Are Preemptive Analgesic Drugs Effective in the Management of Postoperative Pain Relative to Conventional Regimens - Literature review Example

Finding, Evaluating and Applying Evidence Student Name Institutional Affiliation Introduction The existing strategies in the management of acute postsurgical pain comprise the use of analgesic interventions that work by targeting the nociceptive system to minimize postoperative pain perception (Dahl and Moiniche, 2004). Preemptive analgesic drugs are treatment interventions that are administered prior to a surgical procedure and become operational as it is being carried out with the aim of minimizing postoperative pain (Dahl and Moiniche, 2004). They operate by causing a protective effect on an individual patient’s nociceptive pathway, thereby enhancing and accelerating postoperative functional recuperation as well as hasten post-operation discharge from medical facilities (Barreveld et al. 2013). Furthermore, preemptive analgesics help to minimize the chances of the occurrence of hyperalgesia and allodynia among surgical patients (Ong, Lirk, Seymour and Jenkins (2005). Moreover, reduced postoperative pain through administration of preemptive analgesic drugs minimizes acute morbidity (Barreveld et al. 2013). Some clinical trials investigating the efficacy of preemptive analgesic interventions in managing postoperative pain have been equivocal thereby creating disagreement on the efficacy of such interventions (Barreveld et al. 2013). In this paper, I intend to investigate whether preemptive analgesic drugs are an effective intervention in the management of postoperative pain. To this end, I formulate the following question that will be the subject of investigation: Are preemptive analgesic drugs effective in the management of postoperative pain relative to conventional regimens? Summary of the Article The authors investigate the efficacy of preemptive administration of analgesics in postoperative pain management. They present evidence in support of the fact that preemptive analgesics are controversial, pointing out that some reviews draw different conclusions regards their effectiveness relative to conventional post-operative pain management regimens. The meta-analysis applies a statistical review approach in efforts to present objective conclusions. It considers only fully published randomized controlled trials that have investigated the topic of preemptive analgesics in the management of postoperative pain with an inclusion and exclusion criteria being specified. It uses keywords search technique for articles published in leading medical journal databases such as MEDLINE, PubMed, CINAHL, and EMBASE. The specific search terms, which were considered include “preemptive analgesia, “pre-incision,” “preoperative pain” and “pre-incisional.”   Evaluation of the evidence using the CASP tool for a Meta-Analysis Systematic Review The article presents a meta-analysis of the effectiveness of administering preemptive analgesia with the intention of managing postoperative pain. The article is well structured with a presentation of the abstract and an elaborate introduction to the issue of analysis. A clear explanation of the methodology is presented that details how the meta-analysis was carried out. The article also presents the results of the meta-analysis in a concise manner. Finally, a discussion of the results is presented in the end. The meta-analysis considers a precise question which is an evaluation of the effectiveness of administering preemptive analgesia with the intention of managing postoperative pain. It clearly identifies the population being considered as comprising those patients who experience acute postoperative pain. It also clearly identifies the type of intervention given as being pain intensity scores, time before a postoperative patient requests for the first analgesic intervention, as well as a consideration of any supplemental analgesic drugs administered pos-toperatively. The article considers appropriate papers for the meta-analysis. Since the article is considering an analysis of a clinical intervention, the authors have clearly indicated that they only analyzed published randomized controlled trials covering the issue of preemptive analgesia for the management of postoperative pain. This shows that the study design of the analyzed papers was considered with only those considered as having an appropriate study design included in the analysis while those, that lacked, were eliminated. Moreover, the fact that they carried out a search on reliable and appropriate databases that comprised MEDLINE, PubMed, CINAHL and EMBASE makes the meta-analysis trustworthy and clinically imperative. The meta-analysis, however fails to include all the important studies that have been carried out regarding the study question. Such failure arises because the study does not include papers that were in a different language other than English. In addition, unpublished papers are left out of the analysis. Moreover, no attempts were made to contact the authors of the analyzed papers for