Acute Postoperative Pain 2015 Part 1

TEXTBOOK (MILLER) :
OTHER REFERENCES:
Dr Mehran Rezvani pain fellowship anesthesiologist

& acupuncturist
ROBERT W. HURLEY
CHRISTOPHER L. WU
JAMIE D. MURPHY

& acupuncturist
PAIN PATHWAYS AND THE

NEUROBIOLOGY OF NOCICEPTION

& acupuncturist
Surgery produces tissue injury with consequent release

of histamine and inflammatory mediators such as
peptides
(e.g., bradykinin), lipids (e.g., prostaglandins),
neurotransmitters
(e.g., serotonin), and neurotrophins (e.g., nerve growth
factor)

& acupuncturist
Neurotrophin?
Dimeric growth factors that regulate development and
maintenance of central and peripheral nervous systems
Members of this protein family include
Nerve growth factor (NGF)
Neurotrophin-3 (NT-3)
Brain-derived neurotrophic factor (BDNF)
Neurotrophin-4/5 (NT-4/5)
Encyclopedia of Pain. G.F. Gebhart
, Robert F. Schmidt . Springer; 2nd ed. 2013 edition
& acupuncturist
Noxious stimulus &

Nociceptor

& acupuncturist
Definition of certain classes of stimuli as noxious and

creation of the term nociceptor (noci-receptor) were
outgrowths of the dispute in the late 19th Century about
the sensory nature of pain
Charles Sherrington (1906), an eminent physiologist of
the time, proposed that pain ordinarily results from tissue
injury
& acupuncturist
He suggested that events producing disruption of tissue

or representing a physical threat to its integrity could be
labeled noxious regardless of their nature, thereby
providing an encompassing definition for the stimuli
evoking pain
In this concept, sense organs signaling the presence of
noxious events were labeled noci-receptors (now
shortened to nociceptors)
& acupuncturist
Noxious stimulus :
Is one that is painful and potentially
damaging to normal tissues. Stimuli that are
painful can be thermal, mechanical or
chemical

Robert
Schmidt
. Springer; 2nd ed. 2013 edition
Dr Mehran ,Rezvani
painF.
fellowship
anesthesiologist
& acupuncturist
Nociceptor

& acupuncturist
Harmful stimuli activate the peripheral endings of

primary
afferent neurons, also called nociceptors
Their cell bodies lie in the dorsal root ganglia (DRG) or
the trigeminal ganglia
Encyclopedia of Pain. G.F. Gebhart , Robert F. Schmidt . Springer; 2nd ed. 2013 edition

& acupuncturist
Distinct classes of nociceptors encode discrete intensities

and modalities of noxious stimuli
Receptor molecules that lend these specific properties to
diverse classes of nociceptors and mediate transduction
have been cloned
Encyclopedia of Pain. G.F. Gebhart , Robert F. Schmidt . Springer; 2nd ed. 2013 edition
& acupuncturist
Since the nature and intensity of noxious stimuli will vary for different
tissues, the responsive characteristics of nociceptors will differ from one
tissue to another
1-Effective Stimuli
NOCICEPTORS CLASSIFICATIONS
2-Conduction Velocity
3-Molecular Features
Encyclopedia of Pain.
G.F. Gebhart , Robert F. Schmidt
4- Tissue of Origin
5-Central Projection
& acupuncturist
TRPV1 is the endogenous receptor that is selectively

activated by capsaicin
Vanilloid receptor which serves as a transducer of
noxious thermal and chemical (e.g. protons) stimuli, and
can be activated by capsaicin, the active ingredient of
hot chili peppers
Dr Mehran ,Rezvani
painF.
fellowship
anesthesiologist
Robert
Schmidt
& acupuncturist
Release of inflammatory mediators activates peripheral

nociceptors, which initiate transduction and transmission
of nociceptive information to the central nervous system
(CNS) and the process of neurogenic
inflammation, in which release of neurotransmitters (i.e.,
substance P and calcitonin generelated peptide) in the
periphery induces vasodilatation and plasma
extravasation

& acupuncturist
Noxious stimuli are transduced by peripheral nociceptors

and transmitted by A-delta and C nerve fibers from
peripheral visceral and somatic sites to the dorsal horn of
the spinal cord, where integration of
peripheral nociceptive and descending modulatory input
(i.e., serotonin, norepinephrine, -aminobutyric acid,
enkephalin) occurs

