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Chronic pain after tissue trauma is frequent and may have a lasting impact on the functioning and quality of life of the affected person. Despite this, chronic postsurgical and posttraumatic pain is underrecognised and, consequently, undertreated. It is not represented in the current International Classification of Diseases (ICD-10). This article describes the new classification of chronic postsurgical and posttraumatic pain for ICD-11. Chronic postsurgical or posttraumatic pain is defined as chronic pain that develops or increases in intensity after a surgical procedure or a tissue injury and persists beyond the healing process, ie, at least 3 months after the surgery or tissue trauma. In the classification, it is distinguished between tissue trauma arising from a controlled procedure in the delivery of health care (surgery) and forms of uncontrolled accidental damage (other traumas). In both sections, the most frequent conditions are included. This provides diagnostic codes for chronic pain conditions that persist after the initial tissue trauma has healed and that require specific treatment and management. It is expected that the representation of chronic postsurgical and posttraumatic pain in ICD-11 furthers identification, diagnosis, and treatment of these pain states. Even more importantly, it will make the diagnosis of chronic posttraumatic or postsurgical pain statistically visible and, it is hoped, stimulate research into these pain syndromes.

Purpose of Review: Postoperative pain remains poorly treated in many patients. One reason is the inadequate use of nonopioid analgesics. This review examines the most recent findings on nonopioid analgesics and how these translate into clinical practice., Recent Findings: Commonly used nonopioid analgesics are paracetamol, NSAIDs and metamizol (dipyrone). For paracetamol, the efficacy is obviously inferior to NSAIDs and the risk of adverse events might have been underestimated in the past. For NSAIDs, there are increasing data supporting similar efficacy of nonselective and cyclooxygenase-2 selective NSAIDs, although the adverse effects of the latter might make them the preferred option for short-term use in the perioperative setting. Metamizol (dipyrone) is a very effective nonopioid analgesic not worldwide available; the discussion on the relevance of the very rare adverse event agranulocytosis continues., Summary: Nonopioid analgesics are important components of multimodal postoperative analgesia. The selection of the most appropriate compound for an individual patient can be based more and more on ever increasing data on these important analgesics.

Summary: The experience of pain is a subjective one and more than a simple sensation. Pain is commonly defined as an unpleasant sensory and emotional experience due to actual or potential tissue damage or described in such terms. Pain may be broadly classified into physiological and pathological pain. Nociceptive and inflammatory pains are physiological pain states, as they are protective and adaptive, whereas pathological pain is nonprotective and maladaptive. Nociception is the result of suprathreshold stimulation of peripheral nociceptors. Inflammatory pain follows release of various chemical mediators after tissue injury including surgery leading to peripheral sensitization. Nociceptive input is then transmitted to the spinal cord via primary afferents. Modulation of the nociceptive input occurs in the dorsal horn of the spinal cord, influenced by descending inhibitory systems. Central sensitization is a neuromodulatory change that results in the development of secondary hyperalgesia. The modulated nociceptive input then travels up the ascending tracts, mainly via the spinothalamic tract to the thalamus and subsequently to the higher centers of the brain. Pathological pain such as neuropathic pain and central nervous system dysfunctional pain are the result of neuroplasticity of the peripheral and central nervous system. Abnormal ectopic firing of neurons in the absence of a stimulus, increased neuronal hypersensitivity, changes within ion channels, and even alteration in gene expression and changes in the cortical representation are involved in the pathogenesis of these pain states. The development of persistent postsurgical pain is an example for this complex process.

