting opioids, such as alfentanil, sufentanil, or fentanyl, administered intravenously may be most appropriate. These opioids are generally used only to allow the patient to tolerate the procedure more easily. For patients who may have a tolerance to opioids or who are going to remain in the hospital, one may administer small doses of fairly long-acting opioids, such as buprenorphine, levorphanol, or methadone. These medications can maintain some analgesia into the postoperative period and markedly decrease the severity of pain when the nerve block wears off. In the rare patient where, for whatever reason, a nerve block is deemed inappropriate, these medications are very valuable for intraoperative administration to allow some analgesia in the postoperative period. Once the patient leaves the office or goes to the floor from the recovery room, the duration of constant and intermittent pain should be considered when prescribing analgesics. If the patient is expected to have fairly severe constant pain, either due to the extent of the surgery or some tolerance to opioids, then the longer-acting drugs need to be considered. Slow-release morphine tablets are available that can maintain relatively constant analgesia for 8 to 12 hr. Levorphanol (Levo-Dromoran) gives 6 to 8 hr of pain relief, and methadone administered orally can provide analgesia for up to 18 to 36 hr per dose after repeated use. Because of its extremely long and variable half-life, methadone is probably an inappropriate drug for dosing over several days unless the patient is already accustomed to it. It should be noted that methadone is also available as an elixir, so that patients with wired jaws can more easily ingest the medication. For intermittent mild to moderate pain, short-acting opioids should be used. This group includes most of the familiar opioids. Some of these drugs come in
The postoperative pain management of dental and oral surgery pain is, for the most part, an outpatient endeavor. There are some patients who require admission after oral surgery, but the methods described here will be applicable to either inpatient or outpatient pain management. Dentists have long been the champions of neural blockade for pain of the head and neck and particularly the oral cavity. Local anesthesia is certainly a most effective shortterm answer for postoperative pain management. The use of long-acting local anesthetics, such as bupivacaine, etidocaine, and perhaps the newcomer ropivacaine, can extend the duration of analgesia from neural blockade, but at some point the block definitely wears off. This presentation will focus on medications and routes of administration for controling pain after the nerve blocks have
dissipated.
OPIOIDS The use of opioids for postoperative pain is certainly the mainstay of analgesic regimens. Certain features should be considered when deciding on an appropriate opioid regimen for a given patient. Rational choices should include consideration of the patient's previous pain experiences, the patient's opinion of effective opioid medications, any recent opioid usage, and the severity and expected duration of the procedure's pain stimulus. Despite inappropriate labels of opioid allergy when nausea, vomiting, or other side effects have been a problem with certain opioid medications, most patients will avoid opioids they have had disagreeable experiences with in the past. It then becomes important to have a fairly extensive knowledge of the various opioids on the market. During surgery, in the office or surgical suite, it is frequently reasonable to administer opioids both for a certain Address correspondence to Dr. Richard Gregg, Department of Anesthesia, University of Cincinnati Medical Center, Cincinnati, OH 45267. © 1992 by the American Dental Society of Anesthesiology
ISSN 0003-3006/92/$6.00
142
Gregg 143
Anesth Prog 39:142-145 1992 Table 1. Nonsteroidal Antiinflammatory Drugs
Nonproprietary
Chemical Group Salicylates
Representative Trade Names
Subdivisions
Name
Acetylated Nonacetylated
Aspirin Choline salicylate Magnesium salicylate Salsalate
tntca Arthropan Magan, Mobidin Disalcid, MonoGesic, Salflex
Sodium thiosalicylate Diflunisal Fenoprofen Flurbiprofen Ibuprofen
Asproject
Derivative Propionic Acid Derivatives
Acetic Acid Derivatives
Indole Phenyl Pyrrole
Pyrazoles
Oxicams Fenamates Paraaminophenol
Ketoprofen Naproxen (sodium) Diclofenac sodium Etodolac Indomethacin Ketorolac Sulindac Tolmetin Oxyphenbutazone Phenylbutazone Piroxicam Meclofenamate Mefanamic acid Acetaminophen
Dolobid Nalfon Ansaid Motrin, Rufen, PediaProfen Orudis Naprosyn (Anaprox) Voltaren Lodine Indocin Toradol Clinoril Tolectin Oxalid, Tandearil Butazolidin Feldene Meclomen Ponstel Tylenol, Anacin-3, Panadol, etc.
