Postoperative pain than to remove. Painkillers. A list of effective drugs for pain of varying intensity and localization. Full review…. During the operation

What painkillers after surgery can be prescribed? This question worries many people, because from surgical intervention no one is safe. The human body has long been subject to the negative influence of microorganisms: bacteria and viruses that destroy human health. Pests of the body live due to the fact that they infect human tissues and organs and, therefore, cause significant harm to human health.

In our time, medicine is developing so rapidly and rapidly that harmful microorganisms do not have time to adapt to various antibiotics, medicines and preparations. So, one of the most miraculous ways is an operation, during which one or another type of disease is eliminated. However, some people experience severe pain as they gradually recover from anesthesia. How, then, at least for a while, to extinguish severe pain, if it brings a person even to tears?

A variety of drugs today

Any medical substance (for example, painkillers, pills or antibiotics) can help to gain full health to the human body. The question, most likely, is not in the types existing drugs but in the correctness of their application. Thus, if any medical medicine there are many negative consequences.

According to numerous social observations, the most common way of suicide is drug overdose.

Medicine is developing rapidly, making new discoveries almost every day. To date, pain pills after surgery are not something new and unattainable.. So, if the patient experiences acute discomfort after the operation, a variety of medications come to the rescue.

If the operation relieves the human body of the disease, then why does the person experience acute malaise?

An operation is a medical effect on the human body, the purpose of which is to eliminate developing disease in the human body. Of course, the operation is carried out exclusively with the participation of doctors who have received a license in a particular field. However, the question arises: if the operation relieves the body of the disease, why does the person feel unwell after? The answer to it is the structural features of the human body. The fact is that human tissues are a collection of similar cells that perform the same functions. Almost every tissue of the human body is affected by third-party objects, which leads to its modifications. For example, when cut with a knife, tissue is destroyed, after which bleeding begins. Similar action occurs during surgery: the tissues of the human body are amenable to surgical intervention, after which they experience the process of "rehabilitation".

To put it as simply as possible, the doctor destroyed the tissue (made an incision) and restored it (sewn up the wound). The human body feels pain after the action done, as the tissue, restoring its structure, excites the nervous system. It is known that the nervous system is the "foundation" of the human body. When excited nerve endings human body receives signals in the form of pain sensations.

Drugs, antibiotics and pills that can help a person with pain

The pain experienced after surgery is very often so severe that a person cannot even move, as this brings him catastrophic discomfort. However, modern medicine is able to offer a variety of painkillers, drugs and drugs that can extinguish any, even the most severe pain that has arisen in the human body.

The traditional approach in treating a patient after surgery is to "combine" a variety of drugs. Naturally, in order to avoid various injuries, you should not take them on your own. The attending physician should give you recommendations, after which you can proceed directly to the treatment itself. However, more often than not, doctors prefer to treat their patients on their own.

The "combination" method consists in the use of a variety of drugs, the purpose of which is the general repayment of pain after surgery. However, each medicine is unique in its own way and acts on the human body depending on the specified composition. By building a “scheme” for taking medications, the doctor starts the process of pain relief in your body.

To date, painkillers are one of the best friends of the human body. Unique in their structure and action, these drugs are able to save the human body from severe pain.

Types of painkillers after surgery

One of the most popular pain relievers terrible pain after the operation - the famous paracetamol.

Penetrating into the fire, paracetamol tablets activate vital important processes of the human body, which contributes to the speedy recovery of the affected area of ​​the body.

Painkillers are sold in almost every modern pharmacy and have a relatively low price.

Anesthesia of the body after surgery often takes place with the participation of Ketone tablets. This type of medicine is not used for chronic diseases and has a number of limitations. For example, the drug should not be taken: children under the age of 16, pregnant women, breastfeeding, asthma, diathesis, ulcers, and so on. So, under the influence of this drug, anesthesia occurs not only after surgery, but also, for example, with osteochondrosis, menstruation, fractures, tissue structure disorders, oncology, abdominal pain, and even after the removal of a diseased tooth.

