trattamento dolore postop in day surg definitivo 2 maggio 05

Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

Trattamento del Dolore postopin day surgery

Claudio Melloni

Servizio Anestesia e Rianimazione

Ospedale di Faenza(RA)


Effect of analgesia modality on incidence of pain (from literature) following major surgeryDolin, S. J.1; Cashman, J. N. Bland, J. M.Effectiveness of acute postoperative pain management: I. Evidence from published data .BJA 2002;89:409 -423

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i.m. severe i.m.moderate pca severe pca moderate epid severe epid moderate

maxminmedia


Successi e insuccessi della anestesia ambulatoriale

Priorità perché la chir amb abbia successo:

4 A: alertness, ambulation, analgesia and alimentation”.

noi potremmo tradurli in :

Vigile,Ambulante,analgesia,alimentazione=VAAA…

Ritardo di dimissione:

Faticabilità eccessiva,

Nausea,vomito Dolore non alleviato Ricovero

ospedaliero imprevisto..


Rationale of pain treatment in day surgery

Since the proportion of surgery done on an outpatient basis is increasing, and since early discharge and patient satisfaction are important goals, pain management is receiving greater attention.

Rapid recovery after the use of new, short-acting anaesthetic agents has led to the concept of fast-tracking and by-passing the post-anaesthetic care unit (PACU). However, the success of fast-tracking will depend to a considerable extent on effective postoperative pain management routines with simple methods such as oral analgesics. The potential cost saving of outpatient surgery may be negated by unanticipated hospital admission for poorly treated pain.


Importance of the issue Pain is :

» A limiting factor in the early discharge of ambulatory surgical patients» The leading cause of unanticipated hospital admission

PAIN may:» Increase recovery room time» Expand nursing care» Increase total health care costs» Cause high level of patient discomfort---pain,hematoma,wound

dehiscence…» Cause high level of patient dissatisfaction» KO!!!


Macario A, Weinger M,Carney S, Kim A.Which clinical anesthesia outcomes are important to avoid?Anesth.Analg.1999;89:652-8.

02468

101214161820

rank valore relativo

vomito

gagging sul tubo

dolore

nausea

ricordo senza dolore

debolezza residua

brivido

mal di gola

sonnolenza

Dal + indesiderabil

eAl meno

indesiderabile

distribute $100 among the 10 outcomes, proportionally more money being

allocated to the more undesirable outcomes. The dollar allocations were used to determine the relative value of each

outcome.


Quali problemi preferirebbero evitare i

pazienti sottoposti a day surgery? (da Jenkins, K.;

Grady, D.; Wong, J.; Correa, R.; Armanious, S.; Chung, F.*Post-operative recovery: day surgery patients' preferences .Br. J. Anaesth. 2001; 86:272-274)

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doloretossire sul tubo etvomitonauseadisorientamentomal di golabrividosonnolenzasete

Valori relativi !


Sintomi accusati dai pazienti a casa dopo interventi eseguiti in regime di day surgery(da Wu et al.,Anesthesiology 2002).

dolorenauseavomitocefaleasonnolenzagir.di testafatica


Quali problemi preferirebbero evitare i pazienti

sottoposti a day surgery? (da Jenkins, K.; Grady, D.; Wong, J.;

Correa, R.; Armanious, S.; Chung, F.*Post-operative recovery: day surgery patients' preferences Br. J. Anaesth. 2001; 86:272-274)

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doloretossire sul tubo etvomitonauseadisorientamentomal di golabrividosonnolenzasete

Valori relativi !


Beauregard L, Pomp A, Choinière M. Severity and impact of pain after day-surgery Can J Anaesth 1998 / 45 / 304-11

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dolore PONV gir.testa sonnolenza cefalea mal di gola raucedine fatica

I g.II gVII g


Postoperative symtoms at telephone interview 24 hr. Chung F,Mezei G, Adverse outcomes in ambulatory anesthesia .Refresher Course Outline.