aToo numerous to count.
combination with acetaminophen or aspirin, which can give additive pain relief. Some agents are also available as elixirs, which simplifies ingestion in patients with wired jaws. OTHER DRUGS
Nonopioid medications to aid in postoperative pain management have been expanded substantially in the recent past. These agents include nonsteroidal antiinflammatory drugs (NSAIDs), tricyclic antidepressants, neuroleptics, antihistamines, benzodiazepines, and ca2-adrenergic agonists. These medications are not always appropriate, but certain patients may have an indication for one or more of them.
Nonsteroidal Antiinflammatory Drugs NSAIDs have proliferated tremendously in the last 10 yr. There are about 20 such agents now on the market, many with multiple trade names, just to add to the confusion (Table 1). They have multiple actions, including analgesia, antiinflammatory and antipyretic effects, and platelet inhibition. There are relative differences in the degree to which each NSAID causes these effects, and intelligent choices can
be made using those differences. Unfortunately, NSAIDs also have multiple side effects. These include gastrointestinal (GI) irritation and bleeding, sedation, headache, diarrhea, tinnitus, fluid retention, increased blood pressure, kidney or liver damage, Reye's Syndrome, allergic-like responses, agranulocytosis, and intrauterine closure of the patent fetal ductus arteriosus. These side effects have different relative expressions as well among the NSAIDs, and they are frequently unpredictable. Although the analgesic effect of NSAIDs has an onset usually within 1 hr of administration, the antiinflammatory effect is frequently much slower to occur. Sometimes, this delay makes it reasonable to pretreat surgical candidates with NSAIDs to minimize the inflammatory response to the surgery. Certain NSAIDs are more desirable than others for pretreatment. Several of them have little to no effect on platelet function and, therefore, will not significantly affect bleeding during or after surgery. Specifically, these are the nonacetylated salicylates. These NSAIDs also tend to be better tolerated by the GI tract and are useful for decreasing the inflammatory response and pain postoperatively. There has been very little use of NSAIDs intraoperatively or immediately postoperatively, however, because they have not been formulated for parenteral administration. The marketing of ketorolac is a major de-
Anesth
144 Postoperative Pain Control
parture from this rule. Ketorolac is approved for intramuscular administration and, in fact, can be administered intravenously although it is not currently approved by the Food and Drug Administration for that route. One outstanding feature of this agent is its tremendous analgesic efficacy relative to the other nonsteroidal effects. As an example, while the antiinflammatory potency of ketorolac is between indomethacin and naproxen, the analgesic potency is 50 times that of naproxen and six times that of indomethacin. Multiple well-controlled studies of ketorolac have shown therapeutic doses to be equivalent to 6 to 12 mg of parental morphine and to last up to 6 hr rather than the 3 to 4 hr of morphine. Ketorolac is a tremendous breakthrough for patients who have high sensitivity to the side effects of opioids. It can be administered for 4 to 6 doses in the hospital and provides remarkable analgesia relative to other NSAIDs. If administered in the office just before the intravenous line is removed, ketorolac can give significant pain relief until the patient is home and has begun oral administration of ketorolac or another analgesic. The choice of oral NSAIDs should strongly consider patient tolerance by past history. Individuals show tremendous variation regarding their tolerances, and they do not follow a consistent pattern. Statistically, a few medications are better tolerated than others, but individual variation is a tremendously important factor. A history of ulcers may completely rule out the use of these drugs. At that point acetaminophen is a reasonable additive for analgesia. Acetaminophen generally does not have any significant GI toxicity, but unfortunately it is also weakly antiinflammatory. Acetaminophen is often given in addition to NSAIDs and opioids. It should be noted, however, that the combination of acetaminophen and NSAIDs increases the risk of renal toxicity. Also, diflunisal and perhaps other NSAIDs can increase plasma concentrations of acetaminophen by 50%. With regard to patients with intermaxillary fixation, several NSAIDs (including ibuprofen and several salicylate formulations), come in liquid form. Certain specific benefits are associated with some of the NSAIDs. The lack of platelet inhibition by nonacetylated salicylates and the increased analgesia of parenteral ketorolac have been mentioned. Diclofenac and, to a lesser extent, meclofenamate have increased penetration into synovial membrane joints, including the temporomandibular joint. If surgery is performed there, these might be a better choice to reduce the inflammatory response and pain. Sulindac and the nonacetylated salicylates are generally chosen as the NSAIDs with the best GI tolerance. Some drug-specific side effects should also be noted for certain nonsteroidals. Aspirin and salicylates can cause tinnitus. Aspirin also causes a permanent platelet inhibition. Until the affected platelets are replaced (in 7 to 10 days) by new platelets there is a risk of increased bleeding.
