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Journal articles on the topic 'Analgesia Balanceada'

Author: Grafiati

Published: 4 June 2021

Last updated: 4 February 2022

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1

Novaes, Aline Dos Santos, and Leonardo De Freitas Guimarães Arcoverde Credie. "Infusão de lidocaína como parte de anestesia multimodal para laparotomia exploratória em equino com síndrome cólica:." Singular Meio Ambiente e Agrárias 1, no. 1 (August 12, 2019): 28–30. http://dx.doi.org/10.33911/singular-maa.v1i1.39.

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As particularidades anatômicas inerentes a espécie equina predispõem a mesma a síndrome cólica, sendo, predominantemente, seu tratamento cirúrgico. Esta situação impõe alguns desafios, pois o paciente se apresenta hemodinamicamente instável e com alto grau de sensibilidade álgica, tendo normalmente a equipe cirúrgico-anestésica pouco tempo para estabilização e tomada de decisão cirúrgica. Anestésicos inalatórios, como isofluorano, são fármacos amplamente utilizados em anestesia equina, no entanto, podem agravar o quadro hemodinâmico do paciente de maneira dose-dependente, sendo de extrema importância a inserção de anestesia multimodal no protocolo farmacológico, o que deve minimizar efeitos colaterais, otimizando a anestesia e a analgesia no período peri-operatório. Dentre os fármacos utilizados na anestesia balanceada de equinos, infusões contínuas de analgésicos e sedativos têm se mostrado úteis e eficazes nesta espécie. O cloridrato de lidocaína sob a forma de infusão contínua intravenosa apresenta efeito analgésico sistêmico, reduzindo de maneira intensa o requerimento de anestésicos gerais inalatórios, contribuindo também com seu efeito pró-cinético, melhorando o prognóstico em patologias do trato gastrointestinal. A presente revisão tem por objetivo descrever a literatura atual sobre a utilização do cloridrato de lidocaína por meio de infusão contínua intravenosa na espécie equina como parte de anestesia multimodal em procedimentos cirúrgicos para correção de síndrome cólica.

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Rayamajhi, Anuj Jung, Balbrishna Bhattarai, and Birendra Prasad Shah. "Prospective randomized double blind comparison of analgesic efficacy of single shot epidural bupivacaine with or without dexamethasone in patients undergoing lower abdominal surgeries." Journal of Society of Anesthesiologists of Nepal 2, no. 2 (September 30, 2015): 46–51. http://dx.doi.org/10.3126/jsan.v2i2.13529.

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Background: Epidural block with local anaesthetic with or without additives is being used for perioperative analgesia. Various additives have been used to enhance the effect of regional blocks including epidural blocks. This study aimed to investigate the effect of adding a single shot epidural dexamethasone to bupivacaine on postoperative analgesia and dose of rescue analgesics used.Methods: A prospective, randomized, double blinded study was conducted in 90 adult patients undergoing lower abdominal surgery. The patients were randomized into two groups. Group 1 received 9ml of 0.5% bupivacaine plain with 1 ml of normal saline. Group 2 received 9ml of 0.5% bupivacaine plain 9 ml with 1 ml of dexamethasone (4mg). After standard balanced anesthesia technique, patients were observed in postoperative period for pain and hemodynamic variables accordingly.Results: Our study showed significantly longer duration of analgesia of 468 minutes (almost 8 hours) when dexamethasone was added to bupivacaine for single shot epidural injection compared to 271 minutes (approximately 4 and half hours) when bupivacaine alone was used (p<0.001). Consumption of rescue analgesic, Tramadol, was significantly lower in dexamethasone group in 24 hours (169.31±50.82 mg in Group 1 and 114.77±60.59mg in Group 2, p<0.001). No adverse events were noted.Conclusion: Addition of dexamethasone to bupivacaine for single shot epidural block almost doubled the duration of analgesia. Single shot epidural block using bupivacaine with addition of dexamethasone provides effective post operative analgesia and significantly reduced the postoperative rescue analgesic requirement.Journal of Society of Anesthesiologists of Nepal 2015; 2(2): 46-51

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Rockemann, Michael G., Wulf Seeling, Carsten Bischof, Dirk Borstinghaus, Peter Steffen, and Michael Georgieff. "Prophylactic Use of Epidural Mepivacaine/Morphine, Systemic Diclofenac, and Metamizole Reduces Postoperative Morphine Consumption after Major Abdominal Surgery." Anesthesiology 84, no. 5 (May 1, 1996): 1027–34. http://dx.doi.org/10.1097/00000542-199605000-00003.

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Background Surgical trauma induces nociceptive sensitization leading to amplification and prolongation of postoperative pain. While preemptive analgesic treatment with numerous agents has been successful in experimental animals, results of human studies remain conflicting. The authors used a multimodal approach for preemptive analgesia before abdominal surgery: diclofenac and metamizole inhibit prostaglandin synthesis, thus influencing peripheral sensitization; epidural local anesthetics induce conduction block, epidural opioids inhibit nociceptive synaptic transmission, and metamizole induces descending inhibition. The interaction of these drugs might suppress spinal nociceptive sensitization and postoperative analgesic demand. Methods One hundred forty-two patients scheduled for major abdominal surgery were randomly assigned to one of three groups and studied prospectively. Epidural catheters in groups 1 and 2 were placed at interspaces T8-T10, the position of the catheter was confirmed by epidurography, and sensory testing after administration of 5 ml mepivacaine 1%. Group 1 received 75 mg intramuscular diclofenac, 1000 mg intravenous metamizole, 5.3 +/- 1 mg epidural morphine, and 15-20 ml mepivacaine 1% 85 +/- 41 min before skin incision. Epidural analgesia was maintained by injections of 0.1 ml.kg-1.h-1 mepivacaine 1%. Group 2 patients received the balanced analgesia regimen before wound closure (221 +/- 86 min after skin incision). Group 3 patients did not receive any study substances. General anesthesia was induced with 5 mg/kg thiopental and 2 micrograms/kg fentanyl and maintained with enflurane and nitrous oxide. Postoperative analgesia consisted of patient-controlled intravenous morphine over 5 days. Results Median visual analog scale pain intensities were < 3 cm and did not differ among the groups. Morphine consumption per hour on postoperative day 2 was 0.8 +/- 0.1 mg/h (group 1) < 1.2 +/- 0.1 mg/h (group 2) = 1.1 +/- 0.1 mg/h (group 3) and cumulative morphine consumption (in mg) on the morning of day 5 was 95 +/- 9 (group 1) < 111 +/- 11 (group 2) < 137 +/- 10 (group 3). Conclusions A significant reduction of patient controlled analgesia requirements could be achieved by our preincisional balanced analgesia regimen compared to application before wound closure. The more distinct difference between patients receiving balanced analgesia and those in the control group is based on the analgesic action of the study substances, which lasted about 14 h.