Can J Anesth 1999 / 46 / R18-R26

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pain at surgical site headache drowsiness dizziness ponv fever

778 pazienti


Chung F,Mezei G. Adverse outcomes in ambulatory anesthesia .Refresher Course Outline.

Can J Anesth 1999 / 46 / R18-R26


Chung F,Un V, Su J .Postoperative symptoms 24 hours after ambulatory anaesthesiaCAN J ANAESTH 1996 / 43: 11 / pp1121-7

IL tipo di intervento condiziona i sintomi postop. 1,017 patients. Incisional pain (26.9%), headache (11.6%), and drowsiness (11.5%) , Dizziness

9.7% nausea/vomiting by 7.1%. Approximately 50% of patients undergoing laparoscopy, orthopaedic and general

surgery reported 24-hr postoperative incisional pain. The incidence of 24-hr postoperative nausea/vomiting was highest after general

17.4%, orthopaedic, 11.2%, and laparoscopic surgery, 9.4%. Drowsiness was highest after laparoscopy 36.1%, followed by general surgery,

21.4%. Dizziness was most frequent after laparoscopy, 24.1%, followed by general surgery,

16.1%. After laparoscopy, postoperative drowsiness or dizziness was related to anaesthesia duration. After general surgery, postoperative dizziness or drowsiness were related to age; the younger the patient, the more likely the symptoms.

Conclusions: Postoperative pain, nausea/vomiting, drowsiness, dizziness, and headache were the more frequent postoperative symptoms 24 hr after ambulatory surgery and they were influenced by the type of surgical procedure. In addition, the type of surgery and the 24-hr postoperative symptoms determined the degree of return to daily living function.


Cause di ricovero non programmato post

colecistectomia laparoscopica :Lau H, Brooks DC. Predictive factors for unanticipated admissions afterambulatory laparoscopic cholecystectomy. Arch Surg. 2001 Oct;136(10):1150-3

0123456789

10

pain ponv urin.retention pat prfeference medical observation

25/731=3.41%

1.36%

0.82%

0.68%

0.41%

Significant factors associated with unplanned admission :

operative duration >60 minutes thickened gallbladder wall on US

pathological findings. length of operation

the only independent predictive factor


Dolore e PONV

Effects % of Total Patients

Pain relieved, nausea relieved 68.5

Pain reduced, nausea relieved 11.5

Pain relieved, nausea persisted 9.5

Pain persisted, nausea persisted 10.5

Andersen et al. Can Anaesth Soc J 23:366-369, 1976


Fattori predittivi di dolore severo:pre e intraop


Fortier J, Chung F, Su J. Predictive factors of unanticipated admission in ambulatory surgery: a prospective study. Anesthesiology 1996; 85:A27.

215/15175,cioè 1.4% Fattori predittivi Sesso masch Asma Ipertensione mal.cardiache Diabetre ENT,urol,plastic,ortop Chir più lunga Fine op > h 15 Dolore Gir di testa sonnolenza


Interventi più spesso associati a dolore severo

Ortopedia Urologia Anorettali(emorroidectomia…) Ernia inguinale Mastoplastica additiva Colecistectomia laparoscopica ORL Dentari Beauregaard L, Pomp A, Choinière M. Severity and impact of pain after day-surgery. Can J

Anaesth 1998; 45:304-11. Rawal N, Hylander J, Nydahl P-A, Olofsson I, Gupta A. Survey of postoperative analgesia

following ambulatory surgery. Acta Anaesthesiol Scand 1997; 41:1017-22.


Chung F, Ritchie E, Su J. Postoperative pain in ambulatory surgery. Anesth Analg 1997; 85:808-16.

10008 paz in chir amb Dolore severo:1.7-5.3% Fattori predittivi di dolore severo :

» Maschi adulti giovani» ASA I » BMI >26.

Gruppo con dolore severo caratterizzati da:» Durate di anest +lunghe» Minor dosaggio di fent in relaz al BMI e durata chir» Durata di soggiorno nella PACU più lunga» Dimissione più tardiva,


Incidenza percentuale di dolore severoChung F, Ritchie E, Su J. Postoperative pain in ambulatory surger. Anesth Analg 1997; 85:808-16.