Prog 39:142-145 1992
The other NSAIDs do not have this permanent inhibition and therefore have no increased risk of bleeding after 24 to 48 hr of discontinuing use. Increased GI toxicity is associated with indomethacin, phenylbutazone, and piroxicam, and there is an increased incidence of diarrhea with meclofenamate. Mefenamic acid, along with phenylbutazone, has the rare side effects of agranulocytosis and aplastic anemia. Accordingly, phenylbutazone is rarely used currently, and mefenamic acid is not recommended for use beyond 7 days. The fenamates are associated with an unusual incidence of hemolytic anemia. Diflunisal and to some extent ketorolac have a reduced antiinflammatory effect. After oral surgery corticosteroids are frequently administered to reduce swelling. These medications have an analgesic effect as well. However, when used in combination with NSAIDs there is an increased incidence of GI toxicity.
Adjunctive Drugs Adjunctive medications for postoperative pain management are for more difficult patients. Patients wth severe anxiety can benefit from the use of benzodiazepines. Benzodiazepines can also be useful to produce sleep postoperatively. The tricyclic antidepressants can also be very helpful for sleep postoperatively, and they have some analgesic effects. They are appropriate for long-term use; however, they can cause a significant number of side effects that many patients find intolerable. These effects include dry mouth, constipation, oversedation the following day, and difficulty with urination. Occasionally, patients who are very tolerant to opioids may not have an adequate response even at extremely high doses. Essentially, these patients may either be very sedated or, if awake, complain of extremely severe pain. These patients often need to be managed within the hospital. However, the use of neuroleptics such as the phenothiazines or butyrophenones can at least reduce the severe complaints for these patients and help manage the first few days of severe pain. Neuroleptics have a fairly interesting and long list of possible side effects, including extrapyramidal motor disturbances. These medications should generally be reserved for those difficult patients who do not respond satisfactorily to opioids. The a2-adrenergic agonists like clonidine give moderate analgesia in severely opioid-tolerant patients but can cause hypotension. In summary, the armamentarium for postoperative analgesia has expanded greatly in the last decade, particularly regarding the availability and efficacy of adjunctive medications. With careful drug selection and administration few patients should experience even moderate pain. Unfortunately, when any list of medications is enlarged, the list of side effects is usually equally increased, and a
Anesth Prog 39:142-145 1992
working knowledge of these side effects is necessary in order to manage the patients postoperatively. REFERENCES 1. Benedetti C, Chapman CR, Giron G, eds: Opioid Analgesia: Recent Advances in Systemic Administration. Advances in Pain Research and Therapy, Vol 14. New York, Raven Press, 1990. 2. Oden RV, ed: Management of Postoperative Pain. Anesthesiology Clinics of North America, Vol 7. Philadelphia, WB Saunders Co., 1989. 3. Buckley MMT, Brogden RN: Ketorolac: A review of its pharmacodynamic and pharmacokinetic properties and therapeutic potential. Drugs 1990;39:86-109. 4. Danesh B, McLaren M, Russell R, Lowe G, Forbes C: Comparison of the effect of aspirin and choline magnesium trisalicylate on thromboxane biosynthesis in human platelets: Role of the acetyl moiety. Haemostasis 1989;19:169-173. 5. Day RO, Graham GG, Williams KM, Champion GD, De Jager J: Clinical pharmacology of non-steroidal anti-inflammatory drugs. Pharmacol Ther 1987;33:383-433.