original data for verification. Furthermore, the quality of the analyzed papers was rigorously considered with a clear explanation of the inclusion and exclusion criteria. In addition, the paper indicates that there was a follow up on the papers from the reference lists of other papers. The meta-analysis also combines the results of the studies under analysis with similar studies and results being synthesized together to obtain the final value of the meta-analysis. The results of the meta-analysis indicate that preemptive analgesia has a desirable benefit in the management of postoperative pain. Such results can be applied locally with the authors concluding that selected preemptive analgesic regimens are effective in the management of postoperative acute pain. As such, the paper is clinically beneficial and can be relied upon by clinicians and other healthcare providers involved in the management of postoperative pain. How the evidence will find application in the clinical context Katz and Seltzer (2009) explain that surgical injuries are exceptional in that healthcare professionals are precisely aware of the actual timing of the surgery and the consequent post-surgical pain well in advance. As a result, an opportunity exists for healthcare providers to ascertain any risk factors through which they can envisage the progression to patient recovery. Accordingly, an understanding and establishment of individual patient risk factors can enable clinicians to discern those patients with the potential to recover without the pain transitioning to a chronic state. According to Katz and Seltzer (2009), there is a need to recognize and appreciate the fact that chronic postoperative pain progresses from acute pain. Such an appreciation will ensure that clinicians are well placed to manage acute pain in efforts to prevent it from transitioning to chronic pain. Katz and Seltzer (2009) argue that the concept, that pain somehow etched into an individual's central nervous system, is key where clinicians desire to stop postoperative pain from progressing to a chronic state. One strategy, to achieve such a strategy, is to use preemptive analgesic drugs to cause the blockage of deleterious peri-operative sensory impulses, thus preventing them from reaching the central nervous system. Sinatra, Jahr and Watkins-Pitchford (2010) explain that analgesics in the management of pain comprise non-opioids and opioids. Patients with neuropathic pain exhibit a lack of pain relief after administration of non-opioids. As a result, clinicians should ensure that such patients are only administered by opioids putting in mind the complexity of neuropathic pain that necessitates careful analgesic choice, as well as dosage preparation and recommendation (Sinatra, Jahr and Watkins-Pitchford, 2010). The use of preemptive analgesia in the management of postoperative pain resulted from the outcomes of successful experiments on animals. However, similar studies on human beings have presented varying outcomes, a factor that makes their effectiveness inconclusive. There are those who report that preemptive analgesic interventions are effective in the management of post-operative pain, while others report that it may not be effective in some situations. Only some specific analgesic drugs exhibit efficacy in the management of postoperative pain (Ong et al. 2005). Others remain inconclusive about the efficacy of analgesic drugs with some attributing their efficacy on a number of factors (Ong et al. 2005). For example, the administration of nerve blocks as a preemptive analgesic intervention has shown some level of efficacy in the management of postoperative pain relative to conventional regimens (Barreveld et al. 2013). Moreover, the application of peripheral nerve blocks has shown superior analgesic efficacy compared to intravenous injection of the drugs amongst upper and lower end surgical operations (Barreveld et al. 2013). Healthcare professionals are increasingly faced with the challenge of choosing from a myriad of preemptive analgesic drugs in efforts to address different pain conditions that are manifest in individual patients (Sinatra, Jahr and Watkins-Pitchford, 2010). Moreover, it has been noted by Sinatra, Jahr and Watkins-Pitchford (2010) that individual analgesics have been found to exhibit unique sites of action where they are most effective. For instance, some analgesics are most effective when administered peripherally, others centrally and some are still effective in multiple sites. In addition, some have been found to cause notable side effects (Sinatra, Jahr and Watkins-Pitchford, 2010). Because of such an observation, it is necessary to ensure that intravenous administration of analgesic drugs is only carried out in instances where there is a contraindication to their peripheral administration. Contingent on the severity of a patient’s tissue injury postoperatively, any external stimuli that initiate nociceptive signals thereby causing a patient to perceive pain may or may not manifest in tissue damage (Dahl and Moiniche, 2004). A triggering of nociceptive