It is important to have a drug such as aspirin. This drug helps to cope with pain in different parts of the human body, as well as high temperature. However, like all drugs, aspirin has a number of limitations. For example, the use of the drug is contraindicated in inflammation gastrointestinal tract, pain during menstruation and children, including adolescence. Thus, the use of aspirin can cause the development of liver disease in adolescents and even affect human brain. By the way, aspirin is quite cheap.

One of the controversial painkillers modern medicine is analgin, which affects the human body. For example, it is much more effective than paracetamol. However, this drug has a negative effect on circulatory system, liver, kidneys and lymphatic system. Modern doctors are of the opinion that this apparatus should be used only in case of critical need. For example, when other painkillers did not have the desired effect.

Pain after surgery is a complex response to tissue trauma during the procedure, which stimulates hypersensitivity of the central nervous system. The result is pain in the involved areas, including even those not affected by the surgical procedure. Postoperative pain can occur after any surgical procedure, be it minor dental surgery or triple heart bypass surgery. Postoperative pain increases the likelihood of post-surgical complications and prevents the patient from recovering and returning to normal life.

Why does postoperative pain occur?

Pain comes in two different forms: physiological and clinical.

• Physiological pain comes and goes. It is the result of sensations of high intensity. It often acts as a safety mechanism to alert a person (for example, in the event of burns, scratches, or cuts).
• clinical pain, on the contrary, it is characterized hypersensitivity to painful stimuli around the localized area, and is also felt in neighboring, unaffected areas. During the operation, tissues and nerve endings are injured, which leads to pain in the incision. This injury overloads the pain receptors that send messages to the spinal cord. The resulting central sensitization is a type of spinal cord post-traumatic stress disorder that interprets any stimulation as unpleasant. This is why a person may feel pain when moving or touching physically in places far from the surgical site.

Pain after surgery is tolerated differently

People endure postoperative pain individually. Doctors note that some patients experience severe pain in the postoperative period, which requires large doses of painkillers, while others cope well without it. a large number medicines. Several theories have been put forward for this discrepancy regarding, for example, differences in body size or emotional well-being. Not so long ago, biological evidence was discovered that testifies to the birth of individual people with different pain perception thresholds. Scientists have found that changes in the amino acid of one of the genes cause different levels of pain perception. This gene codes for an enzyme associated with brain neurotransmitters, .

How to ease the postoperative period

The goal of pain management after surgery is to reduce the amount of pain the patient experiences after the procedure. New research has shown that prevention excessive load nervous system may lead to a less painful postoperative period. Prepared patients may need fewer drugs and may recover faster. In addition, with improved, less invasive surgical methods, many patients do not have to stay in the hospital after operations at all.

Some non-medical methods can help reduce postoperative pain:

• Knowing about the surgical procedure and its aftermath can help reduce stress, which plays a big part in the perception of pain. The patient knows what to expect and therefore the fear of the unknown goes away.
• Meditation and Methods deep breathing can also reduce stress. These methods reduce arterial pressure and increase oxygen levels, which are critical to recovery.
• Hypnosis before and after surgery can calm and muffle the perception of pain.

Other Methods for Relieving Postoperative Pain

Multimodal analgesia uses more than one method of pain management after surgery. Several methods can actually reduce the amount of medication needed to relieve it and minimize side effects. The use of preoperative, surgical and postoperative methods allows the patient to control pain after surgery. Before any surgical procedure, the patient should speak with the doctor, surgeon and, if possible, the anesthesiologist to get a complete understanding of the procedure and what to expect immediately after the operation. The patient should not eat or drink before the operation. This helps to minimize the side effects of general anesthesia and pain medications, such as nausea and vomiting.

Most important principle in the approach to combating postoperative pain - multimodality. That is, a combination of several methods of anesthesia and a combination of several drugs. Importance also has an assessment of pain syndrome. Currently, the most common so-called VAS is a visual analog scale that allows you to assess the intensity of pain experienced by a person and prescribe the most adequate pain relief. According to this scale, the patient must mark on a piece of paper 10 cm long the point that, according to his impressions, corresponds to pain. The closer to the end of the scale is the point, the stronger the pain.

