Multimodal analgesia strategies for optimal postoperative pain relief
DOI:
https://doi.org/10.18203/2349-3259.ijct20251213Keywords:
Multimodal analgesia, Postoperative pain, Opioid reduction, Regional anaesthesia, NSAIDs, Enhanced recovery, Pain management protocolsAbstract
This narrative review assesses the effectiveness of multimodal analgesia protocols (MAPs) in managing postoperative pain and reducing opioid consumption, focusing on their safety, efficacy, and broader applicability in clinical practice. Recent studies highlight that MAPs, which combine pharmacological and non-pharmacological methods, significantly reduce postoperative pain intensity and opioid use compared to traditional opioid-centric approaches, without increasing adverse events such as nausea and respiratory depression. The inclusion of regional anaesthesia, nonsteroidal anti-inflammatory drugs (NSAIDs), and nerve blocks has shown to enhance recovery, minimize complications, and improve patient outcomes. Specific combinations of medications like ketamine, acetaminophen, and dexamethasone have proven effective in different surgical settings, underscoring the versatility of MAPs. By leveraging the synergistic effects of various pain relief modalities, MAPs optimize pain control while reducing opioid-related risks, offering a promising strategy for improving recovery outcomes. This review emphasizes the need for broader adoption of MAPs and calls for further research to refine these protocols for long-term advancements in surgical care and patient experiences.
Metrics
References
Garimella V, Cellini C. Postoperative pain control. Clin Colon Rectal Surg. 2013;26(03):191-6. DOI: https://doi.org/10.1055/s-0033-1351138
Phillips JK, Ford MA, Bonnie RJ. National Academies of Sciences Engineering, and Medicine. Health and Medicine Division. 2017.
Hall MJ, Schwartzman A, Zhang J, Liu X. Ambulatory surgery data from hospitals and ambulatory surgery centers: United States, 2010. National Health Stat Rep. 2017;102:1-5.
Kaye AD, Urman RD, Rappaport Y, Siddaiah H, Cornett EM. Multimodal analgesia as an essential part of enhanced recovery protocols in the ambulatory settings. J Anaesthesiol Clin Pharmacol. 2019;35(1):40-5. DOI: https://doi.org/10.4103/joacp.JOACP_51_18
Birkmeyer JD, Reames BN, McCulloch P, Carr AJ, Campbell WB, Wennberg JE. Understanding of regional variation in the use of surgery. Lancet. 2013;382(9898):1121-9. DOI: https://doi.org/10.1016/S0140-6736(13)61215-5
Dohlman LE, Kwikiriza A, Ehie O. Benefits and barriers to increasing regional anesthesia in resource-limited settings. Local Regional Anesthesia. 2020;5:147-58. DOI: https://doi.org/10.2147/LRA.S236550
Nasir M, Ahmed A. Knowledge about postoperative pain and its management in surgical patients. Cureus. 2020;12(1):78. DOI: https://doi.org/10.7759/cureus.6685
Pedemonte JC, Plummer GS, Chamadia S, Locascio JJ, Hahm E, Ethridge B, et al. Electroencephalogram burst-suppression during cardiopulmonary bypass in elderly patients mediates postoperative delirium. Anesthesiol. 2020;133(2):280-92. DOI: https://doi.org/10.1097/ALN.0000000000003328
Larach DB, Sahara MJ, As-Sanie S, Moser SE, Urquhart AG, Lin J, et al. Patient factors associated with opioid consumption in the month following major surgery. Ann Surg. 2021;273(3):507-15. DOI: https://doi.org/10.1097/SLA.0000000000003509