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Singh, Rakesh Ranjan, Ashmita Kiran, and Anant Narayan Sinha. "Elucidation of Analgesic Effects of Butorphanol Compared with Morphine: A Prospective Cohort Study." Journal of Biology and Life Science 6, no. 2 (June 17, 2015): 130. http://dx.doi.org/10.5296/jbls.v6i2.7524.

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Pain is a complex subjective experience comprising of both physical and emotional components. The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of damage.”Opioids are essentially important constituent of balanced anaesthesia. They provide adequate analgesia, reduces requirement of inhaled anaesthetic agents, maintain cardiovascular stability and provide adequate post-operative analgesia. Morphine remains the most widely used analgesic and the gold standard against which all new opioids are compared. Butorphanol has been employed successfully for the relief of postoperative pain, labor pain, preanaesthetic medication and in balanced anaesthesia. We studied the analgesic property and the side effects of butorphanol and compared them with equipotent dose of morphine. This study revealed that butorphanol had more or less similar effects on haemodynamic parameters as compared to morphine. But butorphanol showed fewer side effects than morphine. This study suggested that patient compliance was on butorphanol.

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5

Roelants, Fabienne, and Patricia M. Lavand’homme. "Epidural Neostigmine Combined with Sufentanil Provides Balanced and Selective Analgesia in Early Labor." Anesthesiology 101, no. 2 (August 1, 2004): 439–44. http://dx.doi.org/10.1097/00000542-200408000-00025.

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Background This study evaluated the efficacy of an epidural single dose of neostigmine combined with sufentanil to provide selective and balanced analgesia at the beginning of labor. Methods After informed consent, 125 healthy parturients were randomly allocated to receive, after a test dose, a single injection of either epidural sufentanil 20 micrograms (minimal analgesic dose) or 10 micrograms or a combination of sufentanil 10 micrograms with neostigmine 250, 500, or 750 micrograms in a total volume of 12 ml. Pain scores were recorded at regular intervals to determine onset and duration of analgesia. Maternal and fetal vital parameters as well as side effects were closely monitored. Results Parturients did not differ concerning demographic data. Epidural neostigmine 500 micrograms with sufentanil 10 micrograms produced effective analgesia (visual analog scale <30 mm within 10 min in 72% parturients and within 15 min in 85% parturients; average duration of 119 min, confidence interval 96-142 min) that was as effective as epidural sufentanil 20 micrograms. Epidural combination with neostigmine 250 micrograms was ineffective, whereas 750 micrograms did not produce higher effect than 500 micrograms. No motor block was recorded. Maternal and fetal vital parameters remained stable during labor. Conclusions Epidural combination of neostigmine 500 micrograms (e.g., 6-7 micrograms/kg) with sufentanil 10 micrograms provides similar duration of analgesia as epidural sufentanil 20 micrograms and allows effective and selective analgesia devoid of side effects in the first stage of labor.

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6

Kehlet, Henrik, Mads Werner, and Frederick Perkins. "Balanced Analgesia." Drugs 58, no. 5 (1999): 793–97. http://dx.doi.org/10.2165/00003495-199958050-00002.

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Bhattarai, Prajjwal Raj, Balkrishna Bhattarai, Birendra Prasad Sah, Tanvir R. Rahman, Ashish Ghimire, and Shailesh Adhikary. "Comparison of postoperative analgesic effectiveness of combined intraperitoneal instillation and periportal infiltration of bupivacaine with intraperitoneal instillation or periportal infiltration alone for laparoscopic cholecystectomy." Journal of Society of Anesthesiologists of Nepal 1, no. 2 (October 3, 2015): 59–64. http://dx.doi.org/10.3126/jsan.v1i2.13571.

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Background: Visceral pain is the major component of pain after laparoscopic cholecystectomy. Periportal infiltration and peritoneal instillation of local anesthetics have been reported to be effective in various laparoscopic procedures. Aim of this study was to find out the analgesic effectiveness and duration of analgesia following combined intraperitoneal instillation and periportal infiltration of bupivacaine and to compare it with peritoneal instillation or periportal infiltration alone.Methods: A prospective, randomized, double blinded study was conducted in 90 adult patients undergoing elective laparoscopic cholecystectomy. The patients were randomized into three groups. Group 1 received intraperitoneal instillation of 20 ml of 0.5% bupivacaine. Group 2 received periportal infiltration of 10 ml of 0.25% bupivacaine. Group 3 received combination of both. After standard balanced anesthesia technique, patients were observed in postoperative period for pain and hemodynamic variables, that were recorded ½ hourly for 1 hour, then at 4, 8, 12 and 24 hours postoperatively. The time and doses for rescue analgesia, if given, were also recorded.Results: Combined peritoneal instillation and periportal infiltration provided a mean duration of analgesia of 6 hours. Peritoneal instillation alone provided analgesia for three hours while periportal infiltration alone provided analgesia for one hour. The combination group required one third (116.67 mg vs. 173.33 mg) less analgesic than periportal group and one fifth (116.67 mg vs. 148.33 mg) less than that of peritoneal group. No adverse effects were noted.Conclusion: Combined intraperitoneal instillation and periportal infiltration of bupivacaine reduced postoperative pain after laparoscopic cholecystectomy better than intraperitoneal instillation or periportal infiltration of bupivacaine alone.Journal of Society of Anesthesiologists 2014 1(2): 59-64

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BERNARD, J. M., D. LAGARDE, and R. SOURON. "Balanced Postoperative Analgesia." Survey of Anesthesiology 39, no. 4 (August 1995): 241. http://dx.doi.org/10.1097/00132586-199508000-00031.