Multimodal anesthesia includes the following components:

• adequate premedication - preoperative administration of painkillers and sedatives;
• combination of general anesthesia with regional anesthesia - if possible, an epidural catheter is installed for postoperative prolonged anesthesia during surgery on chest, abdominal cavity, small pelvis, lower limbs. During operations on the upper limbs, catheters are installed in the nerve plexuses;
• in postoperative period NSAIDs, paracetamol and, if necessary, narcotic drugs are prescribed - the combination of these drugs allows you to reduce the dose of each of them individually by 30-40%.

Important! The question of the duration of the appointment of painkillers should be decided individually, together with the patient: someone may refuse medication the very next day after the operation, while someone has to take painkillers for 1-2 weeks.

Side effects of pain medications

Pain medications can have unpleasant side effects. For many people, they cause nausea, vomiting, and impaired mental functioning. NSAIDs can cause kidney failure, intestinal bleeding, and liver dysfunction. Some drugs are associated with acute kidney failure. Early screening and careful monitoring can prevent most of these problems.

Denial of responsibility: The information provided in this postoperative pain article is intended to inform the reader only. It cannot be a substitute for the advice of a health professional.

During surgery, tissues, muscles, bones are damaged, so the person feels pain. Pain medications after surgery help relieve a person of pain, which has a beneficial effect on the recovery process.

Any operation is a huge stress for a person, and especially one who has pain threshold low The postoperative period is necessarily accompanied by significant pain, you need to understand this, but you don’t need to endure them. Therefore, after the procedure, the appointment of powerful analgesics, which will help improve a person's well-being and make the recovery period shorter and more efficient. Painkillers, which are available in every home, are unlikely to help here. Directly after the operation, strong painkillers are usually used, and in the future, the doctor may prescribe drugs for pain relief in tablets.

Pain relief methods

In the postoperative period, it is possible to use several types of analgesics:

The easiest and most convenient is the oral route. When an epidural catheter is used, a person may experience pain, discomfort may occur, and inflammation of nearby tissues sometimes develops, but there are times when this method is simply necessary.

The essence of this method is that an analgesic is injected with a puncture needle into the region of the spinal cord, and then a catheter is attached. Often the use of this method is accompanied by unpleasant sensations:

• nausea and vomiting;
• headache;
• drop in blood pressure;
• weakness in the legs.

The least common side effects are observed when an anesthetic gel or ointment is used.

Tablets help relieve pain in about half an hour, while painkillers after surgery have their effect within 2-3 minutes. Therefore, in order to relieve pain after surgery, doctors prescribe injections. Ointments and gels are more often used as an additional remedy.

Most modern method is autoanalgesia, but in order to use it, medical institution must have an appropriate material and technical base. With this method, an infusion pump is used to deliver analgesics to the blood. It has a button with which the patient can independently regulate the amount of medication received.

Pain relievers

Modern analgesics are divided into 2 main groups - they can be narcotic and non-narcotic. Drugs are:

• based on natural substances;
• semi-synthetic;
• synthetic.

These funds have a number of distinctive features:

But these drugs are highly effective as strong painkillers. If you choose the right dose and use them for a short time, the risk of side effects is minimal. Pharmacies dispense narcotic drugs only on special prescription doctor.

At non-narcotic drugs the analgesic effect is much less pronounced, but they also have an anti-inflammatory and antipyretic effect, which is important immediately after the operation. But apart from undeniable benefit, these tools are capable of misuse inflict harm. Their side effects are Negative influence on the mucous membrane of the stomach and intestines, kidneys.

Narcotic pain relievers

One of the strongest narcotic analgesics is morphine. An injection of this drug almost completely relieves a person of any pain. Morphine relieves pain in a few minutes and works for 5 hours.

Morphine is a powerful analgesic that other drugs cannot compete with. Therefore, lighter drugs are usually prescribed immediately after the operation, and Morphine is used only if they are not effective enough. There are serious contraindications for its use:

• severe respiratory and hepatic pathologies;
• epilepsy;
• severe alcohol intoxication.

Morphine is available in the form of injections and tablets, the effectiveness of which is almost the same.

