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Posted: February 4th, 2024

Multimodal Analgesia in Perioperative Care

Multimodal Analgesia in Perioperative Care: Analyzing the Effectiveness and Safety of Combining Pain Management Techniques

Introduction

Postoperative pain is a common and unpleasant experience that can affect the recovery and quality of life of surgical patients. Despite the availability of various analgesic interventions, many patients still suffer from inadequate pain relief and experience adverse effects from opioids, such as nausea, vomiting, constipation, respiratory depression, and addiction [1]. Therefore, there is a need for more effective and safer strategies to manage postoperative pain.

One of the most widely accepted and recommended approaches is multimodal analgesia, which involves the use of two or more analgesic agents or techniques that act on different mechanisms of pain transmission and modulation [2]. The rationale behind this approach is to achieve synergistic or additive effects on pain relief, reduce the dose and side effects of each individual agent, and target different types of pain (such as nociceptive, inflammatory, neuropathic, or visceral) [3].

The aim of this article is to review the evidence for the effectiveness and safety of multimodal analgesia in perioperative care, and to provide practical recommendations for optimal analgesic combinations based on the type of surgery, patient characteristics, and clinical settings.

Multimodal Analgesia: Components and Evidence

The components of multimodal analgesia can be classified into pharmacological and non-pharmacological interventions. Pharmacological interventions include systemic drugs (such as acetaminophen, non-steroidal anti-inflammatory drugs [NSAIDs], cyclooxygenase-2 [COX-2] inhibitors, steroids, gabapentinoids, alpha-2 agonists, ketamine, tramadol, and opioids) and regional or local techniques (such as epidural, spinal, peripheral nerve blocks, wound infiltration, or intraperitoneal instillation of local anesthetics) [4]. Non-pharmacological interventions include psychological (such as education, relaxation, distraction, or hypnosis) and physical (such as massage, acupuncture, transcutaneous electrical nerve stimulation [TENS], or cold therapy) modalities [5].

The evidence for the effectiveness and safety of multimodal analgesia is derived from systematic reviews, meta-analyses, randomized controlled trials (RCTs), and observational studies that have compared multimodal analgesia with conventional opioid-based analgesia or placebo in various surgical procedures. The results of these studies have shown that multimodal analgesia can reduce postoperative pain intensity, opioid consumption, opioid-related side effects, length of hospital stay, time to recovery of bowel function, and postoperative complications [6-10]. Moreover, multimodal analgesia can improve patient satisfaction, quality of recovery, functional outcomes, and health-related quality of life [11-13].

However, the evidence for the best combinations of individual agents or techniques for specific procedures or patient populations is limited and inconsistent. This is due to the heterogeneity of the studies in terms of the type, dose, timing, route, and duration of administration of the analgesic interventions; the variability in the pain assessment methods and outcomes; the lack of standardized definitions and criteria for adverse events; and the potential confounding factors such as surgical technique, anesthesia protocol, fluid management, antibiotic prophylaxis, antiemetic regimen, and enhanced recovery pathways [14]. Therefore,

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