Objective: To quantify benefit and harm of epidural analgesia, compared with systemic opioid analgesia, in adults having surgery under general anesthesia., Background: It remains controversial whether adding epidural analgesia to general anesthesia decreases postoperative morbidity and mortality., Methods: We searched CENTRAL, EMBASE, PubMed, CINAHL, and BIOSIS till July 2012. We included randomized controlled trials comparing epidural analgesia (with local anesthetics, lasting for ≥ 24 hours postoperatively) with systemic analgesia in adults having surgery under general anesthesia, and reporting on mortality or any morbidity endpoint., Results: A total of 125 trials (9044 patients, 4525 received epidural analgesia) were eligible. In 10 trials (2201 patients; 87 deaths), reporting on mortality as a primary or secondary endpoint, the risk of death was decreased with epidural analgesia (3.1% vs 4.9%; odds ratio, 0.60; 95% confidence interval, 0.39-0.93). Epidural analgesia significantly decreased the risk of atrial fibrillation, supraventricular tachycardia, deep vein thrombosis, respiratory depression, atelectasis, pneumonia, ileus, and postoperative nausea and vomiting, and also improved recovery of bowel function, but significantly increased the risk of arterial hypotension, pruritus, urinary retention, and motor blockade. Technical failures occurred in 6.1% of patients., Conclusions: In adults having surgery under general anesthesia, concomitant epidural analgesia reduces postoperative mortality and improves a multitude of cardiovascular, respiratory, and gastrointestinal morbidity endpoints compared with patients receiving systemic analgesia. Because adverse effects and technical failures cannot be ruled out, individual risk-benefit analyses and professional care are recommended.

Purpose of Review: Poor pain management has continued to be a problem after pediatric surgery. This review examines the current situation and recent advances in the area., Recent Findings: Nonopioids such as paracetamol and NSAIDs play an increasing role as components of multimodal analgesia in children. However, studies on the safety and efficacy of many adjuvants in pediatrics are still lacking. The use of opioids is influenced understandably by safety concerns about respiratory depression, but data on its incidence are poor. The role of regional techniques in the treatment of pain after pediatric surgery is growing in line with the developments in adults; the emphasis here is more on peripheral techniques too., Summary: The concept of multimodal analgesia including the use of regional analgesic techniques is governing the current developments and discussions in the area of pediatric postoperative analgesia.

Background: The sublingual administration of opioids is a simple and noninvasive method that provides rapid analgesia. In this phase I study we investigated the pharmacokinetics and bioavailability of a fentanyl wafer in healthy volunteers. The principal study objective was to investigate the pharmacokinetic profile of a new sublingual fentanyl wafer and to establish its absolute bioavailability., Methods: Twenty-four healthy volunteers, mean age 23 years, were randomly assigned to receive the equivalent of fentanyl 100 μg by both the sublingual and IV routes. Blood samples were collected in sterile polypropylene tubes for 24 hours after each fentanyl administration. The pharmacokinetic parameters were determined by model-independent pharmacokinetic analyses of the plasma fentanyl concentration-time profiles., Results: The mean absolute bioavailability of the sublingual fentanyl wafer was 78.9% (90% confidence interval [CI] 51.1% to 121.7%). The first detectable plasma fentanyl concentration time ranged from 2 to 10 minutes in all volunteers, and the mean (±SD) time to peak plasma concentration at 0.91 (±0.73) hours after administration., Conclusion: Sublingual administration of fentanyl as a wafer product resulted in rapidly detectable plasma fentanyl concentrations. The absolute bioavailability of 78.9% indicated a high systemic availability of fentanyl and suggests that further development of this wafer is justified.

Purpose of Review: Perioperative acute pain and the development of persistent pain after thoracotomy are major problems severely affecting health-related quality of life. This review examines and highlights recent strategies and advances in perioperative pain management in this field., Recent Findings: Despite the fact that thoracic epidural analgesia (TEA) is considered the 'gold standard' of perioperative care after thoracotomy, other local and regional techniques have emerged within recent years and seem to become valid alternatives to TEA. The use of continuous paravertebral blockade, in particular, may provide similar analgesia and fewer adverse effects than TEA. Multimodal systemic approaches, including the use of ketamine and gabapentinoids are being investigated as well as the effect of surgical techniques and adjuvant therapies such as transcutaneous electrical nerve stimulation on post-thoracotomy pain., Summary: Even though thoracotomy is associated with significant postoperative complications, a growing understanding of the underlying pathophysiology and advances in multimodal pain therapy concepts in this specific group of patients are promising improved postoperative outcomes and potential reduction of the incidence of persistent pain.