Morphine, among other components, is part of a drug such as Omnopon. This remedy has the same strong analgesic effect as Morphine. Its difference is in fewer side effects. It is available only in the form of injections.

Promedol is a synthetic analogue of Morphine. The analgesic effect is somewhat less pronounced, the duration of exposure is shorter than that of Morphine. It has almost the same side effects, with one exception - less oppression. respiratory center. Therefore, Promedol is used in cases where the use of Morphine is not possible, for example, when the patient has severe respiratory failure. Promedol is available in tablets and ampoules for injection.

Another synthetic opiate is Tramadol. It has a strong analgesic effect, differs in the duration of action - about 8 hours. Available in tablets and in solution for injection, they have almost the same effect. Distinctive feature Tramadol: almost no side effects develop with its use. It is contraindicated only in severe drunkenness and its use is prohibited for pregnant women.

Non-narcotic analgesics

These drugs relieve pain much weaker than narcotic counterparts. Therefore, they are not used for the first time after the operation. First, opioid injections are prescribed, and then, after some time, drugs are used in tablets.

Diclofenac painkillers take effect in about 30 minutes. The drug has a good absorption capacity, due to which its analgesic effect can manifest itself in any organ. The gold standard - this is quite justifiably called this remedy among analogues.

Usually, injections of the drug are first prescribed, and the transition to the tablet form of the drug is gradually made.

Diclofenac has one serious drawback - a wide range of side effects. If it is used for a long time, the mucous membrane is affected digestive tract may develop stomach ulcers or duodenum.

lesser side effect has Nimesulide. It's over modern facility which is more secure. Analgesic properties are almost equal to Diclofenac, but Nimesulide has a longer duration of action. But the drug is not available in the form of injections, but only in tablets. Therefore, immediately after the operation, its use is unjustified. If you use the tool long time the risk of side effects increases.

The most modern, reliable, safe and convenient of painkillers is Rofecoxib. It is produced, in addition to tablets, also in ampoules. Therefore, it is often used in the first days after surgery. A huge plus of the drug is that it is practically safe. It does not affect digestive system, so even patients with peptic ulcer can take it without fear. It differs in the duration of exposure, well reduces pain.

Drugs available in every home

Means from this group can be purchased without a prescription at a pharmacy, and for sure everyone has them at home. Of course, their effectiveness is rather controversial, since they have weak analgesic properties. But if some time has passed after the operation, the person is discharged from the hospital, it is possible to use these analgesics to relieve residual mild postoperative pain.

These drugs include Ketanov. There are certain restrictions on its appointment. For example, it should not be taken by children under 16, pregnant and lactating women, people suffering from asthma, stomach ulcers and some other diseases. Otherwise, the drug is quite effective.

After hemorrhoid surgery, you will need certain time anesthetize damaged tissue. Since the most efficient are local funds, local painkillers are usually prescribed - ointments, suppositories.

How successful it will be surgical treatment hemorrhoids are affected by many conditions. If the doctor appoints surgical therapy diseases, this signals that the disease is at a very advanced stage of its development, in which conservative options treatments proved to be ineffective, so radical options treatment.

Effective invasive interventions do not guarantee the complete elimination of problems with the venous system. After the patient is assigned medical recommendations that involve the use of medications:

Proctologist Lobanov:

More than 30 years of my practice have shown that there are no miracles in the treatment of hemorrhoids, and at the same time, there are remedies that can help a lot of people with this delicate issue.

• ointments;
• suppositories;
• tablet funds.

Proper use of anesthetics and other prescriptions will directly affect the recovery time and recovery time after hemorrhoid surgery.

The key areas of rehabilitation after hemorrhoid removal surgery are:

1. Increasing the rate of regeneration of damaged tissues of the anal area affected by the operation.
2. Getting rid of inflammatory reactions. Prevention of suppuration and swelling.
3. Prevention of wound bleeding immediately after hemorrhoid surgery.
4. Prevention of accumulation of feces in the cavity of the colon and small intestine, respectively, the appearance of constipation.
5. Relief of pain after hemorrhoid surgery.

