NSAIDs and balanced analgesia

Anaesthetists have changed their drug regimens several times in the last few decades. Today, anaesthesia is most frequently carried out with a "balanced" combination of agents to achieve optimal surgical anaesthesia and enhance recovery. Similarly, analgesia, one of the comerstones of anaesthesia, is increasingly considered with a combination of pharmacological agents and the term "balanced analgesia" is frequently considered. Opioids are no longer the sole entity for analgesia as anaesthetists now can combine local anaesthetics and/or non-steroidal anti-inflammatory drugs (NSAIDs) to optimize pain management in the perioperative period. Wall has suggested that prophylactic use of analgesics may decrease their postoperative requirements by reducing noxious input and thereby minimizing the hyperexcitable "windup" state in the central nervous system. 1 NSAID's inhibition of prostaglandin synthesis may reduce peripheral nociception and hence reduce the pain and inflammatory response to surgical trauma. In the following discussion, I will outline the strengths, weaknesses, and potential indications of NSAIDs as applied to the perioperative period. The NSAIDs include a wide number of pharmacological groups under one umbrella. Goodman and Gillman et al. (G and G) outline the prototype aspirin (acetylsalicylic acid), the near historical phenylbutazone and incorporate acetaminophen (paracetamol) into this group. 2 They list the common side effects including gastric or intestinal ulceration, altered platelet function (for the platelet's life with aspirin but a reversible cyclooxygenase inhibition related to the NSAID's half-life), prolongation of gestation (prostaglandins of the E and F series are potent uterotropic agents) and relatively rarely renal dysfunction. 2 The NSAIDs may decrease renal blood flow and the rate of glomerular fdtration in patients who have congestive heart failure, hepatic cirrhosis with ascites, hypovolaemia or chronic renal disease. 2 Clinical action of NSAIDs can vary from drug group to drug group, drug to drug and, as shown in rheuma-