Pain after surgery

Interventions of moderate trauma can cause significant pain after surgery. In this case, traditional opioids (morphine, promedol, etc.) for patients after such operations are of little use, since their use, especially in the early period after general anesthesia, is dangerous due to the development of central respiratory depression and requires monitoring of the patient in an intensive care setting. Meanwhile, according to their condition, patients after such operations do not need to be admitted to the intensive care unit, but they need a good and safe anesthesia.

Almost every person experiences some pain after the operation. In the world of medicine, this is considered a norm rather than a pathology. After all, any operation is an intervention in the whole system of the human body, therefore it takes some time to restore and heal wounds for further full functioning. Pain sensations are purely individual and depend on both the postoperative state of a person and the general criteria of his health. Pain after surgery can be permanent, or it can be periodic, increasing with body tension - walking, laughing, sneezing or coughing or even deep breathing.

[1]

Causes of pain after surgery

Pain after surgery can have a different nature. This may indicate a process of healing wounds and tissue fusion, because in the surgical incision of soft tissues, some small nerve fibers are damaged. This increases the sensitivity of the injured area. Other causes of pain after surgery are edema of tissues. In addition, much depends on how carefully the doctor conducts the operation and manipulation of the tissues, as this too can cause additional trauma.

[2], [3], [4], [5]

Symptoms of pain after surgery

A person may not associate arising pains with a previous operation. But there are a number of signs that will help determine the pain after surgery. First of all, one should pay attention to the general condition: pain after the operation is often accompanied by a violation of sleep and appetite, general weakness, lethargy, drowsiness, decreased activity. Also, these pain can cause a decrease in concentration, difficulty breathing or coughing. These are the most obvious and easily recognizable symptoms of pain after surgery, in the event that you should definitely consult a doctor.

Pain after surgery varicocele

Varikotsele - a fairly common disease in our days. In itself, the disease is not life-threatening, but it gives a lot of problems to a man, both physiological and psychological. The pain after the varicocele operation can be caused by various factors. The most dangerous of them is damage during the operation of the sexual-femoral nerve, which is in the inguinal canal. Pain is felt in the area of the operating wound and may be accompanied by a decrease in the sensitivity of the inner side of the thigh. Another reason for the pain after surgery varicocele may be an infection process in a postoperative wound. To avoid this complication, it is worthwhile to do dressings only with a specialist and, as far as possible, not to allow contact of the operated area with all possible sources of infection. Also, pain after surgery varicocele may indicate hypertrophy or atrophy of the testicle. Thanks to modern medical technologies, after surgical procedures in most cases, and this is about 96% of the operated, no complications arise, therefore the pain should become a signal that it is necessary to consult a doctor, since there is always a chance of falling into the number of 4% of the remaining patients.

Pain after operation of appendicitis

Removal of the appendix is quite common and simple operation in our time. Most operations are relatively easy and without complications. Most patients recover within three to four days. The pain after the operation of appendicitis can be indicative of all the complications that have arisen. If the pain is cutting, this may be a sign that there was a slight divergence of the internal seams as a result of overexertion. Drawing pains after an operation of an appendicitis can speak that there are adhesive processes which in a consequence can influence functioning of other organs of a basin. If these pains are too sharp, then there is a chance that the intestine is being squashed, which can have an unfavorable outcome without medical intervention. Loads on the intestines can also cause pain after removal of appendicitis, therefore it is worthwhile to carefully monitor the nutrition in the first time after the operation. In addition, it is necessary to handle the postoperative seam as carefully as possible in order to avoid infection and suppuration at the postoperative site.

Abdominal pain after surgery

After surgery in the abdominal cavity (as well as after any other surgical intervention), the tissues of the body need time for recovery and healing. This process is accompanied by mild painful sensations, which eventually diminish. But if the pain in the abdomen after the operation becomes very intense, it can talk about some kind of inflammation at the site of the operation. Also, abdominal pain after surgery can cause the formation of adhesions. People with increased meteosensitivity can feel aching pains at the site of the operation, depending on changing weather conditions. Pain in the abdomen after surgery can be accompanied by nausea, dizziness, burning in the postoperative zone, redness. If there is a similar symptomatology should consult a specialist.

