Correspondence  |   January 2003
Preemptive Analgesia: What Do We Do Now?
Author Affiliations & Notes
  • Steen Møiniche, M.D.
  • *Department of Anaesthesiology, Herlev University Hospital, Copenhagen, Denmark.
Article Information
Correspondence   |   January 2003
Preemptive Analgesia: What Do We Do Now?
Anesthesiology 1 2003, Vol.98, 281. doi:0000542-200301000-00048
Anesthesiology 1 2003, Vol.98, 281. doi:0000542-200301000-00048
In Reply:—
We thank Dr. Gottschalk and Dr. Ochroch for their interest in our work and their pertinent comments. We agree with the concerns they express. A major reason for the confusion and misunderstanding of the concept of preemptive analgesia is the variation in its definition. Original observations in experimental studies suggested that the timing of analgesic treatment was important to obtain efficient reduction of postinjury pain hypersensitivity phenomena. Accordingly, a tremendous number of studies have focused on the role of the timing of analgesia, i.e.  , preoperative versus  intraoperative or postoperative initiation of analgesia. The results of our overview of clinical studies showed that this one aspect of the discussion, namely the timing of analgesic administration, had no or only limited clinical impact on postoperative pain relief. Therefore, we believe that there is no need for further trials to investigate the role of timing of preemptive single-dose (and often short-lasting) analgesic treatment when postoperative pain is the end point. However, as emphasized also by Dr. Gottschalk and Dr. Ochroch, a number of reasons may explain the negative results from clinical trials compared with those from the experimental setting: intensity of the noxious stimuli, insufficient afferent blockade and insufficient analgesia, insufficient central inhibition, insufficient duration of the treatment, and so forth. Thus, although the overall results are negative when timing per se  is the variable, this conclusion does not preclude a possible beneficial effect of aggressive, perioperative analgesic treatment of short- and long-term postsurgical pain. As indicated by Dr. Gottschalk and Dr. Ochroch, and already suggested in our overview, future studies should redirect their focus from the timing of perioperative analgesia to protective analgesia aimed at preventing pain hypersensitivity. The agenda would then be to investigate the effects of a prolonged, multimodal (protective) analgesic intervention versus  less aggressive, conventional perioperative analgesia. Eventually, we agree that there may be other potentially beneficial effects of, for instance, intraoperative epidural blockade, such as modulation of the surgical stress response, reduced blood loss, stable intraoperative hemodynamics, and so forth.