& acupuncturist
Noxious stimuli are transduced by peripheral nociceptors

and transmitted by A-delta and C nerve fibers from
peripheral visceral and somatic sites to the dorsal horn of
the spinal cord, where integration of
peripheral nociceptive and descending modulatory input
(i.e., serotonin, norepinephrine, -aminobutyric acid,
enkephalin) occurs

& acupuncturist
Further transmission of nociceptive information is

determined by complex modulating influences in the
spinal cord
Some impulses pass to the ventral and ventrolateral
horns to initiate segmental (spinal) reflex responses,
which may be associated with:
Increased skeletal muscle tone
Inhibition of phrenic nerve function
Decreased gastrointestinal motility
& acupuncturist
Others are transmitted to higher centers through the

spinothalamic
and spinoreticular tracts, where they induce
suprasegmental
and cortical responses to ultimately produce the
perception of and affective component of pain

& acupuncturist
Noxious stimuli & Nociception :

1- Neurogenic inflammation (SP CGRP)
2- Descending modulatory input (i.e.,
serotonin,NEP, -aminobutyric acid, enKephalin)
3-Impulses pass to the ventral and ventrolateral
horns ((spinal) reflex responses)
4- Spinothalamic and spinoreticular tracts

& acupuncturist
Continuous release of inflammatory mediators:

Sensitization of peripheral nociceptors may occur and is
marked by
Decreased threshold for activation
Increased rate of discharge with activation
Increased rate of basal (spontaneous) discharge

& acupuncturist
Sensitization

& acupuncturist
Peripheral Sensitization
Inflammatory mediators such as prostaglandin
enhance the sensitivity of nociceptors, a process
described as peripheral sensitization
Acute pain management , Taylor & Francis Group. CRC press 2015

& acupuncturist
Ongoing peripheral nociceptive stimuli will increase the

excitability of neurons in the spinal cord, leading to
central sensitization
Peripheral and central sensitization result in
amplification of subsequent pain stimuli and a lowered
pain threshold
Dr Mehran
painGroup.
fellowshipCRC
anesthesiologist
Acute pain management , Taylor
& Rezvani
Francis
press 2015
& acupuncturist
Intense noxious input from the periphery may also result

in central
sensitization and hyperexcitability
Central sensitization:
Persistent post injury changes in the CNS that result in
pain hypersensitivity
Hyperexcitability:
Exaggerated and prolonged responsiveness of neurons to
normal afferent input after tissue damage
& acupuncturist
It seems that certain receptors (e.g., Nmethyl-d-aspartate [NMDA]) may be

especially important for the development of
chronic pain after an acute injury, although
other neurotransmitters or second
messenger effectors (e.g., substance P,
protein kinase C) may also play important
roles in spinal cord sensitization and chronic
pain
& acupuncturist
Noxious stimuli can produce expression of new

genes (which are the basis for neuronal
sensitization) in the dorsal horn of the spinal cord
within 1 hour, and these changes are sufficient to
alter behavior within the same time frame

& acupuncturist
The intensity of acute postoperative pain is a

significant predictor of chronic postoperative pain
Chronic postsurgical pain:
CPSP
(miller)
Persistent postsurgical pain: PPP

(Some references)
Persistent Post- Surgical Pain: PPSP

(Some references)

& acupuncturist
Pain Types

& acupuncturist
Nociceptive pain
Somatic
Visceral
Pain
Neuropathic
pain
& acupuncturist
Nociceptive pain
Most common type of pain seen in the acute clinical setting
Somatic
usually well
Sharp, hot, or stinging pain which is

localized to the area of injury
Visceral
is often poorly
Dull, cramping, or colicky pain which

localized Pain may be referred over
a wide area
& acupuncturist
There may be associated symptoms
Neuropathic pain
Hx of Injury of peripheral or central nervous system
Pain confined to the innervation area correlating with
this damage, but poorly localized
Pain is burning, shooting, or stabbing pain
Pain may be spontaneous or paroxysmal, with no clear
triggers
Pain that appears to be responding poorly to opioids
Pain that appears to respond well to antineuropathic
agents
& acupuncturist
Neuropathic pain
Phantom phenomenon
Increased sympathetic activity
Allodynia: The sensation of pain in response to a stimulus that does
not normally cause pain (e.g., light touch)
Hyperalgesia: An increased (i.e., exaggerated) response to a stimulus
that is normally painful
Dysesthesias: Unpleasant abnormal sensations
& acupuncturist
Examples of neuropathic pain in the