[6], [7], [8], [9], [10], [11], [12]

Pain after an operation of inguinal hernia

After an inguinal hernia operation, a minor pain syndrome occurs for some time after the operation, which disappears as the seams and tissues become embedded. After a small period of time after the operation, the patient can already move independently, but when walking still feel pain in the abdominal region. Pain after the operation of inguinal hernia can not always talk about problems with the scar. These can be pains of both a neurological and muscular nature. But at high loads in the postoperative period there can be relapses, which are accompanied by sharp pain and require repeated surgical intervention. Painful sensations in place of the seam can be a sign of both external and internal divergence of the sutures.

Pain after spinal surgery

Some time after the operation on the spine, characteristic pain can occur in the region of the operated site. Most often, pain after surgery on the spine indicates a substandard operation, which subsequently leads to the development of postoperative scar - fibrosis. This complication is characterized by a specific pain that appears after several weeks of well-being. Pain after operation on the spine in most cases have neurological causes. It can also be a relapse of the disease, caused by improper compliance with the postoperative regimen. Pain after surgery on the spine is felt by most patients, but as recovery, their intensity should decrease. Recovery, as a rule, takes from three to six months. In the case of too intense pain, there are a number of methods to solve this problem, from drug treatment to the consultation of neurosurgeons and a reoperation. Operations on the spine are the most complex and dangerous operations and often entail complications, so no pain after the operation on the spine can not be ignored.

Back pain after surgery

After operations, back pain is often enough. This can be caused by a whole range of causes, such as scar formation, neurological symptoms, various pinchings or dislocations in the spine. To avoid complications after surgery, you should carefully consider the doctor's recommendations regarding the rehabilitation program. There may also be pain in the back after a cesarean operation. This is a fairly common problem that should not be ignored, because during pregnancy and surgery there is a strong strain on the woman's spine, which can lead to various injuries. Often after surgery, pain occurs in the lower back, in the lower back. This is due to the formation of adhesions and the negative impact of cicatricial changes. Pain between the shoulder blades often appears after a breast operation, with the strain of the rhomboid muscle. It is often enough to use spinal anesthesia during surgery, which can then cause aching pain in the back.

[13], [14], [15]

Headache after surgery

Headache after surgery is associated with the peculiarities of surgical manipulations or signals an increase in intraocular pressure due to surgery. Also, headache after surgery can be a consequence of anesthesia, especially if the pain is accompanied by nausea and dizziness. This is a rather dangerous symptom, which in any case requires urgent consultation of a neurologist or a doctor who performed the operation. After spinal anesthesia, headache complaints occur more often than after usual general anesthesia. Such complication occurs in the event that a too large aperture in the dorsal brain was made, resulting in a significant increase in intracranial pressure. If in this case the pains are very strong, then use the filling of the hole with blood. Also, headache after surgery can be a side effect of drugs that are prescribed for the postoperative period.

Pain after hemorrhoids operation

If the pain after the operation of gemmorrhoea persists for a long period that exceeds the prognosis of the rehabilitation period, then postoperative treatment is not enough or it is not effective in a particular case and requires immediate correction. Expressed pain after the operation of gemmoroya may be the result of the formation of scars. In cases where the scars are too dense, gut gaps may occur which will be repeated each time during defecation. Also, pain after a gemmorrhoeic operation can indicate the ingress of pathogenic microflora into the postoperative wound and, consequently, suppuration. One of the unpleasant causes of pain can be a fistula, which requires serious treatment. Pain after gemorrhoids should decrease as the wound heals and tissues recover.

Pain after cavitary operation

During each operation, the entire system of human organs takes on a huge load. This process is accompanied by a significant stressful condition, which is exacerbated by the presence of pain after a cavitary operation. The reaction of the body to an open operation can last up to three days and can be expressed in severe pain, fever or pressure, tachycardia. Because of this, often enough patients in the rehabilitation period, there is an oppressed mood and activity decreases, which significantly hampers the recovery process. Pain after the abdominal surgery removes the drugs of the opiate series, sedatives and medications of the anti-inflammatory series. During the reception of drugs, there is a decline in pain after a lumbar operation, body temperature returns to normal, motor activity increases. Over time, the body is recovering almost completely, there can be complaints only about a minor soreness in the abdomen, which also completely disappears with time. After three to four weeks, if the rehabilitation schedule and diet are observed, the body's activity stabilizes, puffiness disappears, pain disappears and a scar is formed.