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ortopurolchir genplastic


Dolore 24 h dopo tonsillectomia;intervista telefonica a casa Sutters KA, Miaskowski C. Inadequate pain

management and associated morbidity in children at home after tonsillectomy. J Ped Nurs 1997; 12:178-85.

In media 3 dosi di Acetaminophen con codeina

23% sollievo inadeguato ;» solo 7% ha contattato il medico

Sintomi;» Sonno inquieto (62%)» Modificazioni comportamentali (75%)» Difficoltà all’assunzione di liquidi per os (56%)» Vomito *1 o + (26%)


Blocco pl.cervic superf

Blocco interscalenicoInfiltrazione intraarticolare

Blocco pl.brach ascellareinfraclavicolare

Bl.nn. al polso,bl.digitate

Bl.ilioinguinaleilioipogastrico

Bl.femorale

Bl.femoro-cutaneo

Bl.digitale

Bl alla caviglia

Bl.sciatico al poplite

Bl femorale 3 in 1Infiltraz localeBl intrarticolare

Bl.del pene

Bl.intercostale

SPI,PD,Caudale….

Topica

Peri-retrobulbare..


Tecniche di analgesia postoperatoria:

cateterizzazione continua dopo anestesia regionale


Requisiti di una valida tecnica per analgesia postoperatoria nella chirurgia ortopedica dell’arto superiore

Perché il blocco sia efficace intraop» Reperi facilmente identificabili » Rapidità e facilità(relativa ) della tecnica

Perché il blocco sia efficace nel postop:» buone condizioni per l’inserimento di un

catetere(new frontiers……)» Assenza di complicazioni


Blocco del plesso brachiale per via infraclavicolare;risultati e eventi avversi

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Ilfeld B, Morey TE, Enneking FK. Continuous Infraclavicular Brachial Plexus Block for Postoperative Pain Control at Home A Randomized, Double-blinded, Placebo-controlled Study . Anesthesiology96:1297-1304, 2002

Randomized double-blinded placebo-controlled Intraop:infraclavicular nerve block + perineural catheter. Postop:discharged home with oral narcotics and a

portable infusion pump delivering study solution (0.2% ropivacaine or 0.9% saline) via the catheter for 3 days.

Daily end points included pain scores at rest and with limb movement, narcotic use and side effects, sleep quality, patient satisfaction, and symptoms of catheter- or local anesthetic-related complications.


Efficacia della infusione di ropivacaina 0.2 attraverso catetere infraclavicolare a riposo e

dopo movimento leggero. Ilfeld B, Morey TE, Enneking FK. Continuous Infraclavicular Brachial Plexus Block for Postoperative Pain Control at Home A Randomized, Double-blinded, Placebo-controlled Study . Anesthesiology96:1297-1304, 2002


Efficacia della infusione di ropivacaina 0.2 attraverso catetere infraclavicolare a riposo e dopo movimento leggero :risparmio di analgesici(ossicodone 5 mg +

paracetamol 500 mg). Ilfeld B, Morey TE, Enneking FK. Continuous Infraclavicular Brachial Plexus Block for Postoperative Pain Control at Home A Randomized, Double-blinded, Placebo-controlled Study . Anesthesiology96:1297-1304, 2002


Efficacia della infusione di ropivacaina 0.2 attraverso catetere infraclavicolare a riposo e dopo movimento leggero :meno effetti collaterali

e migliore cenestesi…. Ilfeld B, Morey TE, Enneking FK. Continuous Infraclavicular Brachial Plexus Block for Postoperative Pain Control at Home A Randomized, Double-blinded, Placebo-controlled

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day1ropi

day 1saline

day 2ropi

day 2saline

day3ropi

day3saline

nausea

sedazione

prurito

difficoltà sonno perdolorerisvegli per dolore

soddisfzione

Punteggio 0-10 max


Andamento del VAS dopo chirurgia della spalla con PCIA(patient controlled interscalene ropivacaine analgesia) vs PCA(patient controlled nicomorphine analgesia)(ev )Borgeat, A.; Tewes, E.; Biasca, N.; Gerber, C..Patient-controlled interscalene analgesia with ropivacaine after major shoulder surgery: PCIA vs PCA .BJA. 1998; 81:603-605.