acute setting
Acute pain management , Taylor & Francis

Group.
& acupuncturist
ACUTE AND CHRONIC EFFECTS OF

POSTOPERATIVE PAIN

& acupuncturist
Uncontrolled postoperative pain may

produce a range of detrimental acute
and chronic effects

& acupuncturist
Acute Effects

& acupuncturist
At one time the responses to acute pain may have had a

beneficial
teleological purpose; however, the same response to the
iatrogenic nature of modern-day surgery may be harmful
Uncontrolled perioperative pain may enhance some of
these perioperative pathophysiologies and increase
patient morbidity and mortality
& acupuncturist
Attenuation of postoperative pain, especially with certain

types of analgesic regimens, may decrease perioperative
morbidity and mortality
The dominant neuroendocrine responses to pain involve

hypothalamic-pituitary-adrenocortical and
sympathoadrenal interactions
& acupuncturist
Suprasegmental reflex responses to pain result in

Increased sympathetic tone
Increased catecholamine
Catabolic hormone secretion
Decreased secretion of anabolic hormones

& acupuncturist
Increased levels of
Sodium and water retention
Blood
glucose
Free fatty
acids
Ketone
bodies
Lactate
A hypermetabolic, catabolic state occurs as
metabolism and oxygen consumption

& acupuncturist
The extent of the stress response is influenced by many

factors, including the type of anesthesia and intensity of
the surgical injury, with the extent of the stress response
being proportional to the degree of surgical trauma

& acupuncturist
The negative nitrogen balance and protein

catabolism may impede convalescence;
however, attenuation of the stress response
and postoperative pain may facilitate and
accelerate the patients recovery
postoperatively

& acupuncturist
COAGULATION
Natural Anticoagulants
Procoagulants
Fibrinolysis
Platelet reactivity
Plasma viscosity
Deep venous
thrombosis
Vascular graft
failure
Myocardial ischemia

& acupuncturist
The stress response may also potentiate postoperative

immunosuppression (the extent of which correlates with the severity of
surgical injury )
Hyperglycemia from the stress response may contribute

to poor wound healing and depression of immune
function

& acupuncturist
Sympathetic activation
Myocardial oxygen consumption
Myocardial oxygen supply
Paralytic ileus

& acupuncturist
Nociceptors activation initiate several detrimental spinal reflex

arcs:
1- Postoperative respiratory function is markedly decreased,( especially after
upper abdominal and thoracic surgery.)
A-Spinal reflex inhibition of phrenic nerve activity is an important

component of this decreased postoperative pulmonary function
B- postoperative pain is also important because patients pain may
breathe less deeply, have an inadequate cough, and be more
susceptible to the development of postoperative pulmonary
complications
2- Initiate spinal reflex inhibition of gastrointestinal tract function and
delay return of gastrointestinal motility
& acupuncturist
Chronic Effects
Chronic postsurgical pain [CPSP] is a largely
unrecognized problem that may occur in 10% to 65% of
postoperative patients (depending on the type of
surgery)
2% to 10% of these patients experiencing severe CPSP
Poorly controlled acute postoperative pain may be an
important predictive factor
& acupuncturist
CPSP is relatively common after :

limb amputation (30% to 83%)
Thoracotomy (22% to 67%)
Breast surgery (11% to 57%)
Gallbladder surgery (up to56%)
Sternotomy (27%)
& acupuncturist
Although severity of acute postoperative

pain may be an important predictor in the
development of CPSP, other factors (i.e.,
area of postoperative hyperalgesia) may be
more important in predicting the
development of CPSP.
One such factor may be the severity of the
patients preoperative pain
& acupuncturist
FACTORS for
PPP
Preoperative
Intraoperative
Postoperative

& acupuncturist
PREOPERATIVE FACTORS
for PPP

& acupuncturist
The main question remains to be answered as to the

neuropathic
vs. the inflammatory component in persistent
postsurgical pain?
Neuropathic component probably is dominant
Postoperative pain : science and clinical practice/Smith, Lar IASP Press .2015
& acupuncturist
Main Preoperative factors for PPP:

Young age
Preoperative pain
Psycho-social factors (anxiety, pain catastrophizing, etc.)
Genetic characterization?
& acupuncturist
Other factors
Pretreatment with opioids ?
Female gender