Gregg 145 6. Denson DD, Katz JA: Nonsteroidal antiinflammatory agents. In: Raj PP, ed: Practical Management of Pain, 2nd ed. St Louis, Mosby-Year Book, Inc., 1992. 7. Ferreira SH: Prostaglandins: Peripheral and central analgesia. In: Bonica JJ, Lindblom U, Iggo A, Jones LE, Benedetti C, eds: Proceedings of the Third World Congress on Pain, Edinburgh. Advances in Pain Research and Therapy, Vol 5. New York, Raven Press, 1983. 8. Insel PA: Analgesic-antipyretics and antiinflammatory agents; drugs employed in the treatment of rheumatoid arthritis and gout. In: Gilman AG, Rall TW, Nies AS, Taylor R, eds: Goodman and Gilman's The Pharmacological Basis of Therapeutics, 8th ed. New York, Pergamon Press, 1990. 9. Kantor TG: Peripherally-acting analgesics. In: Kuhar M, Pasternak G, eds: Analgesics: Neurochemical, Behavioral, and Clinical Perspectives. New York, Raven Press, 1984. 10. Mather LE, Cousins MJ: Clinics in Critical Care Medicine, Acute Pain Management, Vol 8. New York, Churchill Livingstone, Inc., 1986. 11. Nuki G: Pain control and the use of non-steroidal analgesic anti-inflammatory drugs. Br Med J 1990;46:262-278. 12. Verbeeck RK, Blackburn JL, Loewen GR: Clinical pharmacokinetics of non-steroidal anti-inflammatory drugs. Clin Pharmacokinet 1983;8:297-331.
Postoperative Pain Control for Dental and Oral Surgery Richard V. Gregg, MD Department of Anesthesia, University of Cincinnati Medical Center Cincinnati, Ohio
level of analgesia or anesthesia and perhaps to maintain some analgesia in the postoperative period. On an outpatient basis, patients frequently need to have some mental function for getting home even though they have transportation arranged. They usually still have effective local anesthesia; without a pain stimulus, the side effects of opioids tend to be far more predominant. For those circumstances, frequently ultrashort-acting opioids, such as alfentanil, sufentanil, or fentanyl, administered intravenously may be most appropriate. These opioids are generally used only to allow the patient to tolerate the procedure more easily. For patients who may have a tolerance to opioids or who are going to remain in the hospital, one may administer small doses of fairly long-acting opioids, such as buprenorphine, levorphanol, or methadone. These medications can maintain some analgesia into the postoperative period and markedly decrease the severity of pain when the nerve block wears off. In the rare patient where, for whatever reason, a nerve block is deemed inappropriate, these medications are very valuable for intraoperative administration to allow some analgesia in the postoperative period. Once the patient leaves the office or goes to the floor from the recovery room, the duration of constant and intermittent pain should be considered when prescribing analgesics. If the patient is expected to have fairly severe constant pain, either due to the extent of the surgery or some tolerance to opioids, then the longer-acting drugs need to be considered. Slow-release morphine tablets are available that can maintain relatively constant analgesia for 8 to 12 hr. Levorphanol (Levo-Dromoran) gives 6 to 8 hr of pain relief, and methadone administered orally can provide analgesia for up to 18 to 36 hr per dose after repeated use. Because of its extremely long and variable half-life, methadone is probably an inappropriate drug for dosing over several days unless the patient is already accustomed to it. It should be noted that methadone is also available as an elixir, so that patients with wired jaws can more easily ingest the medication. For intermittent mild to moderate pain, short-acting opioids should be used. This group includes most of the familiar opioids. Some of these drugs come in
The postoperative pain management of dental and oral surgery pain is, for the most part, an outpatient endeavor. There are some patients who require admission after oral surgery, but the methods described here will be applicable to either inpatient or outpatient pain management. Dentists have long been the champions of neural blockade for pain of the head and neck and particularly the oral cavity. Local anesthesia is certainly a most effective shortterm answer for postoperative pain management. The use of long-acting local anesthetics, such as bupivacaine, etidocaine, and perhaps the newcomer ropivacaine, can extend the duration of analgesia from neural blockade, but at some point the block definitely wears off. This presentation will focus on medications and routes of administration for controling pain after the nerve blocks have
dissipated.