Purpose of Review: Poor pain management has been a problem after ambulatory surgery. This review examines the current situation and recent advances in the area., Recent Findings: Despite significant scientific advances in the management of postoperative pain, surveys continue to show poor pain control in the routine clinical setting of day-case surgery. Causes are poor implementation of the progress and lack of adherence to established guidelines with too much reliance on opioids and lack of continuation of analgesic techniques into the postoperative period. The current literature with regard to systemic analgesia supports the concept of multimodal analgesia with an emphasis on the widespread use of appropriate nonopioids including NSAIDs or cyclo-oxygenase-2 inhibitors. The other mainstay of pain management after ambulatory surgery should be local anaesthetics, either used single shot, but with appropriate adjuvants, or by continuous peripheral nerve blocks. The latter techniques show increasingly promising results with a good safety record and are reviewed extensively., Summary: Multimodal analgesia and local anaesthetic techniques are the avenues to improve the still disappointing quality of analgesia after ambulatory surgery.

Purpose of Review: Patients with fibromyalgia are at increased risk to experience increased and prolonged postoperative pain. In this review, we will provide an overview of pathophysiological characteristics of fibromyalgia relevant for enhanced pain processing after surgery. Furthermore, we will present some potential treatment options in the perioperative period based on specific symptoms of individual fibromyalgia patients to optimize their pain management after surgery., Recent Findings: Recent evidence points towards enhanced central nervous system sensitization and decreased descending inhibition in patients with fibromyalgia. Even in patients without fibromyalgia, these two mechanisms are seen as major contributors to the severity of acute and chronic pain states after surgery. Furthermore, other symptoms and comorbidities such as anxiety, depression and somatization disorder, frequently associated with fibromyalgia, are independently known to increase the risk of acute and prolonged pain after surgery. Therefore, an optimal treatment approach in the perioperative period should include substances and strategies targeting specific symptoms in fibromyalgia patients to prevent or specifically reduce acute and prolonged pain after surgery. Such multimodal pain management in fibromyalgia patients in the perioperative period should include nonopioid analgesics, gabapentinoids, antidepressants, N-methyl-D-asparate antagonists and use of regional techniques when appropriate., Summary: The perioperative pain management of patients with fibromyalgia is challenging and should include symptom-based approaches to target enhanced central sensitization and decreased inhibition in these patients as well as their psychological syndromes aiming to decrease acute and prolonged pain after surgery.

Background: Studies of parecoxib, the inactive prodrug of the cyclooxygenase-2 selective inhibitor valdecoxib, and valdecoxib for postoperative pain relief in patients undergoing coronary artery bypass graft surgery revealed an increased risk of cardiovascular (CV) adverse events compared with placebo. We conducted this study to address whether parecoxib and valdecoxib increased CV risk in noncardiac surgery patients., Methods: A pooled post hoc analysis was conducted using 2 large datasets: 17 controlled trials of parecoxib for noncardiac studies and 32 studies, including the 17 noncardiac parecoxib studies plus 15 studies of valdecoxib. The 32-study dataset provided 95% power to detect a twofold increase in the incidence of CV adverse events assuming a placebo group incidence of 1% (estimated from previous study data), and 69% power to detect a twofold increase from a 0.5% incidence., Results: The incidence of total CV events for the 17 parecoxib studies was 0.44% (13 of 2966) in patients who received parecoxib and 0.37% (7 of 1915) in those receiving placebo (P > 0.20). In the analysis of 32 studies, the incidence of total CV events was 0.40% (21 of 5285) in the parecoxib/valdecoxib group compared with 0.50% (16 of 3226) in the placebo group (P > 0.20). No significant differences in the incidence of total or any individual CV event category were observed between the parecoxib or parecoxib/valdecoxib and placebo groups in the two analyses. When patients were stratified by number of baseline CV risk factors, no significant difference in CV events was detected in parecoxib/valdecoxib patients compared with placebo., Conclusions: In the largest analysis of the CV risk of cyclooxygenase selective inhibitors or nonsteroidal antiinflammatory drugs for perioperative pain management, parecoxib and valdecoxib were not found to increase the risk of CV adverse events after noncardiac surgery.