& acupuncturist
INTRAOPERATIVE FACTORS

& acupuncturist
Postoperative pain : science and clinical practice/Smith, Lar IASP

Press .2015
& acupuncturist
CPSP is relatively common after :

limb amputation (30% to 83%)
Thoracotomy (22% to 67%)
Breast surgery (11% to 57%)
Gallbladder surgery (up to56%)
Sternotomy (27%)
& acupuncturist
Nerve injury is the most important pathogenic factor for

PPP
Hernia surgery:
Newer surgical techniques to avoid nerve injury have
been developed and where the laparoscopic technique
leads to an almost 50% reduction of nerve injury and PPP
The choice of mesh is important, since lightweight
meshes
reduce PPP
In groin hernia surgery, intraoperative nerve identification
may reduce PPP

& acupuncturist
In breast cancer surgery:

The intercostobrachial nerve is obviously at risk but so
far the studies on different surgical techniques for nerve
sparing are inconclusive
In thoracic surgery, the development of the videoassisted technique seems promising
& acupuncturist

& acupuncturist
The choice of general anesthesia is probably not

important although preliminary data support the
beneficial effect of a propofol-based technique

& acupuncturist
A recent outcome analysis in patients who received

nitrous oxide 70% in oxygen during their surgical
procedure seems to show both a lower incidence
(7% versus 14% in the air-oxygen group) and
reduced severity of PPSP at 3 months after surgery
Chan MT, Wan AC, Gin T, et al. Chronic postsurgical pain after nitrous oxide anesthesia. Pain
2011; 152(11): 251420.
& acupuncturist
POSTOPERATIVE FACTORS

& acupuncturist
Plenty of studies have shown an association between the

intensity of
acute postoperative pain and PPP
However, a critical review of existing data mostly show
inconclusive results

& acupuncturist
Other factors
Psychological:
Depression
Psychological vulnerability
Neuroticism
Anxiety
Radiotherapy to the area of surgery
Chemotherapy
& acupuncturist
CASE

& acupuncturist

& acupuncturist

& acupuncturist
Preventive Analgesia

& acupuncturist
The older terminology of preemptive analgesia referred

to an analgesic intervention that preceded a surgical
injury and was more effective in relieving acute
postoperative pain than the same treatment following
surgery

& acupuncturist
Definitions of preemptive analgesia

include
What is administered before the surgical incision
What prevents the establishment of central sensitization resulting
from incisional injury only (i.e., intraoperative period)
What prevents central sensitization resulting from incisional and
inflammatory injury (i.e., intraoperative and postoperative periods)
The entire perioperative period encompassing preoperative
interventions, intraoperative analgesia, and postoperative pain
management (i.e., preventive analgesia)
& acupuncturist
Preemptive analgesia :
An antinociceptive intervention that starts before surgical
incision and is more effective in relieving acute
postoperative pain than the same treatment starting
after surgery
Regional Anesthesia and Pain Medicine & Volume 36, Number 1, JanuaryFebruary 2011 P 4
& acupuncturist
Preventive analgesia:
Is aimed to block the development of sustained pain. This
broader definition includes any regimen given at any
time during the perioperative period that will be able to
control pain-induced sensitization
Regional Anesthesia and Pain Medicine & Volume 36, Number 1, JanuaryFebruary 2011 P 4
& acupuncturist
The rationale for preemptive analgesia was based on the

inhibition of the development of central sensitization
Although a very popular and discussed theory, a single
analgesic treatment (either peripheral or neuraxial)
before the incision does not reduce postoperative pain
behaviors beyond the expected duration of the analgesic
effect
& acupuncturist
When the block of nociceptive afferents diminishes, the

surgical injury is able to reinitiate central sensitization
For these reasons, this terminology has been abandoned

& acupuncturist
Preventive Analgesia
This definition broadly includes any regimen
given at any time during the perioperative
period that is able to control pain-induced
sensitization

& acupuncturist
Some patients may already have existing acute or

chronic pain and developed central sensitization before
the surgical incision
These patients with preexisting pain may have even
more intense pain in the postoperative period

& acupuncturist
Timing of the intervention may not be as clinically

important as other aspects of preventive analgesia (i.e.,
intensity and duration of the intervention)
An intervention administered before the surgical incision
is not preventative if it is incomplete or insufficient