The composition of medicines that are used to treat hemorrhoids after surgery includes natural constituent elements, which will help stop the blood, eliminate microbes, relieve inflammation and irritation. If the pain is very intense, the doctor uses analgesics (Ketanov, Nise, Nimid, Dicloberl, etc.).

Proctologist Kolesova:

Hemorrhoids is serious illness, which causes a lot of anxiety, fortunately, there are remedies that help both relieve symptoms and help heal. One of them...

Use of any medications, which were not agreed with the attending doctor, is strictly prohibited. The recovery period after the operation is directly dependent on which radical method is chosen to get rid of hemorrhoids.

The recovery period on average lasts up to one and a half months. In the event that the surgical intervention is open, it will take at least two months for complete rehabilitation. If the intervention was performed non-invasively, the recovery period is reduced to three weeks.

What ointments are used after surgical treatment

After hemorrhoid surgery, ointments are used to numb the area of ​​the disease. Such drugs help in that they have analgesic, anti-inflammatory, antimicrobial and anesthetic effects.

These include Levomekol ointment. With the help of his gentle but effective impact, there is a rapid recovery and healing after the operation has been performed.

Levomekol, due to its mild effect, is prescribed even to women during the period of bearing a child, since it is not absorbed into the blood fluid and acts locally. Levomekol perfectly eliminates pain, reduces the intensity of inflammatory processes, relieves purulent infectious process.

Medicines in the form of release ointment are effective for local application. One of the most effective is Relief ointment. It helps to recover and eliminate pain after hemorrhoid surgery. The variety of ointments and the number of applications is determined by the attending doctor.

Another anti-inflammatory ointment is Troxevasin. It can quickly relieve pain. Also, with its help, puffiness, an inflammatory process is eliminated after varicose growths in the rectal region have been removed.

Other pain medications

What painkillers are used after surgery for hemorrhoids - this question is relevant for those people who have undergone removal of formations or minimally invasive methods of treatment.

In order to stop intense pain, immediately after the procedure surgical treatment and in the postoperative period, it is advisable to use painkillers. The most common and one of the most effective are rectal pain suppositories. They operate locally:

1. Suppositories Anestezol - their action is aimed at stopping pain, preventing constipation. The use of these suppositories helps to heal cracks in anus. Thanks to these suppositories, recovery is much faster.
2. Procto-Glivenol is prescribed for the relief of intense pain, it is a good anesthetic. The key task of this drug is to increase the tone of the walls of the venous and vascular system, as well as the elimination of inflammatory reactions.
3. Candles Relief are universal for the treatment of hemorrhoids and in order to speed up recovery in the postoperative period. Such a tool is designed to anesthetize during treatment and recovery.

In addition to suppositories, another pain-relieving drug option is pills, which are designed to eliminate pain, inflammatory processes, increase the tone of the venous and vascular walls. Among them are artificial (Flebodia, Detralex, Venarus) and vegetable (Asklezan, Pilex).

Such drugs are prescribed to improve the circulation of blood fluid, to prevent congestion, to tone the walls of veins and blood vessels, to get rid of pain and swelling.

The next day discomfort are getting smaller. Any medications should be used only after prior consultation with the attending physician and correction of the treatment regimen.

In the event that the pain is very severe, if other methods are ineffective, painkillers are used, the injection is injected directly into the rectal area. After the introduction of the drug, the pain disappears almost after a few minutes, after the absorption of the drug into the tissues.

Laxatives

During recovery period in the postoperative period, stagnation is often observed - the accumulation of feces in the large intestine.

In order for fresh scars after surgical treatment not to be injured by hard stool, doctors recommend the appointment of laxatives in the postoperative period.

The most effective are such drugs:

1. Duphalac - with the help of the content of lactulose in the composition of the product, the intestinal tract is gently emptied, the feces soften and are excreted gently, without mucosal injuries.
2. Mal Par - this medicine contains liquid paraffin and magnesium hydroxide. It has a mild laxative effect, perfectly eliminates constipation, including chronic ones.
3. One of natural remedies to eliminate constipation is the herb senna. A decoction or infusion is prepared from it.