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Bernard, Jean-Marc, Didier Lagarde, and R??my Souron. "Balanced Postoperative Analgesia." Anesthesia & Analgesia 79, no. 6 (December 1994): 1126???1132. http://dx.doi.org/10.1213/00000539-199412000-00018.

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Druzhyna, О. М., О. А. Loskutov, and S. R. Maruniak. "ANALGESIA FOR AGED AND GERIATRIC PATIENTS DURING CARDIAC SURGERY WITH CARDIOPULMONARY BYPASS." Актуальні проблеми сучасної медицини: Вісник Української медичної стоматологічної академії 19, no. 1 (April 26, 2019): 12–16. http://dx.doi.org/10.31718/2077-1096.19.1.12.

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Balanced perioperative multimodal analgesia using multiple synergistic agents minimizes side effects that can be caused by high doses of only one aesthetic agent. The aim of the work was to determine the efficacy of perioperative multimodal low-opioid analgesia as anesthetic assurance techniques in aged and geriatric patients during cardiac surgery with cardiopulmonary bypass.Materials and methods. The study included 18 patients (11 (61.1%) men and 7 (38.9%) women) aged from 63 to 76 years old (mean age 69.5±6.2 years), who underwent coronary artery bypass grafting with cardiopulmonary bypass support. The average body weight was 89.6±13.9 kg (75 to 115 kg). The anaesthesia consisted of intravenous (iv) administration of propofol in a dose of 1.52±0.05 mg/kg and fentanyl in a dose of 1 μg/kg. Muscle relaxation was achieved by injecting pipecuronium bromide in a dose of 0.1 mg/kg. Sevoflurane inhalation was used to maintain anesthesia. Before making incision, the subnarcotic dose of ketamine (0.5 mg / kg) and lidocaine 1 mg/kg bolus were added with simultaneous administration of the continuous infusion of the latter in a dose of 1.5-2 mg/kg per hour. For postoperative analgesia ketorolac tromethamine was used. The intensity of the pain syndrome was assessed using a 10-point visual-analog scale of pain. The level of endocrine-metabolic response was determined by measuring the dynamics of lactate and cortisol.Results. The average dose of fentanyl, which was used for the patient during the whole time of anaesthesia, was 1.09±0.03 μg / kg per hour (on average 358.3±27.1 μg for all time of surgery). During the extracorporeal circulation and in the early postoperative period, the blood circulation parameters in all patients examined corresponded to the hemodynamic profile of the operated pathology. Positive verbal contact with patients was recorded in 18.6±3.4 minutes after the end of anaesthesia. The level of cortisol in the early postoperative period was 479.3±26.4 nmol/l. The average values of the intraoperative level of lactate were 1.61±0.2 mmol/l. The mean pain level in the first postoperative day in the examined patients was 4.6 ± 1.2 (3-6) scores by VAS, one day after the operation – 2.6±1.1 (1.5-4) scores by the VAS.Conclusions. Multimodal low-opioid analgesia provides an adequate analgesic effect in aged and geriatric patients that is confirmed by the absence of hemodynamic and endocrine-metabolic disorders. The use of ketorolac as a component of multimodal low-opioid analgesia is an effective method for achieving adequate postoperative analgesia and contributes to reducing the side effects associated with the use of narcotic analgesics.

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11

Morton, NeilS. "Balanced analgesia for children." Paediatric Nursing 5, no. 10 (December 1993): 8–10. http://dx.doi.org/10.7748/paed.5.10.8.s24.

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Morton, NeilS. "Balanced analgesia for children." Nursing Standard 7, no. 25 (March 10, 1993): 8–10. http://dx.doi.org/10.7748/ns.7.25.8.s77.

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13

COLLINS, P. D., and N. K. MENON. "EXTRADURALS AND BALANCED ANALGESIA." British Journal of Anaesthesia 68, no. 1 (January 1992): 118. http://dx.doi.org/10.1093/bja/68.1.118-a.

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Corletto, F. "Multimodal and Balanced Analgesia." Veterinary Research Communications 31, S1 (July 16, 2007): 59–63. http://dx.doi.org/10.1007/s11259-007-0085-5.

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Code, W. "NSAIDs and balanced analgesia." Canadian Journal of Anaesthesia 40, no. 5 (May 1993): 401–5. http://dx.doi.org/10.1007/bf03009506.

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Shim, Jae Hang. "Multimodal analgesia or balanced analgesia: the better choice?" Korean Journal of Anesthesiology 73, no. 5 (October 1, 2020): 361–62. http://dx.doi.org/10.4097/kja.20505.

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Torres, Luis M., Manuel J. Sánchez-del-Águila, Rafael Salazar, Inmaculada Failde, Ana Leal, and Jesús Villoria. "A Patient-Based National Survey and Prospective Evaluation of Postoperative Pain Management in Spain: Prevalent but Possibly Preventable." Pain Medicine 21, no. 5 (August 7, 2019): 1039–48. http://dx.doi.org/10.1093/pm/pnz149.