Effetti collaterali e richieste analgesiche nei 2 gruppi di pazienti con differenti analgesie postop:PCIA vs PCA: Borgeat, A.; Tewes, E.; Biasca, N.; Gerber, C..Patient-controlled interscalene analgesia with ropivacaine after major shoulder surgery: PCIA vs PCA .BJA. 1998; 81:603-605.

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nausea vomito prurito blocco mot. supplparacetamol

soddiusfazpaziente

PCIAPCA


Hadzic et al. A Comparison of Infraclavicular Nerve Block versus General Anesthesia for Hand and Wrist Day-case Surgeries. Anesthesiology. 101(1):127-132, July 2004.

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Pacu bypass Pain>3 analgesiarequests in Hosp

ambulation home readiness

INB

GA

–INB = 3% 2-chloroprocaine + HCO3 + epinephrine 1:300,000, –followed by propofol sedation; –GA = 12.5 mg dolasetron, propofol induction, –followed by LMA insertion and desflurane for maintenance;– 0.25% bupivacaine for wound infiltration).


Hadzic A,Williams B A, Karaca PE,Hobeika, P,Unis G,Dermksian J,Yufa M,Thys DM,Santos AC.For Outpatient Rotator Cuff Surgery, Nerve Block Anesthesia Provides Superior Same-day Recovery over General Anesthesia. Anesthesiology 2005;102:1001-1007

goal: compare nerve block with general anesthesia with respect to recovery profile and patient satisfaction after rotator cuff surgery

50 outpatients (aged 18-70 yr) were randomly assigned to receive either fast-track general anesthesia followed by bupivacaine (0.25%) wound infiltration or interscalene brachial plexus block (0.75% ropivacaine)

Blinded recovery room nurses assessed the need for pain treatment and rated patient eligibility for bypass of the phase 1 postanesthesia care unit and for discharge home.

Patients were followed up for 2 weeks postoperatively. The primary outcome measures were postanesthesia care unit bypass and same-day discharge. Other same-day recovery

outco! mes included severity of and treatment for pain and time to ambulation. Postoperative outcomes at home included satisfaction with the anesthesia technique and absence of complications (at 2 weeks)

., Results: Patients who received nerve block (vs. general anesthesia) bypassed the postanesthesia care unit more frequently (76 vs. 16%; P < 0.001), reported less pain, ambulated earlier, were ready for home discharge sooner (123 vs. 286 min; P < 0.001), had no unplanned hospital admissions (vs. 4 of 25 patients who underwent general anesthesia; P = 0.05), and were more satisfied with their care. No complications were reported in either treatment group., ù

Conclusions: Nerve block anesthesia for outpatient rotator cuff surgery provides several same-day recovery advantages over general anesthesia.


Vantaggi dell’anestesia regionale nei confronti della AG

Precoce dimissione per pazienti esterni Transizione dolce verso l’analgesia postop. Aum flusso ematico all’estremità Potenziale protezione della distrofia simpatica riflessa Diminuzione degli effetti coll./ sequele

dell’Ag:SONNOLENZA,RITENZIONE VESCICALE,PONV… (evita l’intubaz endotracheale) MENO ricoveri indesiderati


Blocco continuo per via ascellare


Vantaggi del blocco regionale vs AG

Analgesia prolungata Selettività di area Riduzione degli effetti collaterali dell’Ag(ponv...) Sviluppi tecnici;ENS,US..., Miglioramento strumentale;

aghi ,cateteri,catet.stimolatori....


Terapia multimodaleLa risposta giusta…………???