Such funds should also be prescribed only by the attending doctor, in parallel, the diet is adjusted, which is an important factor in the treatment of hemorrhoids and during the recovery period after surgery.

Babayants A.V., Kotaev A.Yu., MMA named after I.M. Sechenov, City Clinical Hospital No. 7, Moscow

Pain management is one of the most important tasks in the postoperative period. Effective pain relief contributes to the early rehabilitation of the patient, reduces the incidence of postoperative complications and chronic pain syndromes.

There is currently a wide selection medicines and methods non-drug pain relief However, numerous studies carried out in different countries, revealed insufficient analgesia in the early postoperative period in almost 50% of patients . Therefore knowledge modern principles anesthesia after surgery is of great practical importance.

The stages of adequate pain relief are:

1. Preoperative assessment of intensity and duration of pain syndrome (Table 1, Table 2).

Table 1. Factors affecting the intensity of pain and the choice of analgesics after surgery

table 2. The effect of surgery on the duration of pain relief after surgery

1. Building a pain management plan(analgesic(s), route of administration, frequency, etc.) (Table 3).

Table 3. Medicines used to treat acute pain

* Metamizole sodium is used in Russia, but is banned in a number of countries due to toxicity.

1. Pain treatment.
2. Postoperative assessment of the effectiveness of pain relief(to adjust the pain management plan for insufficient pain relief).

To determine the quality of anesthesia after surgery, the most widely used visual analog scale (Fig. 1). The patient puts a vertical mark on the line corresponding to the level of pain. Anesthesia is considered adequate if the patient does not notice pain at rest, and when moving, coughing, moderate pain occurs that does not limit them.

Rice. one. Visual analogue scale

Opioid analgesics realize their action through opiate receptors located at the spinal and supraspinal levels, and are the main group medicines for the treatment of pain in the postoperative period.

At the same time, after extensive intracavitary surgical interventions to achieve adequate pain relief in every third patient requires the introduction of opioids in doses exceeding the standard recommended . An increase in the dose of opioid analgesics is accompanied by pronounced adverse reactions(drowsiness, respiratory depression, nausea, vomiting, paresis of the gastrointestinal tract, urination disorders), therefore, it is now recognized that monotherapy with opioid analgesics is not always effective enough, and sometimes even dangerous.

In addition, with traditional subcutaneous and intramuscular injection it is difficult to maintain optimal plasma concentrations of opioids, which may be accompanied by either respiratory depression or inadequate analgesia. Bolus administration of opioid analgesics intrathecally or epidurally provides good pain relief up to 24 hours, however, even small doses of administered drugs (tens of times less than with intramuscular injection) can be accompanied by side and toxic effects.

Tramadol (Tramal) is an opioid agonist that stands apart from all representatives of this class of opioids, primarily because, unlike them, it does not belong to drugs. This has been confirmed by extensive clinical experience its use worldwide and by special scientific research its narcotic potential.

Unlike other opioid agonists, tramadol has a dual mechanism of action. It has been established that the analgesia induced by tramadol is not completely eliminated by the opioid antagonist naloxone and, along with the opioid mechanism, is realized by additional inhibition of pain impulses with the participation of the serotonin and adrenergic systems. Those. the mechanism of analgesic action of tramadol is not completely identical to other opioid agonists.

The analgesic potential of tramadol according to different authors, is from 0.1 to 0.2 of the potential of morphine, it is equal to or slightly greater than the potential of codeine; in terms of effectiveness, 50 mg of tramadol are equivalent to 1000 mg of metamizole, i.e. Tramadol is an analgesic used for the treatment of severe to moderate pain.

Numerous studies have not found significant respiratory depression in postoperative patients under the influence of Tramal in the range of therapeutic doses from 0.5 to 2 mg per 1 kg of body weight, even with intravenous bolus administration, while morphine in therapeutic dose 0.14 mg/kg statistically significantly and significantly reduces the respiratory rate and increases the CO 2 tension in the exhaled air.