OPIOIDS The use of opioids for postoperative pain is certainly the mainstay of analgesic regimens. Certain features should be considered when deciding on an appropriate opioid regimen for a given patient. Rational choices should include consideration of the patient's previous pain experiences, the patient's opinion of effective opioid medications, any recent opioid usage, and the severity and expected duration of the procedure's pain stimulus. Despite inappropriate labels of opioid allergy when nausea, vomiting, or other side effects have been a problem with certain opioid medications, most patients will avoid opioids they have had disagreeable experiences with in the past. It then becomes important to have a fairly extensive knowledge of the various opioids on the market. During surgery, in the office or surgical suite, it is frequently reasonable to administer opioids both for a certain Address correspondence to Dr. Richard Gregg, Department of Anesthesia, University of Cincinnati Medical Center, Cincinnati, OH 45267. © 1992 by the American Dental Society of Anesthesiology
ISSN 0003-3006/92/$6.00
142
Gregg 143
Anesth Prog 39:142-145 1992 Table 1. Nonsteroidal Antiinflammatory Drugs
Nonproprietary
Chemical Group Salicylates
Representative Trade Names
Subdivisions
Name
Acetylated Nonacetylated
Aspirin Choline salicylate Magnesium salicylate Salsalate
tntca Arthropan Magan, Mobidin Disalcid, MonoGesic, Salflex
Sodium thiosalicylate Diflunisal Fenoprofen Flurbiprofen Ibuprofen
Asproject
Derivative Propionic Acid Derivatives
Acetic Acid Derivatives
Indole Phenyl Pyrrole
Pyrazoles
Oxicams Fenamates Paraaminophenol
Ketoprofen Naproxen (sodium) Diclofenac sodium Etodolac Indomethacin Ketorolac Sulindac Tolmetin Oxyphenbutazone Phenylbutazone Piroxicam Meclofenamate Mefanamic acid Acetaminophen
Dolobid Nalfon Ansaid Motrin, Rufen, PediaProfen Orudis Naprosyn (Anaprox) Voltaren Lodine Indocin Toradol Clinoril Tolectin Oxalid, Tandearil Butazolidin Feldene Meclomen Ponstel Tylenol, Anacin-3, Panadol, etc.
aToo numerous to count.
combination with acetaminophen or aspirin, which can give additive pain relief. Some agents are also available as elixirs, which simplifies ingestion in patients with wired jaws. OTHER DRUGS
Nonopioid medications to aid in postoperative pain management have been expanded substantially in the recent past. These agents include nonsteroidal antiinflammatory drugs (NSAIDs), tricyclic antidepressants, neuroleptics, antihistamines, benzodiazepines, and ca2-adrenergic agonists. These medications are not always appropriate, but certain patients may have an indication for one or more of them.