Pain after surgery on a lung

If there are severe chest pains after an operation on the lung it is an alarming signal that you need to see a doctor. Such pain can be a symptom of pulmonary hemorrhage, which appeared as a complication after surgery. Also, pain after surgery on the lung can indicate the formation of adhesions. By themselves spikes are not a disease and do not always require medical intervention, but if the adhesion process is accompanied by a cough, fever and poor overall health, this may require treatment. Pain after surgery on the lung can occur with a sharp motor activity, which can be a sign of inflammation or suppuration in the operated area. Operations on the lungs are very serious operations, in consequence of which, there are often complications. At first, after surgery, the body is supplied with oxygen in order of magnitude worse, which can lead to headache, difficulty breathing and tachycardia. Also increases resistance to diseases such as bronchitis or pneumonia. In addition, it is worth remembering that after surgery, the lungs increase in volume, filling the free space, which can lead to the displacement of other organs in the chest. All this can be the cause of the pain after the operation on the lung.

Muscle pain after surgery

The most common muscle pain after surgery is found in young men. Pain syndrome, as a rule, is associated with the use of curare-like drugs during anesthesia, which relax the muscles. Such drugs are used in emergency situations or in those cases when a meal took place shortly before the operation and the stomach remains filled during the operation. Pain in the muscles after surgery is the consequences of anesthesia. Usually these pains are "wandering", they are symmetrical and affect the shoulder girdle, neck or upper abdomen. With a favorable course of the rehabilitation period, the pain in the muscles after the operation disappears in a few days. Also, the pulling pains in the muscles appear after laparoscopy and continue for some time until complete recovery. In addition, after a long time after surgery, aching pains in the muscles around the postoperative scar may remain, as a reaction to weather changes.

How to relieve pain after surgery?

Most people experience unpleasant pain in one or another intensity after the operation. Such pains can have a different character and duration and increase with certain body positions or movements. If the pain becomes too strong, narcotic analgesics are usually used. These drugs are most effective when the patient needs to get out of bed or the pain can not be tolerated and the weaker painkillers do not help. In some cases, the dosage of these drugs may be increased or supplemented with other medications. It should be noted that such drugs can cause addiction and negative reactions of the body, so they should be taken as needed and under the supervision of a doctor or medical staff. In no case can you take strong painkillers yourself, who have a narcotic effect. This can lead to side effects, such as nausea, excessive sedation, disruption of a favorable course of rehabilitation. It is worth turning to the doctor in charge, who will decide how to remove the pain after surgery, taking into account the individual characteristics of the surgical manipulations and the organism. With moderate pain, doctors recommend using non-narcotic analgesics. This is paracetamol, which, with the correct dosage, practically does not cause any side effects on the part of the body and has a high tolerance. There are many alternative ways to relieve pain after surgery, but traditional doctors strongly advise against self-medication, since in the post-operative period the organism is most susceptible to all kinds of irritants and can react to self-medication inadequately.

To protect from pain after surgery with an emphasis on preventive (before injury and pain) protection is recommended the use of the principle of multimodality and the use of an integrated approach. When drawing up a plan for postoperative analgesia, one should adhere to a number of general principles:

• therapy should be etiopathogenetic (for the spastic nature of pain after surgery, it is sufficient to prescribe an antispasmodic, and not an analgesic);
• the prescribed remedy should be adequate to the intensity of pain after surgery and be safe for a person, not to cause pronounced side effects (respiratory depression, blood pressure lowering, rhythm disorders);
• The duration of the use of narcotic drugs and their doses should be determined individually, depending on the type, causes and nature of the pain syndrome;
• Drug monotherapy should not be used; narcotic analgesic for pain relief after surgery in order to increase efficacy should be combined with non-narcotic drugs and adjuvant symptomatic agents of various assortments;
• prescribe anesthesia should be only when the nature and cause of pain sensations are recognized and the diagnosis is established. Removing the symptom of pain after surgery for an unknown cause is unacceptable. When these general principles are fulfilled, every doctor should, as Professor N.E. Burov, know the pharmacodynamics of the main assortment of painkillers and the pharmacodynamics of the main adjuvant drugs (spasmolytic, anticholinergic, antiemetic, corticosteroids, antidepressants in anxiety-hypnotic states, anticonvulsants, antipsychotics, tranquilizers, antihistamines, sedatives), assess pain intensity after surgery and, depending on it apply a single tactic.