Non-steroidal anti-inflammatory drugs (NSAIDs) have analgesic and anti-inflammatory properties. The mechanism of action is associated with the inhibition of cyclooxygenase, which catalyzes the breakdown of arachidonic acid into various prostaglandins, which are the main mediators of inflammation. In addition, NSAIDs affect the conduction of pain impulses in the central nervous system. NSAIDs are considered effective analgesics for mild to moderate pain. Side effects are related to the main action of NSAIDs- suppression of the synthesis of prostaglandins and develop, as a rule, with long-term use. These include NSAID-gastroduodenopathy (dyspeptic disorders, erosion and ulcers of the stomach and duodenum); nephrotoxicity; violation of blood coagulation activity (inhibition of platelet aggregation and the formation of prothrombin in the liver); hematotoxicity (decrease in the number of erythrocytes and leukocytes in the blood). The severity of side effects is reduced with the use of selective cyclooxygenase-2 inhibitors. .

Methods of regional anesthesia are widely used in surgical interventions to reduce the side effects of systemic anesthesia and can be used in the postoperative period.

There are several ways to apply local anesthetics:

• infiltration anesthesia of wounds;
• blockade peripheral nerves and plexus;
• epidural or intrathecal (spinal, spinal) anesthesia.

Infusion of local anesthetics provides effective analgesia, but may be accompanied by arterial hypotension, motor block, nausea and urinary disorders.

With severe pain syndrome, catheterization of the epidural space is used for repeated administration of an analgesic - long-term epidural anesthesia (long-term spinal anesthesia is used less often).

Clonidine is an agonist of a-noradrenergic receptors and inhibits the transmission of pain impulses by acting on postsynaptic receptors.

Ketamine and magnesium sulfate reduce the conduction of pain impulses and prevent the excitability of neurons on various levels central nervous system (CNS).

In spite of big number painkillers, the use of each of them is associated with the risk of side effects, therefore, at present, one of the main principles of postoperative analgesia is the principle of balanced analgesia, when a combination of opioid analgesics, non-steroidal anti-inflammatory drugs, local anesthetics and other groups of drugs (ketamine, magnesium sulfate) is used. ).

Simultaneous use of drugs different groups (tramadol and acetaminophen (Zaldiar)) allows you to block the conduction of nociceptive (pain) impulses at all levels, reduces the dose of each of the analgesics, improves the quality of pain relief and significantly reduces the number of side effects. The drug can be used after low-traumatic surgical interventions (hernia, sectoral resection of the mammary gland, resection thyroid gland etc.), while many authors still believe that NSAID monotherapy is sufficient for effective pain relief .

For more traumatic operations (most abdominal operations) is the most optimal combination of NSAIDs with opioid analgesics(Zaldiar). The synergism of the analgesic action of opioids and NSAIDs allows for 20-60%. reduce the need for opioid analgesics and reduce their side effects (improved function external respiration, rapid recovery of gastrointestinal motility) .

Tramadol and acetaminophen (paracetamol) are two analgesics that have proven their effectiveness in a wide range of diseases and served as the basis for the creation combination drug Zaldiar(tramadol 37.5 mg/acetaminophen 325 mg). The use of such a combination of drugs is justified, first of all, from the point of view of the pharmacokinetic and pharmacodynamic characteristics of the drugs.

The mechanism of action of acetaminophen (paracetamol) is not well understood. It is assumed that he has central action, while analgesia is achieved by increasing the pain threshold, and the antipyretic effect is achieved through inhibition of prostaglandin synthetase in the hypothalamus. Acetaminophen is prescribed for mild to moderate pain, more often for arthrosis of large joints with a slight severity of inflammation.

The time to reach the maximum concentration in the blood serum (T max) for acetaminophen and tramadol is different. Based on the pharmacokinetic features, the use of a combination of drugs is justified: acetaminophen develops an early analgesic effect, while tramadol realizes its action later, and, having a long half-life, provides prolongation of analgesia. The use of this combination of drugs showed greater clinical efficacy than tramadol 75 mg as monotherapy.