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Abstract Objective To evaluate the national general prevalence of postoperative pain and the associated organizational/structural factors related to the provision of health care services. Design and Setting Observational prospective cohort study performed in 46 tertiary hospitals that were randomly selected from the Spanish National Inventory of Hospitals through a two-stage balanced and stratified procedure. Subjects and Methods Nine-hundred surgical patients representing a wide spectrum of surgical procedures and anesthetic methods were recruited. Those suffering moderate or worse pain while in the postanesthesia care unit/surgery ward (PACU/SW) were followed for 72 hours. Site characteristics were also surveyed. Multilevel models were used to evaluate center- and patient-level factors associated with pain and quality of recovery (QoR). Weighted generalized estimating equations were used to analyze the evolution of pain intensity. Results The prevalence while in and at discharge from the PACU/SW was 48.7% (cluster-adjusted 95% confidence interval [CI] = 38.1–59.2%) and 21.6% (95% CI = 15.4–27.8%), respectively. Pain intensity decreased significantly over time. Less than 20% of the patients received systemic patient-controlled analgesia (PCA) or regional analgesic techniques. Age, preexisting pain, type of surgery, use of general anesthesia, and postoperative potent opioids were associated with pain risk and intensity, as were center-level factors such as patient information, protocol availability, and coordination of care. In turn, QoR was related to pain intensity and patient satisfaction with analgesia and side effects. Conclusions Compared with previous reports, the prevalence of moderate/severe postoperative pain has decreased but remains excessive. Organizational improvements to deploy procedure-specific, opioid-sparing analgesic strategies including regional techniques are recommended.

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Pasero, Christine L. "Using Balanced Analgesia For Postoperative Pain." American Journal of Nursing 96, no. 12 (December 1996): 17. http://dx.doi.org/10.1097/00000446-199612000-00033.

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Pasero, Chris. "Multimodal balanced analgesia in the PACU." Journal of PeriAnesthesia Nursing 18, no. 4 (August 2003): 265–68. http://dx.doi.org/10.1016/s1089-9472(03)00136-9.

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Tiglis, Mirela, Tiberiu Paul Neagu, Mazen Elfara, Camelia Cristina Diaconu, Ovidiu Gabriel Bratu, Ileana Adela Vacaroiu, and Ioana Marina Grintescu. "Nefopam and its Role in Modulating Acute and Chronic Pain." Revista de Chimie 69, no. 10 (November 15, 2018): 2877–80. http://dx.doi.org/10.37358/rc.18.10.6644.

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Pain is a very important issue to take into account during hospitalization. Nefopam, a centrally acting analgesic, has a relative safety pharmacological profile with few and well-tolerated side effects, being used to treat acute or chronic pain. It inhibits the central reuptake of serotonin, norepinephrine and dopamine and modulates the sodium and calcium channels having only few contraindications. Nefopam can be part of balanced analgesia along with others non-opioids agents in order to reduce the opioid consumption and their complications, to control postoperative pain and to reduce the risk of neuropathic pain appearance. In order to avoid its adverse reactions, a slow infusion is always recommended. Nefopam has its role in preventing the shivering appearance during neuraxial or general anesthesia, can modulate the emergence agitation after nasal and maxillofacial surgery and can inhibit the sever hiccup during mechanical ventilation. Some cases about fatal overdoses are reported in the literature.

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Terkawi, Abdullah Sulieman, Dimitris Mavridis, Daniel I. Sessler, Megan S. Nunemaker, Khaled S. Doais, Rayan Sulieman Terkawi, Yazzed Sulieman Terkawi, Maria Petropoulou, and Edward C. Nemergut. "Pain Management Modalities after Total Knee Arthroplasty." Anesthesiology 126, no. 5 (May 1, 2017): 923–37. http://dx.doi.org/10.1097/aln.0000000000001607.

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Abstract Background Optimal analgesia for total knee arthroplasty remains challenging. Many modalities have been used, including peripheral nerve block, periarticular infiltration, and epidural analgesia. However, the relative efficacy of various modalities remains unknown. The authors aimed to quantify and rank order the efficacy of available analgesic modalities for various clinically important outcomes. Methods The authors searched multiple databases, each from inception until July 15, 2016. The authors used random-effects network meta-analysis. For measurements repeated over time, such as pain, the authors considered all time points to enhance reliability of the overall effect estimate. Outcomes considered included pain scores, opioid consumption, rehabilitation profile, quality of recovery, and complications. The authors defined the optimal modality as the one that best balanced pain scores, opioid consumption, and range of motion in the initial 72 postoperative hours. Results The authors identified 170 trials (12,530 patients) assessing 17 treatment modalities. Overall inconsistency and heterogeneity were acceptable. Based on the surface under the cumulative ranking curve, the best five for pain at rest were femoral/obturator, femoral/sciatic/obturator, lumbar plexus/sciatic, femoral/sciatic, and fascia iliaca compartment blocks. For reducing opioid consumption, the best five were femoral/sciatic/obturator, femoral/obturator, lumbar plexus/sciatic, lumbar plexus, and femoral/sciatic blocks. The best modality for range of motion was femoral/sciatic blocks. Femoral/sciatic and femoral/obturator blocks best met our criteria for optimal performance. Considering only high-quality studies, femoral/sciatic seemed best. Conclusions Blocking multiple nerves was preferable to blocking any single nerve, periarticular infiltration, or epidural analgesia. The combination of femoral and sciatic nerve block appears to be the overall best approach. Rehabilitation parameters remain markedly understudied.

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Pasero, Chris, and Margo McCaffery. "Multimodal Balanced Analgesia in the Critically Ill." Critical Care Nursing Clinics of North America 13, no. 2 (June 2001): 195–206. http://dx.doi.org/10.1016/s0899-5885(18)30049-2.

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DAHL, J. B., J. ROSENBERG, W. E. DIRKES, T. MOGENSEN, and H. KEHLET. "PREVENTION OF POSTOPERATIVE PAIN BY BALANCED ANALGESIA." British Journal of Anaesthesia 64, no. 4 (April 1990): 518–20. http://dx.doi.org/10.1093/bja/64.4.518.

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Kobeliatskyi, Yu Yu. "Perioperative anesthesia. Features of anesthesia for patients with different surgeries and traumas." Infusion & Chemotherapy, no. 3.2 (December 15, 2020): 132–34. http://dx.doi.org/10.32902/2663-0338-2020-3.2-132-134.

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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.

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Toleska, Marija, Biljana Kuzmanovska, Andrijan Kartalov, Mirjana Shosholcheva, Jasminka Nancheva, Aleksandar Dimitrovski, and Natasha Toleska. "Opioid Free Anesthesia for Laparotomic Hemicolectomy: A Case Report." PRILOZI 39, no. 2-3 (December 1, 2018): 121–26. http://dx.doi.org/10.2478/prilozi-2018-0050.