To ensure the unity of tactics, it is suggested to use the scale of assessment of pain intensity after the operation. In the role of such a scale is the "analgesic ladder", developed by the World Federation of Societies of Anaesthesiologists (WFOA). The use of this scale allows us to achieve satisfactory analgesia in 90% of cases. The scale provides for the gradation of pain after the operation.

At the third stage - the minimal pain after the operation - monotherapy with non-narcotic drugs is performed to relieve pain.

At the second stage, a combination of non-narcotic analgesics and weak opioids is used, mainly with their oral administration. The most specific and reliable option for stopping pain after surgery seems to be the impact on the central arm, so it is preferable to use central action drugs to relieve pain after surgery. Examples of such analgesics may be butorphanol and nalbuphine.

Butorphanol tartrate is a kappa-agonist and a mu-opiate receptor antagonist. As a result of interaction with kappa receptors, butorphanol has strong analgesic properties and sedation, and as a result of antagonism with mu receptors, butorphanol tartrate weakens the main side effects of morphine-like drugs and has a more beneficial effect on respiration and circulation. With more severe pain, buprenorphine is prescribed. The analgesic effect of butorphanol tartrate with iv introduction comes after 15-20 min.

Nalbuphine refers to the synthetic opioid analgesics of the new generation. In its pure form in a dose of 40-60 mg is used for postoperative analgesia in extra-cavitary operations. With intracavitary large operations, monoanalgesia with nalbuphin becomes insufficient. In such cases, it should be combined with non-narcotic analgesics. Nalbuphine should not be used in conjunction with narcotic analgesics because of their mutual antagonism.

The direction on creation of the combined medicines possessing different mechanisms and time characteristics of action is also perspective. This allows for a stronger analgesic effect compared to each drug at lower doses, as well as a decrease in the incidence and severity of adverse events.

In this respect, combinations of drugs in one tablet are very promising, which makes it possible to simplify the reception mode substantially. The disadvantage of such drugs is the inability to vary the dose of each of the components individually.

At the first stage - with severe pain - apply strong analgesics in combination with regional blockades and non-narcotic analgesics (NSAIDs, paracetamol), mainly parenterally. For example, you can inject strong opioids with SC or IM. If such therapy does not have a sufficient effect, drugs are given IV. The disadvantage of this route of administration is the risk of severe respiratory depression and development of arterial hypotension. There are also side effects such as drowsiness, adynamia, nausea, vomiting, disruption of the peristalsis of the digestive tract, and motility of the urinary tract.

Medications for pain relief after surgery

Most often in the postoperative period, it is necessary to perform pain relief after the operation at the level of the 2 nd stage. Let's consider in more details applied thus medicines.

Paracetamol is a non-selective inhibitor of COX-1 and COX-2, acting predominantly in the central nervous system. It inhibits prostaglandin synthetase in the hypothalamus, prevents the production of spinal prostaglandin E2 and inhibits the synthesis of nitric oxide in macrophages.

In therapeutic doses, the inhibitory effect in peripheral tissues is negligible, it has minimal anti-inflammatory and antirheumatic effects.

The action begins quickly (after 0.5 h) and reaches a maximum after 30-36 min, but remains relatively short (about 2 h). This limits the possibility of its use in the postoperative period.

In the treatment of pain after surgery, as shown by a systematic review of qualitative data for 2001 with an analysis of 41 studies of high methodological quality, the effectiveness at a dose of 1000 mg after orthopedic and cavitary operations is similar to other NSAIDs. In addition, the effectiveness of its rectal form in a dose of 40-60 mg / kg once (1 study) or 14-20 mg / kg multiple (3 studies), but not 10-20 mg / kg once (5 studies).

The advantage is the low incidence of side effects when it is used, it is considered one of the safest analgesics and antipyretics.

Tramadol remains the fourth most frequently prescribed analgesic in the world, and is used in 70 countries. In 4% of cases, it is prescribed for the treatment of pain after surgery.

