Management of postoperative pain and emesis

As more extensive and painful surgical procedures (e.g., laparoscopic cholecystectomy, laminectomy, knee and shoulder reconstruction, hysterectomy) are being performed on an outpatient basis, the availability of sophisticated postoperative analgesic regimens are necessary to optimize the benefits of day-case surgery for both the patient and the health care provider. However, outcome studies are needed to evaluate the effects of these newer therapeutic approaches with respect to postoperative side effects, cost and important recovery variables. Recent studies suggest that factors other than pain per se must be controlled in order to reduce postoperative morbidity and facilitate the recovery process. Not surprisingly, the anaesthetic technique can influence the analgesic requirements and the likelihood of emesis in the early postoperative period. Although opioid analgesics will continue to play an important role, the adjunctive use of both local anaesthetic agents and NSAIDs will probably assume an even greater role in the future. Use of drug combinations (e.g., opioids with local anaesthetics, alpha2 agonists and/or NSAIDs) may provide for improved analgesia with fewer opioid-related side effects than narcotic analgesics alone. Finally, safer and simpler analgesic delivery systems are needed to improve our ability to provide cost-effective pain relief after day-case surgery in the future. In conclusion, as a result of our enhanced understanding of the mechanisms of acute pain and the physiological basis of nociception, the provision of "stress free" anaesthesia with minimal postoperative discomfort is now possible for most patients undergoing ambulatory surgical procedures. The aim of any analgesic technique should not only be to lower the pain scores but also to facilitate earlier mobilization and to reduce perioperative complications, in particular PONV. In future, clinicians should be able to effectively treat postoperative pain using a combination of "balanced," "preemptive," and "peripheral" analgesia techniques without producing emetic sequelae.