Michaloliakou C, Chung F, Sharma S. Preoperative multimodal analgesia facilitates recovery after ambulatory laparoscopic cholecystectomy. Anesth Analg 1996; 82:44-51.

randomized treatment (n = 24) or control (n = 25) prospective, double-blind design. Preoperatively 45 min before induction of anesthesia

trattamento controlloIIM meperidine 0.6 mg/kg + ketorolac 0.5 mg/kg. 2 bolus IM injections of placebo (normal saline» 10 min before incision, local anesthesia saline » infiltrated into the skin of each patient. » Anesthetic management, postoperative pain, and nausea treatment were standardized. » Pain and nausea assessment were done 1 h preoperatively, 0, 0.5, 1, 2, 3, and 4 h postoperatively, at

discharge, and 10, 24, and 48 h postoperatively. » Patients were discharged by scoring criteria. » Postoperatively, significantly more patients in the treatment group were without pain on arrival in the

PACU, 12/21 (57.1%) vs 1/24 (4.2%) in the control group (P < 0.001). Similarly, the severity of pain was sixfold less in the treatment group than in the control group.

» The incidence of nausea in the PACU was significantly less in the treatment group; 4.7% vs 29.5% in the control group (P < 0.05).

» Patients from the treatment group satisfied Postanesthesia Discharge Score significantly earlier than those in the control group (281 ± 12 min vs 375 ± 19 min; P < 005).

» The concomitant use of local anesthetic and nonsteroidal antiinflammatory and opioid drugs proved to be highly effective in our patients, resulting in faster recovery and discharge.


VAS after video lap cholecystectomy ;im.preop mep+ketorolac + local vs placeboMichaloliakou C, Chung F, Sharma S. Preoperative multimodal analgesia facilitates recovery after ambulatory laparoscopic cholecystectomy. Anesth Analg 1996; 82:44-51.


Verbal pain score after video lap cholecystectomyim.preop mep+ketorolac + local vs placebo Michaloliakou C, Chung F, Sharma S. Preoperative multimodal analgesia facilitates recovery after ambulatory laparoscopic cholecystectomy. Anesth Analg 1996; 82:44-51.


Recovery pattern after video lap cholecystectomyim.preop mep+ketorolac + local vs placebo. Michaloliakou C, Chung F, Sharma S. Preoperative multimodal analgesia facilitates recovery after ambulatory laparoscopic cholecystectomy. Anesth Analg 1996; 82:44-51.


Michaloliakou C, Chung F, Sharma S. Preoperative multimodal analgesia facilitates recovery after ambulatory laparoscopic cholecystectomy. Anesth Analg 1996; 82:44-51.

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% o

min

controlli trattati

paz.richiedenti meperid.nella RR

paz.richiedenti ketorolac in reparto

intervallo fino al I analgesico

nausea in RR

nausea in reparto

Preop, at 45 min before induction of anesthesia, the treatment group received an IM bolus injection of meperidine 0.6

mg/kg and ketorolac 0.5 mg/kg. The control group received two bolus IM

injections of normal saline. 10 min before incision, local anesthesia

(treatment group) or saline (control group) was infiltrated into the skin of

each patient.

*10


Risultati principali dello studio dopo chir della mano(IVRA):tramadol vs metamizol vs paracetamol :Rawalet al.Postoperative Analgesia at Home After Ambulatory Hand Surgery: A Controlled Comparison of Tramadol, Metamizol, and Paracetamol . Anesthesia and Analgesia 2001; 92:347-351

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suppl analg PONV

tramadolmetamizolparacetamol

ambulatory hand surgery with IVRA oral analgesic tablets:tramadol 100 mg every 6 h, metamizol 1 g every 6 h, paracetamol (acetaminophen) 1 g every 6 h. Rescue medication : oral dextropropoxyphene 100 mg on demand.