& acupuncturist
Maximal clinical benefit is observed when complete

multisegmental blockade of noxious stimuli occurs, with
extension of this effect into the postoperative period

& acupuncturist
MULTIMODAL APPROACH TO
PERIOPERATIVE RECOVERY

& acupuncturist
The analgesic benefits of controlling

postoperative pain are generally
maximized when a multimodal
strategy to facilitate the patients
convalescence is implemented
& acupuncturist
Principles of a multimodal strategy through the use of

regional anesthetic techniques and a combination of
analgesic drugs (i.e., multimodal analgesia) include
control of postoperative pain to allow :
Early mobilization
Early enteral nutrition
Attenuation of the perioperative stress response

& acupuncturist
The use of epidural administered analgesics can

provide superior analgesia and physiologic
benefits and is therefore an integral part of the
multimodal approach

& acupuncturist
Multimodal analgesia

& acupuncturist
Multimodal analgesia consists of using various modalities

to reduce pain, thus providing more effective analgesia
while reducing doses and side effects
A. Akhabahian., R.Gupta. The Anesthesia Guide. McGraw-Hill Education 2013

& acupuncturist
Use regional techniques when possible:

Continuous or single-injection peripheral nerve
Epidural infusions
Nonopioid analgesics
Opioid analgesics
IV PCA
Adjuvant medications
A. Akhabahian., R.Gupta. The Anesthesia Guide. McGraw-Hill Education 2013
& acupuncturist
Epidural analgesia or even better spinal analgesia decreases

the area of
secondary mechanical hyperalgesia surrounding the wound,
e.g. the extent of central sensitization after open abdominal
surgery and reduces the risk of developing PPSP (15% PPSP at
6 months by comparison with 37% in patients without
neuraxial block)
Lavandhomme P, De Kock M. The use of intraoperative epidural or spinal analgesia modulates
postoperative hyperalgesia and reduces residual pain after major abdominal surgery. Acta
Anaesthesiol Belg 2006; 57(4): 3739.
& acupuncturist
Noxious inputs associated with both abdominal and

thoracic surgery are conveyed by segmental (i.e. spinal
nerves) and heterosegmental (i.e. vagus and phrenic
nerves) innervation
Thereby, an effective block of these components may
require the combination of both analgesic and
antihyperalgesic drugs, in other words, the use of
protective analgesia
Lavandhomme P, De Kock M. The use of intraoperative epidural or spinal analgesia
modulates postoperative hyperalgesia and reduces residual pain after major abdominal
surgery. Acta Anaesthesiol Belg 2006; 57(4): 3739.
& acupuncturist
Subanesthetic doses of ketamine strongly potentiate epidural

analgesia either by a supra-spinal effect blocking brainstem
sensitization or by an anti-inflammatory effect
Clonidine, displays antihyperalgesic properties after neuraxial
(intrathecal and epidural) but not systemic administration
De Kock M, Lavandhomme P. Waterloos H. The Short-Lasting Analgesia and Long-Term Antihyperalgesic
Effect of Intrathecal Clonidine in Patients Undergoing Colonic Surgery. Anesth Analg 2005; 101(2): 566
572.

& acupuncturist
Intravenous lidocaine infusion
(up to 36 hours
after the procedure) reduces postoperative pain and
improves bowel function after digestive surgery
Todate, a single study has found a preventive effect at 3
months after breast cancer surgery in terms of PPSP
incidence (11.8% versus 47.4%)
Grigoras A, Lee P, Sattar F, Shorten G. Perioperative intravenous lidocaine decreases the
incidence of persistent pain after breast surgery. Clin J Pain 2013; 28(7): 56772.

& acupuncturist
Patients undergoing major abdominal or thoracic

procedures and who participate in a multimodal
strategy :
Have a reduction in hormonal and metabolic stress
Preservation of total-body protein
Shorter times to tracheal extubation
Lower pain scores
Earlier return of bowel function
Earlier fulfillment of ICU discharge criteria
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TREATMENT METHODS

& acupuncturist
Many options are available for the treatment of

postoperative pain:
Systemic (i.e., opioid and nonopioid) analgesics
Regional (i.e., neuraxial and peripheral) analgesic
techniques

