Pain, often severe and inadequately treated, accompanies the more than 23 million surgical procedures performed annually in the U,S. Almost 2/3 of patients cite postoperative pain as their major preoperative fear. Apart from the mounting evidence that pain interferes with physiologic functions such as breathing, blood pressure regulation, etc., the pain associated with surgery limits the ability of patients to care for themselves, can be prolonged, may lead to chronic pain syndromes, and could possibly influence a patient's decision to delay or postpone potentially lifesaving surgery. Recent evidence indicates that residual pain following major surgery is more common than first appreciated, and that this pain is associated with significant decreases in functionality and self-perception of health. Painful stimuli initiate a cascade of responses which sensitize the nervous system so that subsequent painful stimuli are perceived with greater intensity and even typically painless stimuli can elicit pain. Preemptive analgesia is an intervention designed to prevent the sensitization of the nervous system produced by painful stimuli by beginning the analgesic regimen before the onset of pain stimuli. There is a definitive body of laboratory evidence and a growing body of clinical evidence that preemptive analgesia can reduce pain and analgesic needs following surgery, and our recent research indicates that this benefit can be observed in humans long after discharge from the hospital in the form of increased activity and decreased residual pain. One of the most common and clinically effective preemptive analgesic regimens involves the use of an epidural catheter. Adequate doses of medications introduced into the epidural space before the start of surgery and continued into the postoperative period appear to limit sensitization of the nervous system despite adequate levels of general anesthesia. However, preemptive epidural analgesia requires additional physician and other resources before, during and after surgery, Consequently, such an intervention will be supported by individual practitioners and third-party payers only in the face of demonstrable efficacy. This application considers the short- and long-term costs and benefits of aggressive preemptive epidural analgesia in generally healthy adult patients undergoing a common major abdominal surgical procedure. Pain during hospitalization and after discharge, activity levels, nursing needs, and the return to normal function will be quantitatively and economically assessed. These results will quantify the role played by aggressive perioperative pain management, will further link reductions in perioperative pain and outcome, and by quantifying the impact of recovery from major surgery will permit more rational allocation of scarce healthcare resources to effective strategies for acute pain management.
