Perioperative anesthesia. Features of anesthesia for patients with different surgeries and traumas
Authors: Kobeliatskyi Yu.Yu. 
Published: July 2021

Background. Chronic postoperative and post-traumatic pain is included in the new edition of the International Classification of Diseases, which should become valid on 01.01.2022. Routine adherence to specialized differentiated evidence-based protocols for perioperative management of patients is the best way to optimize perioperative analgesia. The patient and his relatives should be informed about the possibility of postoperative pain (POP) and treatment options. It is advisable to use multimodal analgesia (MMA) with non-pharmacological methods to eliminate POP.

Objective. To describe modern points of view on perioperative analgesia.

Materials and methods. Analysis of literature data on this topic.

Results and discussion. Analgesics are divided into antinociceptive drugs (hyperalgetics (morphine and μ-agonists) and antihyperalgetics – paracetamol, nonsteroidal anti-inflammatory drugs (NSAID), glucocorticoids, nefopam, tramadol) and non-antinociceptive antihyperalgetics (ketamine, gabapentine, topical anesthetics, clonidine, adenosine, neostigmine). Whenever possible, every anesthesiologist should take a multimodal approach. In the absence of contraindications, all patients should receive NSAID around the clock, including cyclooxygenase-2 inhibitors or acetaminophen (paracetamol). Intravenous paracetamol has a number of advantages over oral one. With the infusion of paracetamol (Infulgan, “Yuria-Pharm”), the time to achieve clinically significant analgesia is only 8 minutes, and to achieve maximum anesthesia – 15 minutes. Preoperative intravenous paracetamol has convincingly demonstrated an opioid-sparing effect in various surgical interventions (joint replacement, bariatric surgery, surgery for head and neck tumors) and delivery. The financial and economic feasibility of treatment with intravenous paracetamol has been proven. Additionally, the administration of regional blockades with topical anesthetics should be considered. It is also advisable to use pregabalin or gabapentin. The choice of drug, dose, route of administration and duration of therapy should be individualized. Intramuscular administration of analgesics should be avoided. In neuropathic POP, first-line drugs include tricyclic antidepressants, norepinephrine and serotonin reuptake inhibitors, antiepileptics, topical anesthetics (bupivacaine – Longocaine, “Yuria-Pharm”), second-line – opioids, tramadol, and third-line – mexiletine, NMDA-receptor antagonists, capsaicin. It should be noted that bupivacaine is 2-3 times more effective than lidocaine and 6-12 times more effective than novocaine. Local anesthetics can be used for infiltration anesthesia, blockade, intraperitoneal injection and direct infusion into the wound. Dexmedetomidine, which also provides sedation and additional analgesia, can be used to prolong sensory and motor anesthesia with bupivacaine. Analgesia in different interventions is slightly different. Thus, in total joint arthroplasty, a single blockade of the adductor canal is effective. When restoring the rotator cuff, it is advisable to use an arthroscopic approach, paracetamol (Infulgan), NSAID, dexamethasone and regional anesthesia. In spinal surgery, postoperative MMA involves the use of cold compresses, pregabalin, cyclobenzaprine, tramadol, if necessary – oxycodone. In total mastectomy, gabapentin and paracetamol should be prescribed before surgery, and opioids, ondansetron, and/or lorazepam on demand – after surgery. After abdominal hysterectomy, in severe pain opioids are used in combination with cyclooxygenase-2 inhibitors or non-selective NSAID, in mild pain – cyclooxygenase-2 inhibitors or non-selective NSAID in combination with paracetamol and, if necessary, weak opioids. Postoperative management of women after caesarean section involves the use of oral NSAID and paracetamol, opioids (rescue analgesia) and long-term infusions of local anesthetics into the wound.

Conclusions. 1. Anesthesia plays a leading role in accelerated postoperative rehabilitation programs. 2. When choosing an approach to analgesia one should take into account the area of intervention. 3. Rational reduction in the opioids amount is achieved through balanced MMA. 4. The most basic components of MMA include NSAID, paracetamol and regional techniques.