& acupuncturist
Monitoring and Documentation of Postoperative

Analgesia
Analgesic Medication
Side Effects
Medication, concentration, and dose of

drug
Settings of PCA device: demand dose,
lockout interval, continuous infusion
Amount of drug administered
(including number of unsuccessful and
successful doses)
Limits set (e.g., 1- and 4-hour limits on
dose administered)
Supplemental or breakthrough
analgesics
Cardiovascular: hypotension,
bradycardia, or tachycardia
Respiratory status: respiratory rate,
level of sedation
Nausea and vomiting, pruritus, urinary
retention
Neurologic examination
Assessment of motor block or function
and sensory level
Evidence of epidural hematoma
Routine Monitoring
Instructions Provided
Vital signs: temperature, heart rate, blood

Treatment of side effects
pressure, respiratory rate
Concurrent use of other CNS depressants
average pain score
Parameters for triggering notification of the
Pain score at rest and with activity
covering physician
pain relief
Provision of contact information (24 hours/7
Use of breakthrough medication
days per
week) if problems occur
Dr Mehran Rezvani pain fellowship
anesthesiologist
& acupuncturist
Emergency analgesic treatment if the PCA

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Enviado por

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TEXTBOOK (MILLER) :

Dr Mehran Rezvani pain fellowship anesthesiologist

Dr Mehran Rezvani pain fellowship anesthesiologist

PAIN PATHWAYS AND THE

Dr Mehran Rezvani pain fellowship anesthesiologist

Surgery produces tissue injury with consequent release

Dr Mehran Rezvani pain fellowship anesthesiologist

Noxious stimulus &

Dr Mehran Rezvani pain fellowship anesthesiologist

Definition of certain classes of stimuli as noxious and

He suggested that events producing disruption of tissue

Encyclopedia of Pain. G.F. Gebhart

Dr Mehran Rezvani pain fellowship anesthesiologist

Harmful stimuli activate the peripheral endings of

Dr Mehran Rezvani pain fellowship anesthesiologist

Distinct classes of nociceptors encode discrete intensities

TRPV1 is the endogenous receptor that is selectively

Release of inflammatory mediators activates peripheral

Dr Mehran Rezvani pain fellowship anesthesiologist

Noxious stimuli are transduced by peripheral nociceptors

Dr Mehran Rezvani pain fellowship anesthesiologist

Noxious stimuli are transduced by peripheral nociceptors

Dr Mehran Rezvani pain fellowship anesthesiologist

Further transmission of nociceptive information is

Others are transmitted to higher centers through the

Dr Mehran Rezvani pain fellowship anesthesiologist

Noxious stimuli & Nociception :

Dr Mehran Rezvani pain fellowship anesthesiologist

Continuous release of inflammatory mediators:

Dr Mehran Rezvani pain fellowship anesthesiologist

Dr Mehran Rezvani pain fellowship anesthesiologist

Dr Mehran Rezvani pain fellowship anesthesiologist

Ongoing peripheral nociceptive stimuli will increase the

Intense noxious input from the periphery may also result

It seems that certain receptors (e.g., Nmethyl-d-aspartate [NMDA]) may be

Noxious stimuli can produce expression of new

Dr Mehran Rezvani pain fellowship anesthesiologist

The intensity of acute postoperative pain is a

Persistent postsurgical pain: PPP

Persistent Post- Surgical Pain: PPSP

Dr Mehran Rezvani pain fellowship anesthesiologist

Dr Mehran Rezvani pain fellowship anesthesiologist

Sharp, hot, or stinging pain which is

Dull, cramping, or colicky pain which

There may be associated symptoms

Examples of neuropathic pain in the

Dr Mehran Rezvani pain fellowship anesthesiologist

Acute pain management , Taylor & Francis

ACUTE AND CHRONIC EFFECTS OF

Dr Mehran Rezvani pain fellowship anesthesiologist

Uncontrolled postoperative pain may

Dr Mehran Rezvani pain fellowship anesthesiologist

Dr Mehran Rezvani pain fellowship anesthesiologist

At one time the responses to acute pain may have had a

Attenuation of postoperative pain, especially with certain

The dominant neuroendocrine responses to pain involve

Suprasegmental reflex responses to pain result in

Dr Mehran Rezvani pain fellowship anesthesiologist

Sodium and water retention

A hypermetabolic, catabolic state occurs as

metabolism and oxygen consumption

The extent of the stress response is influenced by many

Dr Mehran Rezvani pain fellowship anesthesiologist