Background: Thoracotomy induces severe postoperative pain and impairment of pulmonary function, and therefore regional analgesia has been intensively studied in this procedure. Thoracic epidural analgesia is commonly considered the "gold standard" in this setting; however, evaluation of the evidence is needed to assess the comparative benefits of alternative techniques, guide clinical practice and identify areas requiring further research., Methods: In this systematic review of randomized trials we evaluated thoracic epidural, paravertebral, intrathecal, intercostal, and interpleural analgesic techniques, compared to each other and to systemic opioid analgesia, in adult thoracotomy. Postoperative pain, analgesic use, and complications were analyzed., Results: Continuous paravertebral block was as effective as thoracic epidural analgesia with local anesthetic (LA) but was associated with a reduced incidence of hypotension. Paravertebral block reduced the incidence of pulmonary complications compared with systemic analgesia, whereas thoracic epidural analgesia did not. Thoracic epidural analgesia was superior to intrathecal and intercostal techniques, although these were superior to systemic analgesia; interpleural analgesia was inadequate., Conclusions: Either thoracic epidural analgesia with LA plus opioid or continuous paravertebral block with LA can be recommended. Where these techniques are not possible, or are contraindicated, intrathecal opioid or intercostal nerve block are recommended despite insufficient duration of analgesia, which requires the use of supplementary systemic analgesia. Quantitative meta-analyses were limited by heterogeneity in study design, and subject numbers were small. Further well designed studies are required to investigate the optimum components of the epidural solution and to rigorously evaluate the risks/benefits of continuous infusion paravertebral and intercostal techniques compared with thoracic epidural analgesia.

Purpose of Review: The ongoing debate on the outcome benefits of regional anaesthesia and analgesia over general anaesthesia and systemic analgesia has led to a large number of recently published papers, in particular systematic reviews and meta-analyses that justify a review of the current status of the debate., Recent Findings: Meta-analyses have shown consistently improved analgesia with epidural techniques, but the results are by far less consistent with regard to other outcomes, in particular morbidity and mortality. Specific outcomes in specific types of surgery, however, such as bowel recovery after abdominal surgery, can be improved by neuraxial blockade, which also remains the technique of choice for obstetric analgesia and anaesthesia. In certain indications, peripheral nerve blocks may have the potential to replace neuraxial blocks while maintaining the benefits of the regional technique, such as paravertebral blocks for thoracotomies., Summary: Although there are a considerable number of recent publications on the topic, the complex issues around the effect of regional anaesthesia on outcome is not completely resolved, possibly because the data are often not procedure specific. In addition, however, it may be that our current literature cannot provide a definitive answer.

Volatile anesthetics reduce ciliary beat frequency in vitro. It has been reported that impaired bronchial mucus transport velocity (BTV) is associated with significantly increased pulmonary complications. In this study, we sought to determine in vivo differences in BTV, comparing patients having total IV anesthesia (TIVA) with propofol and remifentanil to anesthesia with sevoflurane and remifentanil. Twenty-two patients scheduled for elective general surgery were randomized to one of two groups: TIVA (propofol/remifentanil) or SEVO (sevoflurane/remifentanil). Thirty minutes after tracheal intubation, BTV was assessed by fiberoptic observation of the movement of methylene blue dye applied to the dorsal surface of the right main bronchus. BTV was significantly reduced in the SEVO group compared with the TIVA group (mean, 1.5 +/- 0.7 [0-2.3] versus 4.8 +/- 2.1 [2.3-8.8] mm/min; P < 0.0001). Anesthesia with sevoflurane may lead to significantly impaired bronchociliary clearance in comparison to TIVA. This could have implications for perioperative pulmonary complications, in particular in patients at risk for pulmonary complications.

Postoperative pain requires treatment not only to provide comfort to patients but also to improve postoperative outcome. Anti-inflammatory compounds are an important component of multimodal analgesia in the postoperative period. The newer cyclooxygenase (COX)-2 inhibitors are as effective as classical nonsteroidal anti-inflammatory drugs (NSAIDs) in this setting. However, COX-2 inhibitors offer a number of advantages over NSAIDs when used to treat postoperative pain. These include a reduced incidence of gastrointestinal ulceration and no inhibitory effect on platelet function and thereby a reduced risk of blood loss. Other benefits are less impairment of bone healing and no induction of bronchospasm in patients with aspirin-sensitive asthma. Increased cardiovascular thromboembolic events by COX-2 inhibitors have been reported after coronary artery bypass graft surgery only, but in general, surgery studies the incidence of such complications was comparable to placebo. Overall, COX-2 inhibitors offer a number of advantages over classical NSAIDs in the postoperative pain setting, but require the same caution with regard to renal effects.