According to the results of a randomized, double-blind, placebo-controlled study in 1783 patients (odontogenic pain syndrome, postoperative orthopedic, gynecological patients), the combination of tramadol / acetaminophen was more effective than the use of both drugs separately . According to other authors, the use of 2 tablets of Zaldiar (tramadol 75 mg + acetaminophen 750 mg) in patients with odontogenic surgical interventions had a faster and lasting effect than tramadol monotherapy.

Most often, the principle of balanced analgesia is applied after surgical interventions, accompanied by a large trauma (extended oncological operations with lymphadenectomy; operations performed by thoracoabdominal access; resection of the esophagus with plastic surgery of the gastric tube or colon; extensive liver resections, etc.).

To improve the quality of postoperative pain relief in last years applied patient-controlled analgesia (CPA) technique. The CPA device is an automatic syringe with microprocessor control, actuated by a button in the hands of the patient.

The use of CPA allows to reduce the dose of analgesics (and their side and toxic effects) and to level individual characteristics drug action in different patients.

CPA based intravenous administration morphine is indicated for patients with low risk development of cardiopulmonary complications and requires the introduction of opioid analgesics for at least 2 days after surgery. 10 to 30% of patients need this technique .

The condition for conducting CPA is the restoration of consciousness and the adequacy of the patient, as well as mandatory monitoring of vital important functions, which together with high cost devices for CPA limits the application of the method.

The traditional concept of postoperative pain management has been to use analgesics only after the onset of severe pain. However, it is now proven that pain relief is much more difficult to achieve if the sensation of pain has already formed.

During surgery, tissue injury occurs, which is accompanied by the formation of a large number of nociceptive (pain) impulses. Then, inflammatory mediators and other biologically active substances are released from the damaged tissues, which, interacting with the membrane of the nerve endings of nociceptive receptors, increase their sensitivity to mechanical and thermal factors. Sensitization (increased sensitivity) of nociceptors in the area of ​​damage develops, which is manifested by a decrease in the threshold of their activation (peripheral sensitization) .

The flow of nociceptive impulses, increased due to peripheral sensitization, leads to an increase in the excitability of spinal neurons involved in the conduction of pain impulses (central sensitization).

When a state of sensitization occurs, stimuli that would not normally cause pain begin to be perceived as painful, and painful stimuli begin to be perceived as hyperbolic (hyperalgesia). The sensitization of nociceptive CNS neurons resulting from tissue damage may persist for several hours or days after the cessation of the receipt of nociceptive impulses from the periphery.

The principle of preventive analgesia (pain prevention) consists in the use of analgesics (usually NSAIDs) before the operation, which helps to prevent the occurrence of peripheral and central sensitization (Fig. 2) .

Rice. 2. Pain management strategy (quoted from Kissin I., 2000, with changes)

The thickness of the arrows corresponds to the effectiveness of the impact

The optimal method of postoperative pain relief does not currently exist. The choice of drugs and methods of pain relief is determined by the experience of the anesthetist, financial resources and other factors.

We present example of a possible anesthesia scheme during gastrectomy with extended lymphadenectomy in the volume D2.

Premedication - on the eve of the operation at 22:00 and 20-60 minutes before the operation, midazolam (0.07-0.1 mg/kg) and 100 mg of ketoprofen are administered intramuscularly. Catheterization of the epidural space is carried out at the level of ThVII-ThIX. The initial dose of local anesthetic is 6-10 ml of ropivacaine (or bupivacaine 0.25%) with the addition of 50-100 mg of fentanyl, then a constant infusion of ropivacaine (8-12 ml / hour) and fentanyl (2-2.5 mcg / kg / hour). Maintenance of anesthesia is carried out by any accessible way(neuroleptoanesthesia, total intravenous anesthesia). In the postoperative period, lower concentrations of local anesthetics (0.2% ropivacaine or 0.2% bupivacaine) are used for epidural anesthesia. Minimum effective dose is selected by titration (infusion rate can vary from 4 to 12 ml per hour). In case of insufficient analgesia, the infusion rate or concentration of the anesthetic should not be increased, but NSAIDs, other non-narcotic analgesics or opioids should be used.

It is important to note that intractable pain syndrome in the postoperative period requires the exclusion of postoperative complications (suture failure, pancreatic necrosis, etc.).