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Multimodal pain management – beware of generalizations
- Boris Yanovski, [Bruce Ben-David], and [Jacques Chelly] (2 February 2009)
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Boris Yanovski, anesthesiology UPMC Shadyside Hospital, [Bruce Ben-David], and [Jacques Chelly]
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To the Editor — We read with interest the article by Mathiesen et al (1) who found in total hip replacement surgery no further reduction of pain or postoperative opioid consumption with the addition of dexamethasone to pregabalin premedication. This result contrasts with other studies who have found significant analgesic effect of perioperative steroid administration (2,3) and an additive analgesic effect of gabapentanoids to other anti-inflammatory drugs (4). Given the confusing morass of seemingly conflicting results we would at the very least urge caution against generalizing the authors’ conclusion that “combining pregabalin and dexamethasone provided no additional effects on pain or opioid requirements”. We should not assume that this conclusion applies to any dose combination of these two drugs or to other surgical models. More specifically, we think this study lacked sufficient resolution to uncover potentially useful additive effects of these two medications. In the same way that the added analgesic benefit of a drug might be obscured if both control and study group receive a large dose of opiate, the large dose of pregablin may have clouded an analgesic effect of the dexamethasone. The rather high dose of pregabalin (300 mg) by itself resulted in a 50% reduction in 24 h postoperative morphine requirement. This is substantially more than the 35% reduction seen by Reuben et al4 who used only 150 mg of pregabalin and who did show an additive effect with the anti-inflammatory celecoxib. Certainly postoperative pain management targets maximal pain reduction as a primary goal. But modern pain management takes a broader view in considering the importance of the side effects of that treatment. Central to the concept of multimodal pain management is the idea that lower doses of individual drugs may be used in combination in order to avoid such side effects. Not surprisingly, the elected dose of pregabalin in this study resulted in marked sedation. Neither was it surprising that the dexamethasone group had a lower incidence of nausea. But is it not possible that a lower dose of pregabalin combined with dexamethasone might provide not only the same reduction in morphine requirement but do so without the sedation and with the same reduction in nausea? It is also important to recognize that the mechanisms of acute pain following, for example, orthopedic surgery may differ greatly from those after visceral surgery. Efficacy of analgesic drugs can differ substantially between orthopedic and bowel surgery patients (5,6). Therefore the surgical model itself places limitations on the generalizability of one’s results. As a final point, this study focused only on the first 24 postoperative hours. For pregabalin, as well as for anti-inflammatory drugs, there is accumulating evidence of a profound late effect in terms of reducing persistent postoperative pain and improving functional outcomes. It is not clear what drug combination and what doses will provide the most benefits in long term outcomes. In summary, multimodal pain management is multifaceted and the conclusions of a research should be confined to the specific conditions studied. One must be cautious in applying the lessons of both positive and negative findings. Overgeneralization of positive results may lead to unwarranted practices. Overgeneralization of negative conclusions could provide a false sense of futility rather than serve as a constuctive step in the refinement of optimal drug regimens. Let the reader beware. References 1.Mathiesen O, Jacobsen LS, Holm HE, Randall S, Adamiec-Malmstroem L, Graungaard BK, Holst PE, Hilsted KL and Dahl JB. Pregabalin and dexamethasone for postoperative pain control: a randomized controlled study in hip arthroplasty. Br J Anaesth 2008;101: 535–41. 2.Kardash KJ, Sarrazin F, Tessler MJ, Velly AM. Single-dose dexamethasone reduces dynamic pain after total hip arthroplasty. Anesth Analg 2008;106:1253-7. 3.Bisgaard T, Klarskov B, Kehlet H, Rosenberg J. Preoperative dexamethasone improves surgical outcome after laparoscopic cholecystectomy: a randomized, double-blind placebo-controlled trial. Ann Surg 2003;238:651–60. 4.Reuben SS, Buvanendran A, Kroin JS, Raghunathan K. The analgesic efficacy of celecoxib, pregabalin, and their combination for spinal fusion surgery. Anesth Analg 2006;103:1271-7. 5.Martin F, Cherif K, Gentili ME, Enel D, Abe E, Alvarez JC, Mazoit JX, Chauvin M, Bouhassira D, Fletcher D. Lack of impact of intravenous lidocaine on analgesia, functional recovery, and nociceptive pain threshold after total hip arthroplasty. Anesthesiology. 2008;109:118-23. 6.Marret E, Rolin M, Beaussier M, Bonnet F. Meta-analysis of intravenous lidocaine and postoperative recovery after abdominal surgery. Br J Sur. 2008; 95: 1331-8. Conflict of Interest:None declared |
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