Merry, A. F.; Swinburn, P. F.; Middleton, N. G.; Edwards, J. L.; Calder, M. V. Tenoxicam and paracetamol-codeine combination after oral surgery: a prospective, randomized, double-blind, placebo-controlled study Br. J. Anaesth. 1998; 81:875-880

We studied 90 adults undergoing surgical removal of at least both lower third

molar teeth as day cases under standardized general anaesthesia. Patients were allocated randomly (with stratification for surgeon) to receive tenoxicam 40 mg, tenoxicam 20 mg or placebo i.v. at induction of anaesthesia and orally (effervescent tablets) with food on each of the subsequent 2 days. Panadeine (paracetamol 500 mg-codeine 8 mg) was given before operation and was available as needed for pain thereafter, to a limit of two tablets every 4 h. Nefopam i.v. was also available. Efficacy variables and adverse reactions were assessed over 6 days. Over the 6-day period, patients who received tenoxicam reported less pain on rest (area under the curve; P<0.05) and less disturbance in sleep (P<0.01) even though they used fewer Panadeine tablets (P<0.05). Differences between tenoxicam 40 mg and 20 mg were not significant. There was no significant difference in nefopam requirements or side effects, and no adverse event attributable to the study medication.


Area del dolore sotto la curva(mm di Vas per 5 gg dopo estrazione di due molari) Merry, A. F.; Swinburn, P. F.; Middleton, N. G.; Edwards, J. L.; Calder, M. V. Tenoxicam and paracetamol-codeine combination after oral surgery: a prospective, randomized, double-blind, placebo-controlled study Br. J. Anaesth. 1998; 81:875-880


Dose totale di panadeine(paracetamol 500 + codeina 8 mg) consumata in 5 gg dopo l ’intervento di estrazione di due molari.Merry, A. F.; Swinburn, P. F.; Middleton, N. G.; Edwards, J. L.; Calder, M. V. Tenoxicam and paracetamol-codeine combination after oral surgery: a prospective, randomized, double-blind, placebo-controlled study Br. J. Anaesth. 1998; 81:875-880


Il trattamento del dolore postoperatorio in day

surgery;efficacia degli analgesici

somministrati per os

C.Melloni Servizio di Anestesia e Rianimazione

Ospedale di Faenza(RA)


Elenco analgesici inefficaci Codeina 60 mg da sola non è un analgesico efficace!

NNT 16.7 Destropropossifene (liberen) 65 mg da solo non è un

analgesico efficace Diidrocodeina da sola (30-60 mg) non è un analgesico

efficace Petidina 50 mg im non è un analgesico efficace.


Aspirina !

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% paz con sollievo >50%

aspirina placebo NNT

500600-65010001200650+codeina60

Dosi in mg


Celecoxib:Artilog,Celebrex,Solexa

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% paz con sollievo > 50%

celecoxib placebo NNT

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400

Durata:6 h!


Diclofenac:Algosenac,artrofenac,dealgic,deflamat,diclofan,dicloreum,fenadol,fender,flogofenac,forgenac,lisiflen,novapirina,ribex,voltaren,voltfast

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% di paz con sollievo>50%

diclofenac placebo NNT

2550100

mg


Etoricoxib:

0102030405060708090

100

% di paz con sollievo>50%

etoricoxib placebo NNT

60120180240

mg


Ibuprofen:algofen,antalgil,antalisin,arfen,brufen,buscofen,calmine,cibalgina,dolocyl,faspic,ganaprofene,moment,nureflex,nurofen

0102030405060708090

100


ibuprofen placebo NNT

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600

800

mg


Ketorolac:lixidol,toradol

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Ketorolac placebo NNT

10 im30 im60 im10 iv5 os10 os20 os


Confronto dei valori di NNT

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phin

e 10

mg

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6

NNT

etor

icox

ib60

etor

icox

ib12

0

etor

icox

ib18

0

keto

rola

c10

nim

keto

rola

c30

im

keto

rola

c60

im

keto

rola

c10

iv

keto

rola

c10

os

keto

rola

c20

os

ibup

rofe

n50

ibup

rofe

n100

ibup

rofe

n200

ibup

rofe

n400

ibup

rofe

n600

ibup

rofe

n800

dicl

ofen

ac25

dicl

ofen

ac50

dicl

ofen

ac10

0

cele

coxi

b200

cele

coxi

b400

asp

irina

600-

650

asp

650+

code

ina6

0

mor

phin

e 10

mg

petid

ina

100

mg

etoricoxib60etoricoxib120etoricoxib180ketorolac10 nimketorolac30 imketorolac60 imketorolac10 ivketorolac10 osketorolac20 osibuprofen50ibuprofen100ibuprofen200ibuprofen400ibuprofen600ibuprofen800diclofenac25diclofenac50diclofenac100celecoxib200celecoxib400 aspirina600-650asp 650+codeina60morphine 10 mgpetidina 100 mg

