Pain Management

Given the relevance of correct management of postoperative pain, over the years various analgesic techniques have been used, such as: systemic, neuroaxial, peripheral nerve block and use of local infiltrations, as well as a varied number of adjuvant drugs. In spite of this, none of these strategies has found the perfect result and in the last time the use of a combination of techniques and analgesic agents has begun to be promoted to alleviate the pain in its different levels of generation. This is what is known as "multimodal" pain management. This strategy has shown positive results in several studies because in addition to being at least as effective as the use of a single technique or drug for pain management, it adds the benefit of reducing adverse effects compared to a unimodal technique. It also promotes faster recovery, reduced hospital stay, decreased use of rescue opioids, and increased participation in early rehabilitation programs, particularly in patients undergoing total hip and knee arthroplasty.

On the other hand, the level at which action is attempted to manage pain has changed over time from a focus on the central nervous system to an emphasis on the surgical site, with the intention of reducing adverse effects of classical opioid-based analgesia and other classic regional techniques, which although they produce good analgesia may be associated with a delay in functional recovery in traumatological surgery. Thus, peripheral nerve block techniques and peri or intra-articular injections are gaining more and more weight.

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Preoperative

Woolf published in 1983 laboratory results showing that the administration of an analgesic before the acute painful stimulus was more effective in minimizing changes at the dorsal horn level associated with central sensitization than the same analgesia used after the stimulus 47 . However, it would be a mistake to extrapolate these experimentally obtained data to what happens in clinic with patients; moreover, two systematic reviews show controversial results for the use of PRE stimulus versus POST stimulus analgesia. However, it seems reasonable to begin analgesic management as soon as possible, although the evidence in this regard is not categorical in this behavior.

In the case of traumatological surgery, a study of knee or hip arthroplasty surgery, in which the use of analgesia was compared with a standard protocol based on the use of peridural analgesia versus a similar protocol to which the use of cycloxygenase 2 (COX-2) inhibitors was added, administered for 2 weeks prior to surgery and continued up to 10 days postoperatively, showed that in the latter group there was a significant decrease in the incidence of pain control problems.

In another study in which patients undergoing total knee arthroplasty were enrolled, the experimental group was given 50 mg rofecoxib (COX-2) 24 h before and between 1 and 2 h before surgery, 50 mg daily for 5 post-operative days and 25 mg daily for 8 more days, compared with placebo, showed in the experimental group a significant decrease in the use of in-hospital opioids, less pain measured by EVA during hospital stay, less incidence of vomiting and importantly, a significant increase in the degree of knee flexion at the time of hospital discharge and one week after discharge.

Intraoperative

Type of anaesthesia for traumatological and orthopaedic surgery in regional anesthesia. The question of the superiority of the intraoperative use of a regional anaesthesia technique in comparison to general anaesthesia in regional anesthesia undergoing traumatological surgery is a point of controversy to this day.

In general, it can be said that both neuroaxial anesthesia and general anesthesia have been successfully used for trauma surgery for many years. Over time there has been a trend toward an increased use of regional anesthesia in trauma surgery. Between 1981 and 1982, general anesthesia was used in 94.8% of hip fracture surgeries in U.S. hospitals, while between 1993-1994, it was used in only 49.6%. General anesthesia has the advantages of having better control over the duration of the anesthesia, its depth and hemodynamic parameters, as well as complete control over the patient's airway and ventilation, but it has adverse effects associated with the use of opioids and specifically in the elderly, some studies have associated it with an increased risk of presenting postoperative delirium, however, not all studies have demonstrated that.