We investigated adverse events (AEs) associated with perioperative tenoxicam in a double-blind, prospective, randomised study. Patients undergoing surgery, screened for contraindications to non-steroidal anti-inflammatory drug, received tenoxicam (n=750) on 2843 days or placebo (n=251) on 988 days, in courses of 1-12 days. There was no increase in the overall incidence of side effects with tenoxicam (33 vs 38% with placebo: P=0.15), or in major side effects (3.9 vs 2.0% with placebo: P=0.11). Of major side effects possibly or probably related to tenoxicam (2.1 vs 1.2% with placebo: P=0.26), all but one involved post-operative surgical site bleeding. However, in the subgroup of patients undergoing otorhinolaryngology surgery, surgical site bleeding occurred in 18 of 171 (10.5%) patients on tenoxicam and one of 57 (1.8%) on placebo (P=0.026); of these, nine in the tenoxicam group and 0 in the placebo were classified as major (P=0.07). One patient on tenoxicam experienced endoscopically proven duodenal ulceration with malaena. In conclusion, perioperative tenoxicam is well tolerated in comparison with placebo and the incidence of drug-related major AEs (other than post-operative bleeding) is no greater than 1 in 150 in low risk patients, but in patients undergoing otorhinolaryngological surgery there may be an increased risk of post-operative bleeding.

Purpose of Review: The discussion on the value of epidural anaesthesia and analgesia for surgery is fuelled by current controversies regarding effects on postoperative morbidity and mortality, potential benefits for outcome and the fear of rare, but catastrophic neurological complications. This review of the most recent publications on the topic since April 2002 illustrates some of the aspects contributing to the ongoing discussion., Recent Findings: In contradiction to previous meta-analyses, recent trials could not demonstrate significant improvements of overall morbidity or mortality by epidural anaesthesia and analgesia. However, the technique was shown again to provide superior analgesia and a reduction of perioperative stress response and respiratory complications. Analysis of the current literature strongly supports that epidural anaesthesia and analgesia remains a safe practice with a low rate of severe complications, in particular in paediatric surgery. Several developments in equipment, techniques and especially drugs have been reported, resulting in improved balanced anaesthesia and analgesia and contributing to the safety of this technique., Summary: In an era of evidence-based medicine, further meta-analyses and well-planned large randomized trials have to address the controversial issues of epidural anaesthesia and analgesia and postoperative outcome. In the context of a more holistic 'rehabilitative' management of the perioperative period, this technique might well represent a key factor to improve outcome, reduce hospital stay and thereby healthcare costs. Recent innovations and developments in techniques and drugs as well as established guidelines should further minimize potential errors and harmful complications.

Recent years have seen a dramatic increase in the number of agents used for neuraxial blockade. Together with the developments in local anaesthetics and opioids, completely new categories of agents have been investigated for intrathecal and epidural use. A review of the recent literature reveals the potential for improvement in achieving balanced anaesthesia and analgesia, in particular combining agents to reduce adverse effects.