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Abstract Opioid free anesthesia (OFA) is deffined as anaesthesiological technique where opioids are not used in the intraoperative period (systemic, neuroaxial or intracavitary). Anaphylaxis caused by opioids (fentanyl) is very rare, and the reaction is presented with hypotension and urticaria. When we have proven allergy to fentanyl, patients’ refusal of placing epidural catheter and refusal of receiving bilateral ultrasound guided transversus abdominis plane block (USG TAPB), we must think of using multimodal nonopioide analgesia. The concept of multimodal balanced analgesia is consisted of giving different analgesic drugs in purpose to change the pathophysiological process which is included in nociception, in way to receive more effective intraoperative analgesia with less adverse effects. This is a case report of a 60-year-old male patient scheduled for laparotomic hemicolectomy, who previously had proven allergy to fentanyl. We have decided to give him an opioid free anaesthesia. Before the induction to anaesthesia, the patient would receive dexamethasone (dexasone) 0.1 mg/kg and paracetamol 1 gr intravenously. The patient was induced into general endotracheal anesthesia according to a standardized protocol, with midazolam 0.04 mg/kg, lidocaine hydrochloride 1 mg/kg, propofol 2 mg/kg and rocuronium bromide 0.6 mg/kg. Anaesthesia was maintained by using sevoflurane MAC 1 in order to maintain mean arterial pressure (MAP) with a value of +/- 20% of the original value. After tracheal intubation, the patient had received ketamine hydrochloride 0.5 mg/kg (or 50 mg ketamine) in bolus intravenously and a continuous intravenous infusion with lidocaine hydrochloride (lidocaine) 2 mg/kg/hr and magnesium sulfate (MgSO4) 1,5 gr/hr. At the end of surgery the continuous intravenous infusion with lidocaine and magnesium sulfate was stopped while the abdominal wall was closed and 2.5 g of metamizole (novalgetol) was given intravenously. VAS score 2 hours after surgery was 6/10 and 1 gr of paracetamol was given and the patient was transferred to the Department. Over the next 3 days, the patient had a VAS score of 4-6/10 and only received paracetamol 3x1g and novalgetol 3x1 gr daily, every four hours.

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Foss, Nicolai Bang, Morten Tange Kristensen, Billy Bjarne Kristensen, Pia Søe Jensen, and Henrik Kehlet. "Effect of Postoperative Epidural Analgesia on Rehabilitation and Pain after Hip Fracture Surgery." Anesthesiology 102, no. 6 (June 1, 2005): 1197–204. http://dx.doi.org/10.1097/00000542-200506000-00020.

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Background Hip fracture surgery usually carries a high demand for rehabilitation and a significant risk of perioperative morbidity and mortality. Postoperative epidural analgesia may reduce morbidity and has been shown to facilitate rehabilitation in elective orthopedic procedures. No studies exist on the effect of postoperative epidural analgesia on pain and rehabilitation after hip fracture surgery. Methods Sixty elderly patients were included in a randomized, double-blind study comparing 4 days of continuous postoperative epidural infusion of 4 ml/h bupivacaine, 0.125%, and 50 mug/ml morphine versus placebo. Both patient groups received balanced analgesia and intravenous nurse-controlled analgesia with morphine. All patients followed a well-defined multimodal rehabilitation program. Pain, ability to participate in four basic physical functions, and any factors restricting participation were assessed on the first 4 postoperative days during physiotherapy. Results Epidural analgesia provided superior dynamic analgesia during all basic physical functions, and patients were significantly less restricted by pain, which was the dominating restricting factor in the placebo group. Motor blockade was not a restricting factor during epidural analgesia. Despite improved pain relief, scores for recovery of physical independence were not different between groups. Conclusion Postoperative epidural analgesia after hip fracture surgery provides superior analgesia attenuating pain as a restricting factor during rehabilitation without motor dysfunction. However, superior analgesia did not translate into enhanced rehabilitation. Future studies with multimodal rehabilitation are required to establish whether superior analgesia can be translated into enhanced rehabilitation and reduced morbidity in hip fracture patients.

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POWER, I., G. M. R. BOWLER, G. C. PUGH, and W. A. CHAMBERS. "Ketorolac as a component of balanced analgesia after thoracotomy." British Journal of Anaesthesia 72, no. 2 (February 1994): 224–26. http://dx.doi.org/10.1093/bja/72.2.224.

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Zafeiri, Aikaterini, and Paul A. Fowler. "Expression Patterns of Analgesic Metabolising Machinery in 1st and 2nd Trimester Human Fetal Liver and Gonads." Journal of the Endocrine Society 5, Supplement_1 (May 1, 2021): A488. http://dx.doi.org/10.1210/jendso/bvab048.998.

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Abstract Use of over-the-counter analgesics during pregnancy is widespread globally. Most analgesic compounds can freely diffuse through the placental feto-maternal interface and reach the developing fetus. Current literature suggests an endocrine disruptor (ED) potential of in utero exposure to these compounds. The liver is the primary site of contact with EDs in the fetus. Exposure of the fetal gonads can also alter reproductive function with potential intergenerational effects. We aimed to characterise the metabolic capability of these fetal organs. RNA sequencing was performed in 80 second trimester human fetal livers and 48 fetal gonads (balanced for fetal age and fetal sex). Samples were collected from elective terminations of normal pregnancies (liver 11-19 weeks, FeGo study: REC 04/S0802/21, and gonads 6-17 weeks, as previously described1. RNA was extracted and Illumina NextSeq was used to produce 76 bp single end (liver) or paired end 2x50 bp (gonads) sequencing reads. Reads were quality controlled, aligned to the human reference genome and quantified at gene regions. Statistical analyses involved an ANOVA model of two-way interactions between fetal sex and fetal age. All organs expressed phase I and II metabolising enzymes and drug transporters involved in the pharmacokinetic and pharmacodynamic pathways of over-the-counter analgesics. The human fetal liver expressed ABCC2, ABCC3, ABCC4 and ABCG2 receptors at similar levels between males and females. Expression of cytochrome p450 enzymes CYP2A6, CYP2C8, CYP2C9, CYP2E1, CYP3A4 involved in metabolism of the analgesics paracetamol and ibuprofen, all increased with gestational age in the liver. Expression of GSTM1, GSTP1, GSTT1, SULT1A1, SULT1A3, SULT1A4, SULT1E1, SULT2A1, UGT2B4, UGT2B7 and UGT2B15 metabolising enzymes also increased during gestation, while fetal hepatic GSTP1 expression showed a significant 2-way interaction between both sex and age. Fetal gonads expressed ABCC4 and ABCG2 transporters, with transcript levels demonstrating significant sex-specific and gestational age differences. Fewer analgesic metabolising enzymes were expressed in the gonads than the fetal liver, including CYP2E1, GSTP1 and SULT1A1, all significantly altered by gestation and fetal sex. Our results reveal expression of major analgesics metabolic and transport components within the human fetal liver, ovaries and testes between gestation weeks 7-19. Significant sex alterations in transcript levels also suggest sexually dimorphic metabolic activity of these organs during fetal life. In conclusion, analgesics can be transported into fetal liver and gonad cells and metabolised into bioactive forms, posing toxicity risks for the developing fetus.1. Lecluze E, Rolland AD, Filis P, et al. Dynamics of the transcriptional landscape during human fetal testis and ovary development. Hum Reprod. 2020;35(5):1099-1119.