signals devoid of any tissue damage commonly results in a reproducible as well as a proportionate correlation between that specific stimuli and the response. Subsequently, a cessation of the pain causing stimuli results in a complete waning of the pain from the patient’s nociceptive system (Dahl and Moiniche, 2004). As a result of the controversy and inconclusiveness of the efficacy of preemptive analgesics, clinicians need to recognize this fact and recommend only those drugs that have exhibited high degrees of efficacy in the management of postoperative pain among their patients. Moreover, they need to understand that there are some factors that influence the level of efficacy for varied preemptive analgesic regimens. According to Sinatra, Jahr and Watkins-Pitchford (2010), the existence of genetic disparities in relation to pain perception and response to a particular analgesic regimen requires clinicians to take adequate considerations as they explain varying opioid resistance among some patients. Moreover, According to Van de Ven and Hsia (2012), it is possible for surgical patients who have undergone an identical surgical process to report different postoperative pain experiences among themselves due to different genetic makeups. Such realization ensures that there is effective management of the pain being experienced by patients. Where there is evidence of a lack of success in the management of pain using a particular analgesic in a patient, such a drug should not be administered. Instead, an alternative analgesic should be considered to enhance effective patient care. Evaluation of the evidence presented in the article Healthcare professionals should recognize the fact that there is no modest pain intervention strategy for managing peri-operative pain in the current scenario whereby the cause of peri-operative pain has not been conclusive. However, preemptive analgesic interventions remain imperative strategies for minimizing peri-operative pain (Dahl and Moiniche, 2004). As Ong, Lirk, Seymour and Jenkins (2005) state, preoperative epidural administration of analgesics demonstrates superior efficacy in the management of acute postoperative pain. It is evidenced by lower pain scores, lower quantities of supplemental analgesic regimens. A prolonged period before a patient's request for additional analgesic regimens is also common (Ong, Lirk, Seymour and Jenkins, 2005). Ong, Lirk, Seymour and Jenkins (2005) further note that a consideration of various pain intensity measures stands out as a reliable assessment of the efficacy of various clinical interventions in the management of postoperative pain. Therefore, clinicians should assess pain perception among their patients after administration of preemptive analgesic regimens in an effort to evaluate their efficacy and offer alternative regimens as appropriate to enhance patient comfort and recuperation. Another measure of analgesic efficacy is the amount of supplemental analgesic regimens administered to a patient to reduce painful experiences among patients who have undergone surgery. This is one aspect that clinicians should consider as a means of analyzing the effectiveness of preemptive analgesic regimens in postoperative pain management. Conclusion The meta-analysis by Ong, Lirk, Seymour and Jenkins (2005) assess the efficacy of preemptive analgesic regimens in the management of postoperative pain among patients. The evidence presented indicates that preemptive administration of analgesics helps in the reduction of postoperative pain as evidenced by lower pain scores reduced patient requests for postoperative analgesic regimens. It also extends the time that elapses before a patient's request for supplemental analgesia. Moreover, epidural administration of analgesic regimens registers the most beneficial effect in managing postoperative pain. References Barreveld, A., Witte, J., Chahal, H., Durieux, M. E., & Strichartz, G. (2013). Preventive analgesia by local anesthetics: the reduction of postoperative pain by peripheral nerve blocks and intravenous drugs. Anesthesia and analgesia,116(5), 1141. Clarke, H., Bonin, R. P., Orser, B. A., Englesakis, M., Wijeysundera, D. N., & Katz, J. (2012). The prevention of chronic postsurgical pain using gabapentin and pregabalin: a combined systematic review and meta-analysis. Anesthesia & Analgesia, 115(2), 428-442. Dahl, J. B., & Moiniche, S. (2004). Pre-emptive analgesia. British Medical Bulletin, 71(1), 13 27. Katz, J., Clarke, H., & Seltzer, Z. E. (2011). Preventive analgesia: quo vadimus?. Anesthesia & Analgesia, 113(5), 1242-1253. Ong, C. K. S., Lirk, P., Seymour, R. A., & Jenkins, B. J. (2005). The efficacy of preemptive analgesia for acute postoperative pain management: a meta-analysis. Anesthesia & Analgesia, 100(3), 757-773. Sinatra, R. S., Jahr, J. S., & Watkins-Pitchford, J. M. (Eds.). (2010). The essence of analgesia and analgesics. Cambridge University Press. Van de Ven, T. J., & Hsia, H. L. J. (2012). Causes and prevention of chronic postsurgical pain. Current opinion in critical care, 18(4), 366-371. Read More