Postoperative pain management - New drugs and techniques

Provision for providing safe and effective analgesia is one of the major challenges in day-case anaesthesia because of the increase in the number of extensive and painful surgical operations (e.g. repair of the anterior cruciate ligament of the knee, laparoscopic cholecystectomy and hysterectomy) performed on an out-patient basis. Alternative drug delivery systems which are effective and safe are necessary to optimise pain management. Although the use of non-pharmacological techniques such as transcutaneous electrical nerve stimulation, acupuncture-like transcutaneous electrical nerve stimulation and percutaneous electrical nerve stimulation (electroacupuncture) have potential for postoperative use, their clinical efficacy remains controversial. An ideal analgesic technique should provide pain relief not only at rest but also during mobilisation which will permit earlier discharge from the out-patient facility. A multimodal approach, combining the use of local anaesthetic techniques with opioids and NSAIDs should improve efficacy and enhance safety of commonly used analgesic drugs. Furthermore, it must be noted that the anaesthetic technique can influence the analgesic requirement in the early postoperative period. Finally, with increasing acceptance of the concept of pre-emptive analgesia there has been a widespread use of analgesic agents (opioids, NSAIDs or local anaesthetics) before the onset of surgery, in an effort to decrease the severity of postoperative pain and thus reduce the analgesic requirements after discharge. However, carefully controlled clinical stuidies are needed to address the issues raised by experimental analgesic research.