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Germano, Antonio, Andrea Occhipinti, Francesca Barbero, and Massimo E. Maffei. "A Pilot Study on Bioactive Constituents and Analgesic Effects of MyrLiq®, a Commiphora myrrha Extract with a High Furanodiene Content." BioMed Research International 2017 (2017): 1–11. http://dx.doi.org/10.1155/2017/3804356.

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The analgesic properties of myrrh (Commiphora myrrha) have been known since ancient times and depend on the presence of bioactive sesquiterpenes with furanodiene skeletons. MyrLiq is a C. myrrha extract with a standardized content of curzerene, furanoeudesma-1,3-diene, and lindestrene (12.31±0.05 g kg−1, 18.84±0.02 g kg−1, and 6.23±0.01 g kg−1, resp.) and a high total furanodiene content (40.86±0.78 g kg−1). A balanced sample of 95 female and 89 male volunteers (with ages ranging from 18 to older than 60 years) exhibiting different pain pathologies, including headache, fever-dependent pain, joint pain, muscle aches, lower back pain, and menstrual cramps, was divided into two groups. The experimental group received 1 capsule/day containing either 200 mg or 400 mg of MyrLiq (corresponding to 8 mg and 16 mg of bioactive furanodienes, resp.) for 20 days, and the placebo group was given the same number of capsules with no MyrLiq. A score was recorded for all volunteers based on their previous experience with prescribed analgesics. For the male volunteers, pain alleviation was obtained with 400 mg of MyrLiq/day for almost all pathologies, whereas, for female volunteers, alleviation of lower back pain and fever-dependent pain was observed with only 200 mg of MyrLiq/day. These results indicate that MyrLiq has significant analgesic properties.

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Evangelista, Marina C., Javier Benito, Beatriz P. Monteiro, Ryota Watanabe, Graeme M. Doodnaught, Daniel S. J. Pang, and Paulo V. Steagall. "Clinical applicability of the Feline Grimace Scale: real-time versus image scoring and the influence of sedation and surgery." PeerJ 8 (April 14, 2020): e8967. http://dx.doi.org/10.7717/peerj.8967.

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Background The Feline Grimace Scale (FGS) is a facial expression-based scoring system for acute pain assessment in cats with reported validity using image assessment. The aims of this study were to investigate the clinical applicability of the FGS in real-time when compared with image assessment, and to evaluate the influence of sedation and surgery on FGS scores in cats. Methods Sixty-five female cats (age: 1.37 ± 0.9 years and body weight: 2.85 ± 0.76 kg) were included in a prospective, randomized, clinical trial. Cats were sedated with intramuscular acepromazine and buprenorphine. Following induction with propofol, anesthesia was maintained with isoflurane and cats underwent ovariohysterectomy (OVH). Pain was evaluated at baseline, 15 min after sedation, and at 0.5, 1, 2, 3, 4, 6, 8, 12 and 24 h after extubation using the FGS in real-time (FGS-RT). Cats were video-recorded simultaneously at baseline, 15 min after sedation, and at 2, 6, 12, and 24 h after extubation for subsequent image assessment (FGS-IMG), which was performed six months later by the same observer. The agreement between FGS-RT and FGS-IMG scores was calculated using the Bland & Altman method for repeated measures. The effects of sedation (baseline versus 15 min) and OVH (baseline versus 24 h) were assessed using linear mixed models. Responsiveness to the administration of rescue analgesia (FGS scores before versus one hour after) was assessed using paired t-tests. Results Minimal bias (−0.057) and narrow limits of agreement (−0.351 to 0.237) were observed between the FGS-IMG and FGS-RT. Scores at baseline (FGS-RT: 0.16 ± 0.13 and FGS-IMG: 0.14 ± 0.13) were not different after sedation (FGS-RT: 0.2 ± 0.15, p = 0.39 and FGS-IMG: 0.16 ± 0.15, p = 0.99) nor at 24 h after extubation (FGS-RT: 0.16 ± 0.12, p = 0.99 and FGS-IMG: 0.12 ± 0.12, p = 0.96). Thirteen cats required rescue analgesia; their FGS scores were lower one hour after analgesic administration (FGS-RT: 0.21 ± 0.18 and FGS-IMG: 0.18 ± 0.17) than before (FGS-RT: 0.47 ± 0.24, p = 0.0005 and FGS-IMG: 0.45 ± 0.19, p = 0.015). Conclusions Real-time assessment slightly overestimates image scoring; however, with minimal clinical impact. Sedation with acepromazine-buprenorphine and ovariohysterectomy using a balanced anesthetic protocol did not influence the FGS scores. Responsiveness to analgesic administration was observed with both the FGS-RT and FGS-IMG.