Tramadol, a synthetic opioid analgesic, is a mixture of two enantiomers. One of its enantiomers interacts with opioid mu, delta and kappa receptors (with greater tropism for mu receptors). The main metabolite (Ml) also has an analgesic effect, and its affinity for opiate receptors is almost 200 times greater than that of the starting substance. The affinity of tramadol and its Ml metabolite to mu receptors is much weaker than the affinity of morphine and other true opiates, so although it exhibits opioid effects, it refers to medium strength analgesics. Another enantiomer inhibits neuronal seizure of norepinephrine and serotonin, activating the central descending inhibitory noradrenergic system and disrupting transmission of pain impulses to the gelatinous substance of the brain. It is the synergy of the two mechanisms of its action which determines its high efficiency.

It should be noted a low affinity for opiate receptors, due to which it rarely causes mental and physical dependence. The results obtained after 3 years of drug testing after its introduction on the market in the United States indicate that the degree of development of drug dependence was low. The overwhelming number of cases of drug dependence development (97%) was detected among people who had a history of drug dependence on other substances.

LS does not have a significant effect on the parameters of hemodynamics, respiratory function and intestinal motility. In postoperative patients, under the influence of tramadol in the range of therapeutic doses from 0.5 to 2 mg per 1 kg of body weight, even with the bolus injection, significant respiratory depression is not established, whereas morphine at a therapeutic dose of 0.14 mg / kg is statistically significant and significantly reduced the respiratory rate and increased the stress of CO2 in the exhaled air.

Tramadol also has no effect on blood circulation. On the contrary, with an intravenous injection of 0.75-1.5 mg / kg, it can increase systolic and diastolic blood pressure by 10-15 mm Hg. Art. And slightly increase the heart rate with a rapid return to the original values, which is explained by the sympathomimetic component of its action. There was no effect of drugs on the level of histamine in the blood and on mental functions.

Postoperative analgesia based on tramadol positively proved itself in elderly and senile people due to the absence of negative influence on the functions of the aging organism. It is shown that with epidural blockade, postoperative use after major abdominal interventions and after cesarean delivery provides adequate pain relief after surgery.

The maximum activity of tramadol develops in 2-3 hours, the half-life and duration of analgesia is about 6 hours. Therefore, its use in combination with other, faster-acting analgesic drugs is more favorable.

Combination of drugs to relieve pain after surgery

Combinations of paracetamol with opioids recommended for use by WHO and abroad are the most sold combined analgesics for pain relief after surgery. In the UK in 1995, the number of paracetamol prescriptions along with codeine (paracetamol 300 mg and codeine 30 mg) accounted for 20% of all prescription analgesics.

Recommended use of the following drugs in this group: Solpadeina (paracetamol 500 mg, codeine 8 mg, caffeine 30 mg); Sedalgina-Neo (acetylsalicylic acid 200 mg, phenacetin 200 mg, caffeine 50 mg, codeine 10 mg, phenobarbital 25 mg); Pentalgina (metamizole 300 mg, naproxen 100 mg, caffeine 50 mg, codeine 8 mg, phenobarbital 10 mg); Nurofen-Plus (ibuprofen 200 mg, codeine 10 mg).

Nevertheless, the power of action of these drugs is not sufficient for their wide application for pain relief after surgery.

Zaldiar is a combined drug paracetamol with tramadol. Zal'diar was registered in Russia in 2004 and is recommended for dental and postoperative pain, back pain, osteoarthritic pain and fibromyalgia, anesthesia after minor and moderate trauma surgery (arthroscopy, hernia repair, sectoral breast resection, thyroid resection, safenectomy).

One Zaldiar tablet contains 37.5 mg of tramadol hydrochloride and 325 mg of paracetamol. The choice of dose ratio (1: 8.67) was made on the basis of the analysis of pharmacological properties and was proved in a number of in vitro studies. In addition, the analgesic efficacy of such a combination was studied in the pharmacokinetic / pharmacodynamic model in 1,652 subjects. It was shown that the anesthetic effect with Zaldiar is less than 20 minutes and lasts up to 6 hours; Thus, Zaldiar's action develops twice as fast as tramadol, lasting 66% longer than tramadol, and 15% longer than paracetamol. The pharmacokinetic parameters of Zaldiar do not differ from the pharmacokinetic parameters of its active ingredients and there are no undesirable drug interactions between them.

The clinical efficacy of the combination of tramadol and paracetamol was high and exceeded the efficacy of monotherapy with tramadol at a dose of 75 mg.