Nonsteroidal Antiinflammatory Drugs NSAIDs have proliferated tremendously in the last 10 yr. There are about 20 such agents now on the market, many with multiple trade names, just to add to the confusion (Table 1). They have multiple actions, including analgesia, antiinflammatory and antipyretic effects, and platelet inhibition. There are relative differences in the degree to which each NSAID causes these effects, and intelligent choices can
be made using those differences. Unfortunately, NSAIDs also have multiple side effects. These include gastrointestinal (GI) irritation and bleeding, sedation, headache, diarrhea, tinnitus, fluid retention, increased blood pressure, kidney or liver damage, Reye's Syndrome, allergic-like responses, agranulocytosis, and intrauterine closure of the patent fetal ductus arteriosus. These side effects have different relative expressions as well among the NSAIDs, and they are frequently unpredictable. Although the analgesic effect of NSAIDs has an onset usually within 1 hr of administration, the antiinflammatory effect is frequently much slower to occur. Sometimes, this delay makes it reasonable to pretreat surgical candidates with NSAIDs to minimize the inflammatory response to the surgery. Certain NSAIDs are more desirable than others for pretreatment. Several of them have little to no effect on platelet function and, therefore, will not significantly affect bleeding during or after surgery. Specifically, these are the nonacetylated salicylates. These NSAIDs also tend to be better tolerated by the GI tract and are useful for decreasing the inflammatory response and pain postoperatively. There has been very little use of NSAIDs intraoperatively or immediately postoperatively, however, because they have not been formulated for parenteral administration. The marketing of ketorolac is a major de-
Anesth
144 Postoperative Pain Control
parture from this rule. Ketorolac is approved for intramuscular administration and, in fact, can be administered intravenously although it is not currently approved by the Food and Drug Administration for that route. One outstanding feature of this agent is its tremendous analgesic efficacy relative to the other nonsteroidal effects. As an example, while the antiinflammatory potency of ketorolac is between indomethacin and naproxen, the analgesic potency is 50 times that of naproxen and six times that of indomethacin. Multiple well-controlled studies of ketorolac have shown therapeutic doses to be equivalent to 6 to 12 mg of parental morphine and to last up to 6 hr rather than the 3 to 4 hr of morphine. Ketorolac is a tremendous breakthrough for patients who have high sensitivity to the side effects of opioids. It can be administered for 4 to 6 doses in the hospital and provides remarkable analgesia relative to other NSAIDs. If administered in the office just before the intravenous line is removed, ketorolac can give significant pain relief until the patient is home and has begun oral administration of ketorolac or another analgesic. The choice of oral NSAIDs should strongly consider patient tolerance by past history. Individuals show tremendous variation regarding their tolerances, and they do not follow a consistent pattern. Statistically, a few medications are better tolerated than others, but individual variation is a tremendously important factor. A history of ulcers may completely rule out the use of these drugs. At that point acetaminophen is a reasonable additive for analgesia. Acetaminophen generally does not have any significant GI toxicity, but unfortunately it is also weakly antiinflammatory. Acetaminophen is often given in addition to NSAIDs and opioids. It should be noted, however, that the combination of acetaminophen and NSAIDs increases the risk of renal toxicity. Also, diflunisal and perhaps other NSAIDs can increase plasma concentrations of acetaminophen by 50%. With regard to patients with intermaxillary fixation, several NSAIDs (including ibuprofen and several salicylate formulations), come in liquid form. Certain specific benefits are associated with some of the NSAIDs. The lack of platelet inhibition by nonacetylated salicylates and the increased analgesia of parenteral ketorolac have been mentioned. Diclofenac and, to a lesser extent, meclofenamate have increased penetration into synovial membrane joints, including the temporomandibular joint. If surgery is performed there, these might be a better choice to reduce the inflammatory response and pain. Sulindac and the nonacetylated salicylates are generally chosen as the NSAIDs with the best GI tolerance. Some drug-specific side effects should also be noted for certain nonsteroidals. Aspirin and salicylates can cause tinnitus. Aspirin also causes a permanent platelet inhibition. Until the affected platelets are replaced (in 7 to 10 days) by new platelets there is a risk of increased bleeding.
Prog 39:142-145 1992
The other NSAIDs do not have this permanent inhibition and therefore have no increased risk of bleeding after 24 to 48 hr of discontinuing use. Increased GI toxicity is associated with indomethacin, phenylbutazone, and piroxicam, and there is an increased incidence of diarrhea with meclofenamate. Mefenamic acid, along with phenylbutazone, has the rare side effects of agranulocytosis and aplastic anemia. Accordingly, phenylbutazone is rarely used currently, and mefenamic acid is not recommended for use beyond 7 days. The fenamates are associated with an unusual incidence of hemolytic anemia. Diflunisal and to some extent ketorolac have a reduced antiinflammatory effect. After oral surgery corticosteroids are frequently administered to reduce swelling. These medications have an analgesic effect as well. However, when used in combination with NSAIDs there is an increased incidence of GI toxicity.
