Preemptive Analgesia

Moiniche S, Kehlet H, Dahl JB: A qualitative and quantitative systematic review of preemptive analgesia for postoperative pain relief:The role of timing of analgesia. ANESTHESIOLOGY 2002;96:725?41

The accompanying editorial [Hogan QH. No preemptive analgesia: is that so bad? Anesthesiology 2002 Mar; 96(3): 526-527] may be read at <http://ipsapp003.lwwonline.com/content/getfile/3941/125/3/fulltext.htm>.

One could not fault the authors' article because it was a meta-analysis of a 7 Level I studies on preemptive analgesia. However, the editorial writer was free to have mentioned, were he aware of it, the phenomenon of dissociative techniques, which, despite the absence of a Level I study, work very nicely to provide preemptive analgesia. As a young Stanford resident, I was always impressed at how good regional block patients looked the day after surgery compared with GA patients; i.e. less wrung out. Having much greater contact with my office based patients, I know they feel better too. Interesting that the surgeons who care for these patients, like Peter Fodor, also disagree with Moiniche's conclusion that there is no such thing. Satchel Paige said it best when he said (paraphrased), It ain't what you know that gets you into trouble. It's what you know that ain't so.

I am certain on of the lights on the list can explain, absent preemptive analgesia, how it is, without inflicting pain, that my patients do quite well after subpectoral, breast augmentations, & abdominoplasties on 1,000 mg oral acetaminophen, 30 mg IV ketorolac or nothing at all and are able to be comfortably discharged to home in less than one hour. I think it was Beecher's study of pain and wartime injuries that may hold a clue. Soldiers who's wounds were enough to get them home appeared to have less pain (or better tolerate the pain) than those who knew or suspected they would get well enough to be returned to duty. Elective cosmetic surgery patients have a much more positive attitude towards their surgical experience and may therefore tolerate levels of discomfort that the medically indicated 'elective' surgical patient would not. This may only explain part of the phenomenon I alluded to. I believe there is something profoundly different about blocking the NMDA receptors prior to injecting the local, prior to incision, that sets the stage for preemptive analgesia. If you are not conducting anesthesia in this fashion, it would be impossible to conclude that there is no preemptive analgesia.

My outcomes are congruent with my belief system. I have no difficulty if our readers disagree with me.

Yours for better outcomes,

Barry L. Friedberg, M.D.