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Eriksson, H., A. Tenhunen, and K. Korttila. "Balanced analgesia improves recovery and outcome after outpatient tubal ligation." Acta Anaesthesiologica Scandinavica 40, no. 2 (February 1996): 151–55. http://dx.doi.org/10.1111/j.1399-6576.1996.tb04412.x.

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Alemán-Laporte, Jilma, Luciana A. Bandini, Mariana SA Garcia-Gomes, Dennis A. Zanatto, Denise T. Fantoni, Marco A. Amador Pereira, Pedro E. Navas-Suárez, et al. "Combination of ketamine and xylazine with opioids and acepromazine in rats: Physiological changes and their analgesic effect analysed by ultrasonic vocalization." Laboratory Animals 54, no. 2 (May 30, 2019): 171–82. http://dx.doi.org/10.1177/0023677219850211.

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In this study, the effect of four anaesthetic protocols that included the combination of xylazine (X) and ketamine (K) with acepromazine (A) and opioids (methadone (Me), morphine (Mo) or tramadol (T)) was evaluated in laboratory rats of both sexes. Ultrasonic vocalization (USV) was used as an indicator of pain during the recovery period. The objective was to evaluate the physiological parameters and the analgesic effect of each protocol to determine which protocol was the safest and fulfil the requirements of a balanced anaesthesia. The better protocols were the XKA protocol for both sexes and the XKMe protocol for females because the combinations achieve surgical plane of anaesthesia in rats. However, pain assessment during the formalin test revealed that rats anaesthetized with XKA produced more numbers of USV, suggesting that it is not a good protocol for the control of immediate postoperative pain. All protocols produced depression in body temperature and respiratory and heart rates, and had important effects, such as micturition and maintenance of open eyes. Only rats anaesthetized with XKA protocol did not present piloerection. These results demonstrated that good monitoring and care during anaesthesia must be included to prevent complications that compromise the life of the animal and to ensure a good recovery. The inclusion of analgesia in anaesthesia protocols must be used routinely, ensuring minimal presence of pain and thus more reliable results in the experimental procedures.

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Rapanos, T., P. Murphy, JP Szalai, and J. Kay. "INDOMETHACIN IN CONJUNCTION WITH MORPHINE FOR BALANCED ANALGESIA AFTER CARDIAC SURGERY." Anesthesia & Analgesia 86, Supplement (April 1998): 115SCA. http://dx.doi.org/10.1097/00000539-199804001-00115.

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Kehlet, Henrik, and J??rgen B. Dahl. "The Value of ???Multimodal??? or ???Balanced Analgesia??? in Postoperative Pain Treatment." Anesthesia & Analgesia 77, no. 5 (November 1993): 1048???1056. http://dx.doi.org/10.1213/00000539-199311000-00030.

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Martin Jurado, Olga, Martina Mosing, and Regula Bettschart-Wolfensberger. "Anaesthetic Management of a 1-Month-Old Puppy Undergoing Lateral Thoracotomy for Vascular Ring Anomaly Correction." Case Reports in Veterinary Medicine 2011 (2011): 1–6. http://dx.doi.org/10.1155/2011/536064.

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A 1-month-old male flat-coated retriever was anaesthetized for correction of oesophageal constriction caused by a vascular ring anomaly. Anaesthesia was uneventfully induced with intravenous fentanyl, diazepam, and propofol and maintained with isoflurane in oxygen and air. An intercostal block with bupivacaine and lidocaine was performed, and additional analgesia with an infusion of fentanyl was provided. Fluid therapy consisted in 5% glucose in lactated Ringer’s solution and hetastarch 6%, which proved adequate to maintain normoglycemia and normovolemia. A lateral thoracotomy was performed, and the ligamentum arteriosum was ligated. Intraoperatively, heart rate (HR) varied between 120 and 180 beats min−1without accompanying changes in blood pressure. No arrhythmias were observed or bleeding occurred. The dog recovered uneventfully. Postoperative analgesia consisted in fentanyl infusion adjusted to the patient's requirement and metamizol. This paper describes for the first time the use of balanced anaesthesia and multimodal analgesia in a paediatric dog undergoing thoracotomy.

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Michielsen, A. J. H. C., and S. Schauvliege. "Epidural anesthesia and analgesia in horses." Vlaams Diergeneeskundig Tijdschrift 88, no. 4 (August 30, 2019): 233–40. http://dx.doi.org/10.21825/vdt.v88i4.16013.

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Epidural anesthesia is a loco-regional anesthesia technique where drugs are injected in the epidural space. In the 19th century, this technique was developed for human medicine, and later found its way into veterinary medicine. It is useful for surgical interventions in the standing horse, as part of a balanced anesthetic protocol or for postoperative pain management. Analgesia and anesthesia involves the pelvis, pelvic limbs, tail, vagina, vulva, anus, perineum and abdomen. However, several contraindications and complications have been reported for epidural anesthesia. In horses, epidural injections can be performed cranially (lumbosacral space) or caudally (sacro-coccygeal or Co1-Co2 ). While single injections can be performed, the use of epidural catheters allows repeated administration. Depending on the desired effect, different drugs (local anesthetics, alpha2-agonists, opioids, ketamine, tramadol or tiletamine-zolazepam), drug combinations and volumes can be chosen.

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CORDELL, W., S. WRIGHT, A. WOLFSON, B. TIMERDING, T. MANEATIS, R. LEWIS, L. BYNUM, and D. NELSON. "Comparison of Intravenous Ketorolac, Meperidine, and Both (Balanced Analgesia) for Renal Colic." Annals of Emergency Medicine 28, no. 2 (August 1996): 151–58. http://dx.doi.org/10.1016/s0196-0644(96)70055-0.

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De Kock, Marc, Patricia Lavandʼhomme, and Hilde Waterloos. "‘Balanced analgesia’ in the perioperative period: is there a place for ketamine?" Pain 92, no. 3 (June 2001): 373–80. http://dx.doi.org/10.1016/s0304-3959(01)00278-0.

