The Perioperative Management of Pain from Intracranial Surgery
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REVIEW ARTICLE
The Perioperative Management of Pain from Intracranial Surgery Allan Gottschalk Æ Myron Yaster
Published online: 1 October 2008 Ó Humana Press Inc. 2008
Abstract Analgesic therapy following intracranial procedures remains a source of concern and controversy. Although opioids are the mainstay of the ‘‘balanced’’ general anesthetic techniques frequently used during intracranial procedures, neurosurgeons and others have been reluctant to administer opioid analgesics to patients following such procedures. This practice is supported by the concern that the sedation and miosis associated with opioid administration could mask the early signs of intracranial catastrophe, or even exacerbate it through decreased ventilatory drive, elevated arterial carbon dioxide levels, and increased cerebral blood flow. This reluctance to use opioids following intracranial surgery is enabled by decades of training and anecdote emphasizing that pain is minimal following these procedures. However, recent data suggests otherwise, and raises the question of how to provide safe and effective analgesia for these patients. Here, this data is reviewed along with the relevant pain pathways, analgesic drugs and techniques, and the available data on their use following intracranial surgery. Although pain following intracranial surgery appears to be more intense than initially believed, it is readily treated safely and effectively with techniques that have proven useful following other types of surgery, including patient-controlled administration of opioids. The
A. Gottschalk and M. Yaster are without conflict with respect to the interventions described in this review. A. Gottschalk (&) M. Yaster Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, The Johns Hopkins Medical Institutions, 600 North Wolfe Street, Baltimore, MD 21287-4965, USA e-mail: [email protected]
use of multimodal analgesic therapy is emphasized not only for its effectiveness, but to reduce dosages and, therefore, side effects, primarily of the opioids, that could be of legitimate concern to physicians and affect the comfort of their patients. Keywords Craniotomy Neurosurgery Analgesia Analgesics Opioids Acute pain
Introduction Historically, the pain associated with intracranial surgery has been undertreated because of a presumed lack of need and a fear that use of opioids, the analgesics most often used to treat moderate to severe pain, may interfere with the neurologic examination or lead to its deterioration [1]. Even with the immediate availability of modern imaging technology, the neurologic exam remains the primary instrument for perioperative evaluation of patients following intracranial surgery. Opioids may produce sedation, miosis, nausea and vomiting, symptoms that mask or mimic signs of intracranial catastrophe. Furthermore, opioids, even when administered in therapeutic doses, may depress minute ventilation leading to hypercapnia, increased intracerebral blood volume, and potentially increased intracranial pr
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