²


NAPROXEN:aleve,algonapril,axer,floginax,floxalin,gibixen,laser,momendol,naprius,napronex,naprosyn, neo

eblimon,prexan,synalgo,synflex,ticoflrx,xenar.

05

101520253035404550

% paz con solievo > 50%

naproxen placebo NNT

naproxen 220

naproxen 400

naproxen 550


PARACETAMOL:acetamol,efferalgan,levadol,normaflu,panadol,puernol,tachipirinaParacetamol + codeina:coefferalgan (500+30),lonarid (400+10),tachidol(400+30)

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20

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60

80

% paz consollievo >50%

par

acet

amol

pla

cebo

NN

T

para

ceta

mol

325

para

ceta

mol

500

para

ceta

mol

600/

650

para

ceta

mol

100

0

para

ceta

mol

150

0

para

c300

+co

dein

a30

para

ceta

mol

500

+Cod

eina

30

para

ceta

mol

600+

code

ina

60pa

race

tam

ol 8

00+

code

ina

60pa

race

tam

ol10

00+co

dein

a 60

pa

race

tam

ol65

0+Tra

mad

eol 75

para

ceta

mol

975+

tram

adol

112

paracetamol 325

paracetamol 500

paracetamol600/650

paracetamol 1000

paracetamol 1500

parac300+codeina30

paracetamol 500+ Codeina 30

paracetamol600+codeina60

paracetamol 800+ codeina 60

paracetamol 1000+codeina 60

paracetamol 650+Tramadeol 75

paracetamol 975+tramadol112


Paracetamol

0123456789

10

NNT

paracetamol 325

paracetamol 500

paracetamol600/650

paracetamol 1000

paracetamol 1500

parac300+codeina30

paracetamol 500+ Codeina 30

paracetamol600+codeina60

paracetamol 800+ codeina 60

paracetamol 1000+codeina 60

paracetamol 650+Tramadeol 75

paracetamol 975+tramadol112


Parecoxib:

0

10

20

30

40

50

60

70

80


parecoxib placebo NNT

parecoxib 20 ivparecoxib 20 imparecoxib 40 ivparecoxib 40 im


Piroxicam:algoxan,antiflog,artroxicam,brexin,brexivel,bruxicam,cicladol,dexicam,euroxi,feldene,flodol,lampoflex,polipirox,reucam,reudene,reumagil,riacen,roxene,roxenil,roxiden.

0

0,5

1

1,5

2

2,5

3

piroxicam placebo NNT

piroxicam os 20

Piroxicam os 40Solo 15 vs 15


ROFECOXIB:Arofex,Coxxil,dolcoxx,dolostop,miraxx,vioxx

0

10

20

30

40

50

60

% paz con sollievo > 50%

rofecoxib placebo NNT

rofecoxib 50


Tramadol (contramal,fortradol,fraxidol,prontalgin,tradonal),per os e studi comparativi

05

101520253035404550


placebo NNT

codeina 60

tramadol 50

tramadol 75

tramadol 100

tramadol 150

paracetamol 650+propossifene 100

aspirin 650+ codeina 60


VALDECOXIB per os

0

10

20

30

40

50

60

70

80

valdecoxib placebo NNT

valdecoxib 20

valdecoxib 40


FINE

trattamento dolore postop in day surg definitivo 2 maggio 05

Documents

faenzara servizio

alimentazion e

incidence of pain

impact of pain

issue pain

treated pain

general surgery

outpatient surgery