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MØINICHE, S., N.-C. HJORTSØ, B. L. HANSEN, J. B. DAHL, J. ROSENBERG, P. GEBUHR, and H. KEHLET. "The effect of balanced analgesia on early convalescence after major orthopaedic surgery." Acta Anaesthesiologica Scandinavica 38, no. 4 (May 1994): 328–35. http://dx.doi.org/10.1111/j.1399-6576.1994.tb03902.x.

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MOINICHE, S., N.-C. HJORTSOS, B. L. HANSEN, J. B. DAHL, J. ROSENBERG, P. GEBUHR, and H. KEHLET. "The Effect of Balanced Analgesia on Early Convalescence after Major Orthopaedic Surgery." Survey of Anesthesiology 39, no. 1 (February 1995): 46. http://dx.doi.org/10.1097/00132586-199502000-00055.

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Silva, Wallace Andrino, Aline Macêdo Pinheiro, Cipriano Correia Junior, Paulo Henrique Lima, Kellen Micheline Alves Henrique Costa, José Hipólito Dantas Júnior, and Paulo José Medeiros. "ANESTHESIA FOR RENAL TRANSPLANT SURGERY IN ADULTS." JOURNAL OF SURGICAL AND CLINICAL RESEARCH 11, no. 2 (December 18, 2020): 128–34. http://dx.doi.org/10.20398/jscr.v11i2.21090.

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Renal transplant surgery may be associated with important perioperative complications. In this scenario, the anesthetic technique should provide optimal conditions for the surgical team, guarantee hemodynamic stability and kidney perfusion, and adequate analgesia. Preoperative evaluation should always be performed. In the intraoperative period, standard monitoring is sufficient in most cases. General balanced anesthesia, alone or in combination with spinal anesthesia or peripheral block, is the technique of choice. Management of blood pressure during the surgery is crucial. Before reperfusion, a mean arterial blood pressure of 65 mmHg is recommended, increasing to 80–90 mmHg when reperfusion is imminent until the end of surgery. Vasopressors, such as ephedrine, may be necessary to achieve blood pressure targets. Mannitol and furosemide are commonly used to increase urine output. In the postoperative period, analgesia should be ensured.

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ZSIGMOND, E. K., A. P. WINNIE, S. M. A. RAZA, X. Y. WANG, and E. BARABAS. "Nalbuphine as an Analgesic Component in Balanced Anesthesia for Cardiac Surgery." Survey of Anesthesiology 32, no. 3 (June 1988): 158. http://dx.doi.org/10.1097/00132586-198806000-00022.

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Zsigmond, Elemer K., Alon P. Winnie, Syed M. A. Raza, Xiu Y. Wang, and Eva Barabas. "Nalbuphine as an Analgesic Component in Balanced Anesthesia for Cardiac Surgery." Anesthesia & Analgesia 66, no. 11 (November 1987): 1155???1164. http://dx.doi.org/10.1213/00000539-198711000-00015.

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Blackburn, Amanda, Jeremy D. Stevens, Robert G. Wheatley, Tamara H. Madej, and Deborah Hunter. "Balanced analgesia with intravenous ketorolac and patient-controlled morphine following lower abdominal surgery." Journal of Clinical Anesthesia 7, no. 2 (March 1995): 103–8. http://dx.doi.org/10.1016/0952-8180(94)00040-b.

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Blackburn, Amanda, Jeremy D. Stevens, Robert G. Wheatley, Tamara H. Madej, and Deborah Hunter. "Balanced analgesia with intravenous ketorolac and patient-controlled morphine following lower abdominal surgery." Journal of Clinical Anesthesia 7, no. 8 (December 1995): 710. http://dx.doi.org/10.1016/0952-8180(95)90040-3.

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46

Henriksen, M. G., M. B. Jensen, H. V. Hansen, T. W. Jespersen, and I. Hessov. "Enforced mobilization, early oral feeding, and balanced analgesia improve convalescence after colorectal surgery." Nutrition 18, no. 2 (February 2002): 147–52. http://dx.doi.org/10.1016/s0899-9007(01)00748-1.

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&NA;. "Epidural Neostigmine Combined with Sufentanil Provides Balanced and Selective Analgesia in Early Labor." Obstetric Anesthesia Digest 24, no. 3 (September 2004): 138–39. http://dx.doi.org/10.1097/00132582-200409000-00012.

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Gaiser, Robert. "Epidural Neostigmine Combined With Sufentanil Provides Balanced and Selective Analgesia in Early Labor." Survey of Anesthesiology 49, no. 1 (February 2005): 22–23. http://dx.doi.org/10.1097/01.sa.0000151215.99017.97.

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Bande, David, Marc Sadurni, Carlos García, Jesús Carazo, Marta Corcoy, and Antonio Montes. "Is balanced analgesia (tramadol + paracetamol + dexketoprofen) a good option in laparoscopic colon surgery?" Clinical Nutrition ESPEN 12 (April 2016): e38-e39. http://dx.doi.org/10.1016/j.clnesp.2016.02.029.

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von Ritgen, Stephanie, Fabienne Bach, Pablo E. Otero, and Ulrike Auer. "Multimodal perioperative pain management in a horse undergoing partial phallectomy." Veterinary Record Case Reports 8, no. 3 (September 2020): e001104. http://dx.doi.org/10.1136/vetreccr-2020-001104.

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A well-balanced multimodal pain management including local anaesthetic techniques was used to provide perioperative analgesia in a horse undergoing partial phallectomy. This surgical intervention has been associated with moderate to severe pain and may present additional challenges to the veterinarian when providing pain relief postoperatively.In the present case, preoperative analgesia included morphine and flunixin meglumine, both intravenously. Throughout surgery, adaptable constant rate infusions (CRIs) with ketamine and xylazine were supplemented to address different receptors of the pain pathway. Additionally, a pudendal nerve block with ropivacaine was added intraoperatively to reduce nociception and decrease sensitisation of the central nervous system. An epidural injection of morphine and dexmedetomidine was performed after recovery from general anaesthesia. Postoperative pain treatment included morphine and flunixin meglumine that resulted in adequate pain relief, based on pain assessment every 6–12 hours. Neither side effects nor complications were observed during the hospital stay.

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