To compare the analgesic effect of two multicomponent analgesics - tramadol 37.5 mg / paracetamol 325 mg and codeine 30 mg / paracetamol 300 mg - a double-blind, placebo-controlled study was conducted in 153 people for 6 days after arthroscopy of the knee and shoulder joints. On average, in groups, the daily dose of tramadol / paracetamol was comparable to that of codeine / paracetamol, which was 4.3 and 4.6 tablets per day, respectively. The efficacy of the combination of tramadol and paracetamol was higher than in the placebo group. According to the final evaluation of the result of anesthesia, the intensity of pain during the day was higher in the group of patients who were anesthetized with a combination of codeine and paracetamol. In the group receiving the combination of tramadol and paracetamol, a more pronounced decrease in the intensity of the pain syndrome was achieved. In addition, adverse events (nausea, constipation) occurred less frequently with tramadol and paracetamol than with codeine and paracetamol. Therefore, the combination of tramadol 37.5 mg and paracetamol 325 mg reduces the average daily dose of the first, which in this study was 161 mg.

A number of clinical trials of Zaldiar in dental surgery were carried out. In a double-blind, randomized comparative study in 200 adult patients after molar removal, a combination of tramadol (75 mg) with paracetamol was shown to be as effective as a combination of paracetamol with hydrocodone (10 mg), but less likely to cause side effects. A double-blind, randomized, placebo-controlled multicentre trial was conducted, including 1,200 patients who received molar extraction, compared to analgesic efficacy and tolerability of tramadol 75 mg, paracetamol 650 mg, ibuprofen 400 mg and tramadol 75 mg with paracetamol 650 mg after a single dose Drugs. The total analgesic effect of the combination of tramadol and paracetamol was 12.1 points and was higher compared with placebo, tramadol and paracetamol, used as monotherapy. In patients of these groups, the total analgesic effect was 3.3, 6.7 and 8.6, respectively. The onset of action in anesthesia with a combination of tramadol and paracetamol was observed on the average in the group at the 17th minute (with a 95% confidence interval from 15 to 20 min), while after the administration of tramadol and ibuprofen, the development of analgesia was noted at the 51st (at 95 % confidence interval from 40 to 70 minutes) and the 34th minute, respectively.

Thus, the use of a combination of tramadol and paracetamol was accompanied by an increase and prolongation of the analgesic effect, a faster development of the effect compared to that observed after the administration of tramadol and ibuprofen. The duration of the analgesic effect also turned out to be higher for the combined drug tramadol and paracetamol (5 h) in comparison with these substances separately (2 and 3 h respectively).

The Cochrane Collaboration conducted a meta-analysis (review) of 7 randomized, double-blind, placebo-controlled trials in which 1,763 patients with moderate or severe postoperative pain received tramadol in combination with paracetamol or monotherapy with paracetamol or ibuprofen. The indicator of the number of patients who need an analgesic therapy to reduce pain intensity by at least 50% in one patient was determined. It was found that in patients with moderate or severe pain after dental operations, this indicator for 6 hours of observation for the combined drug tramadol with paracetamol was 2.6 points, for tramadol (75 mg) - 9.9 points, for paracetamol (650 mg) - 3.6 points.

Thus, a meta-analysis showed a higher effectiveness of Zaldiar compared with the use of individual components (tramadol and paracetamol).

In a simple open non-randomized study conducted in the Russian Research Center of the Russian Academy of Medical Sciences in 27 patients (19 women and 8 men whose mean age was 47 ± 13 years, body weight 81 ± 13 kg), with moderate or severe pain in the postoperative period, Zaldiar's administration was initiated after complete restoration of consciousness and function of the digestive tract. The study included patients with acute pain after surgery due to abdominal (laparoscopic cholecystectomy, hernia repair), thoracic (lobectomy, pleural cavity puncture) and extracorporeal (microdiscectomy, safenectomy) by surgical interventions.

Contraindications to the appointment of drugs were: the inability to take inside, increased sensitivity to tramadol and paracetamol, the use of central drugs (hypnotics, hypnotics, psychotropic, etc.), renal (creatinine clearance less than 10 ml / min) and liver failure, chronic obstructive pulmonary disease with signs of respiratory failure, epilepsy, taking anticonvulsants, taking MAO inhibitors, pregnancy, breast-feeding.

Zal'diar was prescribed in standard doses: with pain of 2 tablets, while the maximum daily dose did not exceed 8 tablets. The duration of anesthetic therapy was 1 to 4 days. In case of insufficient anesthesia or lack of effect, other analgesics (promedol 20 mg, diclofenac 75 mg) were additionally prescribed.

