Rosero Eric B, Joshi Girish P
Dallas, Tex. From the Department of Anesthesiology and Pain Medicine, University of Texas Southwestern Medical Center.
Plast Reconstr Surg. 2014 Oct;134(4 Suppl 2):85S-93S. doi: 10.1097/PRS.0000000000000671.
To improve postoperative pain management, several concepts have been developed, including preemptive analgesia, preventive analgesia, and multimodal analgesia. This article will discuss the role of these concepts in improving perioperative pain management. Preemptive analgesia refers to the administration of an analgesic treatment before the surgical insult or tissue injury. Several randomized clinical trials have, however, provided equivocal evidence regarding the benefits of preincisional compared with postincisional analgesic administration. Current general consensus, therefore, indicates that use of preemptive analgesia does not translate into consistent clinical benefits after surgery. Preventive analgesia is a wider concept where the timing of analgesic administration in relation to the surgical incision is not critical. The aim of preventive analgesia is to minimize sensitization induced by noxious stimuli arising throughout the perioperative period. Multimodal analgesia consists of the administration of 2 or more drugs that act by different mechanisms for providing analgesia. These drugs may be administered via the same route or by different routes. Thus, the aim of multimodal analgesia is to improve pain relief while reducing opioid requirements and opioid-related adverse effects. Analgesic modalities currently available for postoperative pain control include opioids, local anesthetic techniques [local anesthetic infiltration, peripheral nerve blocks, and neuraxial blocks (epidural and paravertebral)], acetaminophen, nonsteroidal anti-inflammatory drugs, and cyclooxygenase-2-specific inhibitors as well as analgesic adjuncts such as steroids, ketamine, α-2 agonists, and anticonvulsants.
为改善术后疼痛管理，已提出了几种概念，包括超前镇痛、预防性镇痛和多模式镇痛。本文将讨论这些概念在改善围手术期疼痛管理中的作用。超前镇痛是指在手术创伤或组织损伤前给予镇痛治疗。然而，几项随机临床试验关于切开前给予镇痛与切开后给予镇痛的益处提供了不明确的证据。因此，目前的普遍共识表明，使用超前镇痛在术后并不会带来一致的临床益处。预防性镇痛是一个更广泛的概念，其中镇痛药物给药时间与手术切口的关系并不关键。预防性镇痛的目的是尽量减少围手术期有害刺激引起的敏化。多模式镇痛包括给予两种或更多种通过不同机制发挥镇痛作用的药物。这些药物可以通过相同途径或不同途径给药。因此，多模式镇痛的目的是在减少阿片类药物需求和阿片类药物相关不良反应的同时改善疼痛缓解。目前可用于术后疼痛控制的镇痛方式包括阿片类药物、局部麻醉技术[局部麻醉药浸润、外周神经阻滞和神经轴阻滞（硬膜外和椎旁阻滞）]、对乙酰氨基酚、非甾体抗炎药、环氧化酶-2特异性抑制剂以及镇痛辅助药物，如类固醇、氯胺酮、α-2激动剂和抗惊厥药。