Adjunctive Drugs Adjunctive medications for postoperative pain management are for more difficult patients. Patients wth severe anxiety can benefit from the use of benzodiazepines. Benzodiazepines can also be useful to produce sleep postoperatively. The tricyclic antidepressants can also be very helpful for sleep postoperatively, and they have some analgesic effects. They are appropriate for long-term use; however, they can cause a significant number of side effects that many patients find intolerable. These effects include dry mouth, constipation, oversedation the following day, and difficulty with urination. Occasionally, patients who are very tolerant to opioids may not have an adequate response even at extremely high doses. Essentially, these patients may either be very sedated or, if awake, complain of extremely severe pain. These patients often need to be managed within the hospital. However, the use of neuroleptics such as the phenothiazines or butyrophenones can at least reduce the severe complaints for these patients and help manage the first few days of severe pain. Neuroleptics have a fairly interesting and long list of possible side effects, including extrapyramidal motor disturbances. These medications should generally be reserved for those difficult patients who do not respond satisfactorily to opioids. The a2-adrenergic agonists like clonidine give moderate analgesia in severely opioid-tolerant patients but can cause hypotension. In summary, the armamentarium for postoperative analgesia has expanded greatly in the last decade, particularly regarding the availability and efficacy of adjunctive medications. With careful drug selection and administration few patients should experience even moderate pain. Unfortunately, when any list of medications is enlarged, the list of side effects is usually equally increased, and a
Anesth Prog 39:142-145 1992
working knowledge of these side effects is necessary in order to manage the patients postoperatively. REFERENCES 1. Benedetti C, Chapman CR, Giron G, eds: Opioid Analgesia: Recent Advances in Systemic Administration. Advances in Pain Research and Therapy, Vol 14. New York, Raven Press, 1990. 2. Oden RV, ed: Management of Postoperative Pain. Anesthesiology Clinics of North America, Vol 7. Philadelphia, WB Saunders Co., 1989. 3. Buckley MMT, Brogden RN: Ketorolac: A review of its pharmacodynamic and pharmacokinetic properties and therapeutic potential. Drugs 1990;39:86-109. 4. Danesh B, McLaren M, Russell R, Lowe G, Forbes C: Comparison of the effect of aspirin and choline magnesium trisalicylate on thromboxane biosynthesis in human platelets: Role of the acetyl moiety. Haemostasis 1989;19:169-173. 5. Day RO, Graham GG, Williams KM, Champion GD, De Jager J: Clinical pharmacology of non-steroidal anti-inflammatory drugs. Pharmacol Ther 1987;33:383-433.
Gregg 145 6. Denson DD, Katz JA: Nonsteroidal antiinflammatory agents. In: Raj PP, ed: Practical Management of Pain, 2nd ed. St Louis, Mosby-Year Book, Inc., 1992. 7. Ferreira SH: Prostaglandins: Peripheral and central analgesia. In: Bonica JJ, Lindblom U, Iggo A, Jones LE, Benedetti C, eds: Proceedings of the Third World Congress on Pain, Edinburgh. Advances in Pain Research and Therapy, Vol 5. New York, Raven Press, 1983. 8. Insel PA: Analgesic-antipyretics and antiinflammatory agents; drugs employed in the treatment of rheumatoid arthritis and gout. In: Gilman AG, Rall TW, Nies AS, Taylor R, eds: Goodman and Gilman's The Pharmacological Basis of Therapeutics, 8th ed. New York, Pergamon Press, 1990. 9. Kantor TG: Peripherally-acting analgesics. In: Kuhar M, Pasternak G, eds: Analgesics: Neurochemical, Behavioral, and Clinical Perspectives. New York, Raven Press, 1984. 10. Mather LE, Cousins MJ: Clinics in Critical Care Medicine, Acute Pain Management, Vol 8. New York, Churchill Livingstone, Inc., 1986. 11. Nuki G: Pain control and the use of non-steroidal analgesic anti-inflammatory drugs. Br Med J 1990;46:262-278. 12. Verbeeck RK, Blackburn JL, Loewen GR: Clinical pharmacokinetics of non-steroidal anti-inflammatory drugs. Clin Pharmacokinet 1983;8:297-331.