The intensity of pain was determined by the verbal scale (HB). The initial intensity of pain was recorded, as well as its dynamics within 6 hours after Zaldiar's first administration; evaluation of analgesic action on a 4-point scale: 0 points - no effect, 1 - minor (unsatisfactory), 2 - satisfactory, 3 - good, 4 - complete analgesia; duration of the analgesic action duration of the course; the need for additional analgesics; registration of undesirable phenomena.

Additional administration of analgesics was required in 7 (26%) patients. Throughout the entire follow-up period, the intensity of pain in the VS was from 1 ± 0.9 to 0.7 ± 0.7 cm, which corresponds to pain of low intensity. Only in two patients Zaldiar's application proved to be ineffective, which was the reason for stopping taking. The remaining patients rated anesthesia as good or satisfactory.

Pain after operation of moderate intensity for HB took place in 17 (63%) patients, strong - in 10 (37%) patients. On average, the intensity of pain in the group according to the HSS was 2.4 ± 0.5 points. After the first reception of Zaldiar, adequate anesthesia was achieved in 25 (93%) patients, including. Satisfactory and good / complete - in 4 (15%) and 21 (78%), respectively. Reduction of pain intensity after the initial dose of Zaldiar from 2.4 ± 0.5 to 1.4 ± 0.7 points was noted by the 30th minute (first assessment of pain intensity) of the study, and the maximum effect was observed after 2-4 h, 24 ( 89%) of the patient indicated a distinct reduction in pain intensity by at least half, and the duration of the analgesic effect averaged over the group of 5 ± 2 h. The mean daily dose in the Zaldiara group was 4.4 ± 1.6 tablets.

Thus, Zaldiar's appointment in the case of severe pain after surgery or moderate intensity is advisable from 2 to 3 days postoperative period of 2 tablets. In this case, the maximum daily dose should not exceed 8 tablets.

The portability profile of Zaldiar, according to various studies, is relatively favorable. Side effects develop in 25-56% of cases. Thus, in the study [20], nausea (17.3%), dizziness (11.7%) and vomiting (9.1%) were noted in the treatment of osteoarthritis. At the same time, 12.7% of patients had to stop taking drugs because of side effects. No serious adverse events were reported.

In a study in postoperative patients, the tolerability of drugs and the frequency of adverse reactions in the anesthesia with a combination of tramadol 75 mg / paracetamol 650 mg were comparable to those in patients taking tramadol 75 mg as the sole analgesic. The most frequent adverse events in these groups were nausea (23%), vomiting (21%) and drowsiness (5% of cases). Zaldiar was discontinued because of undesirable events in 2 (7%) patients. None of the patients had a clinically significant respiratory depression or allergic reaction.

In a four-week, multicenter, comparative study of the use of combinations of tramadol / paracetamol (Zaldiar) and codeine / paracetamol in patients with chronic pain after surgery in the back and pain caused by osteoarthritis, Zaldiar, compared with the codeine / paracetamol combination, showed a more favorable tolerability profile effects like constipation and drowsiness).

In the Cochrane Collaboration meta-analysis, the incidence of side effects with the combined tramadol (75 mg) with paracetamol (650 mg) was higher than for paracetamol (650 mg) and ibuprofen (400 mg): the potential harm index (the number of patients treated which developed one side effect) was 5.4 (95% confidence interval 4.0 to 8.2). At the same time, monotherapy with paracetamol and ibuprofen did not increase the risk compared with placebo: the relative risk ratio was 0.9 for them (95% confidence interval 0.7 to 1.3) and 0.7 (95% confidence interval from 0.5 to 1.01), respectively.

When assessing adverse reactions, it was found that the combination of tramadol / paracetamol does not lead to an increase in the toxicity of the opioid analgesic.

Thus, in the case of pain relief after surgery, the most expedient approach seems to be the planned use of one of the NSAIDs in the recommended daily dose in combination with tramadol, which allows achieving good analgesia in the active state of operated patients without serious side effects characteristic of morphine and promedol (drowsiness, lethargy, hypoventilation of the lungs ). The method of postoperative analgesia based on tramadol in combination with one of the analgesic agents of peripheral action is effective, safe, allows anesthetizing the patient in the general ward, without special intensive observation.

[16], [17]