Unlabelled: Our aim in this prospective, randomized, double-blinded study was to compare the analgesic effectiveness and side effects of epidural infusions with ropivacaine 2 mg/mL alone (Group R; n = 60) and in combination with fentanyl 1 microg/mL (R1F; n = 59), 2 microg/mL (R2F; n = 62), and 4 microg/mL (R4F; n = 63) for up to 72 h after major abdominal surgery. Effective epidural neural blockade was established before surgery; postoperatively, the infusion rate was titrated to a maximum of 14 mL/h for analgesia. No additional analgesics other than acetaminophen were permitted during the infusion. The median of individual visual analog scale score with coughing were <20 mm for all groups (0 = no pain, 100 = worst pain) and was significantly lower (P < 0.01) for Group R4F at rest and with coughing (compared with Group R). Infusions were discontinued due to inability to control pain in significantly fewer patients in Group R4F (16%) than the other groups (34% to 39%; P < 0.01). For all groups, >90% of patients had no detectable motor block after 24 h. Hypotension, nausea, and pruritus were more common with the larger dose of fentanyl. We conclude that, after major abdominal surgery, an epidural infusion of ropivacaine 2 mg/mL with fentanyl 4 microg/mL provided significantly more effective pain relief over a 3-day period than ropivacaine alone or ropivacaine with lower concentrations of fentanyl., Implications: Postoperative epidural analgesic infusions are widely used, but there is little information regarding optimal strengths of opioid with local anesthetic. In this blinded, prospective study, we compared four different epidural infusion solutions for efficacy and side effects over a clinically useful postoperative period and conclude that an epidural infusion of ropivacaine 2 mg/mL with fentanyl 4 microg/mL was most effective.

Unlabelled: Opioids play a fundamental role in the management of postoperative pain, but their use is associated with a number of side effects, including nausea and vomiting, sedation, and respiratory depression. Co-administration of a nonopioid has been proposed as a method of reducing opioid intake and minimizing side effects. Sixty-one ASA physical status I and II patients were enrolled in a double-blind, randomized, placebo-controlled, parallel study to investigate the effect of a combination of acetaminophen and morphine after open reduction and internal fixation of acute limb fractures. Patients were randomized to receive either oral acetaminophen (1 g every 4 h) or placebo as an adjuvant to morphine by patient-controlled analgesia (PCA) postoperatively. They were assessed daily for 72 h or until the PCA was discontinued according to standardized guidelines. The outcome variables collected were pain scores (11-point scale), amount of morphine self-administered, duration of PCA use, compliance with study design, incidence of nausea and sedation, and overall patient satisfaction. The acetaminophen group had lower pain scores on Day 1 (2.1 vs 3.3; P = 0.03) and a shorter average duration of PCA use (35.8 vs 45.5 h; P = 0.03). Overall patient satisfaction was also significantly greater in the acetaminophen group (8.7 vs 7.9; P = 0.04). These data suggest that acetaminophen is a useful adjunct to morphine PCA., Implications: This study assesses the benefit of combining two analgesics for the treatment of postoperative pain. Such a combination improves the quality of pain relief and patient satisfaction.

While there are increasing demands for improved post-operative analgesia and the implementation of Acute Pain Services (APS), the safety of such an approach remains under discussion. This paper analyses the safety outcome of 3016 consecutive post-operative patients treated under the care of a formalised Acute Pain Service. No serious complication resulting in morbidity or mortality occurred. Potentially severe complications without sequelae were discovered in 16 patients (0.53%); this incidence was similar for techniques of systemic opioid administration and continuous regional analgesia. Patient-controlled analgesia (PCA) alone had a significantly lower rate of respiratory depression than PCA with a background infusion or continuous morphine infusion. In 1069 patients receiving continuous regional analgesia (epidural, interpleural, peripheral) no trauma to nervous structures, no infection and no local anaesthetic toxicity occurred. In conclusion, an anaesthesiology-based APS can provide postoperative pain relief using a wide range of relatively invasive techniques without endangering patient safety.

A long-term study was undertaken on 286 patients who underwent perineal resection for rectal cancer to ascertain the incidence of chronic post-surgical pain in this group and to determine the likely cause for these pains. In 33 patients (11.5%) experiencing persistent perineal pain over the 5-year follow-up, most (70%) developed pain within weeks after surgery. The remaining 30% presented with pain several months later. This group with late onset pain died from known recurrence of adenocarcinoma in 80% of cases, giving this symptom the highest early confirmatory sign for tumour over other clinical tests. Those with early onset pain had a 26% tumour recurrence rate and clinical features of pain indicative of phantom anorectal pains in most cases. While the pain-onset time from surgery was the most sensitive predictor of cause and outcome, other distinguishing features in respect of site and quality of pain as well as differing responsiveness to drug therapy allowed for further separation of deafferentation from nociceptive pain for these two clinical groups.