Shanthanna H, Ladha KS, Kehlet H, Joshi GP. Perioperative opioid administration: a critical review of opioid-free versus opioid-sparing approaches. Anesthesiology. 2021;134(4):645-59. DOI: https://doi.org/10.1097/ALN.0000000000003572
Bergman L, Bäckmark I, Ones H, von Euler C, Olivestedt G, Kvanta A, et al. Preoperative sub–tenon’s capsule injection of ropivacaine in conjunction with general anesthesia in retinal detachment surgery. Ophthalmol. 2007;114(11):2055-60. DOI: https://doi.org/10.1016/j.ophtha.2006.12.031
Chhabra A, Sinha R, Subramaniam R, Chandra P, Narang D, Garg SP. Comparison of sub-Tenon's block with iv fentanyl for paediatric vitreoretinal surgery. Br J Anaesthesia. 2009;103(5):739-43. DOI: https://doi.org/10.1093/bja/aep230
Smith TW, Wang X, Singer MA, Godellas CV, Vaince FT. Enhanced recovery after surgery: a clinical review of implementation across multiple surgical subspecialties. Am J Surg. 2020;219(3):530-4. DOI: https://doi.org/10.1016/j.amjsurg.2019.11.009
Caldwell GL, Selepec MA. Surgeon-administered nerve block during rotator cuff repair can promote recovery with little or no post-operative opioid use. HSS Journal®. 2020 Dec;16(2_suppl):349-57. DOI: https://doi.org/10.1007/s11420-019-09745-4
Fawcett WJ, Mythen MG, Scott MJ. Enhanced recovery: joining the dots. Br J Anaesth. 2021;126(4):751-5. DOI: https://doi.org/10.1016/j.bja.2020.12.027
Manyam SC, Gupta DK, Johnson KB, White JL, Pace NL, Westenskow DR, et al. Opioid–volatile anesthetic synergy: a response surface model with remifentanil and sevoflurane as prototypes. J Am Soc Anesthesiol. 2006;105(2):267-78. DOI: https://doi.org/10.1097/00000542-200608000-00009
Verret M, Lam NH, Fergusson DA, Nicholls SG, Turgeon AF, McIsaac DI, et al. Intraoperative pharmacologic opioid minimisation strategies and patient-centred outcomes after surgery: a scoping review protocol. BMJ open. 2023;13(3):70748. DOI: https://doi.org/10.1136/bmjopen-2022-070748
Frauenknecht J, Kirkham KR, Jacot‐Guillarmod A, Albrecht E. Analgesic impact of intra‐operative opioids vs. opioid‐free anaesthesia: a systematic review and meta‐analysis. Anaesthesia. 2019;74(5):651-62. DOI: https://doi.org/10.1111/anae.14582
Mauermann E, Clamer D, Ruppen W, Bandschapp O. Association between intra-operative fentanyl dosing and postoperative nausea/vomiting and pain: a prospective cohort study. Euro J Anaesthesiol. 2019;36(11):871-80. DOI: https://doi.org/10.1097/EJA.0000000000001081
Murphy GS, Avram MJ, Greenberg SB, Shear TD, Deshur MA, Dickerson D, et al. Postoperative pain and analgesic requirements in the first year after intraoperative methadone for complex spine and cardiac surgery. Anesthesiol. 2020;132(2):330-42. DOI: https://doi.org/10.1097/ALN.0000000000003025
Salpeter SR, Buckley JS, Bruera E. The use of very-low-dose methadone for palliative pain control and the prevention of opioid hyperalgesia. J Pall Med. 2013;16(6):616-22. DOI: https://doi.org/10.1089/jpm.2012.0612
Roeckel LA, Le Coz GM, Gavériaux-Ruff C, Simonin F. Opioid-induced hyperalgesia: cellular and molecular mechanisms. Neurosci. 2016;338:160-82. DOI: https://doi.org/10.1016/j.neuroscience.2016.06.029
Khanna AK, Bergese SD, Jungquist CR, Morimatsu H, Uezono S, et al. Prediction of opioid-induced respiratory depression on inpatient wards using continuous capnography and oximetry: an international prospective, observational trial. Anesthesia Analgesia. 2020;131(4):1012-24. DOI: https://doi.org/10.1213/ANE.0000000000004788
Connolly JG, Tan KS, Mastrogiacomo B, Dycoco J, Caso R, Jones GD, et al. Intraoperative opioid exposure, tumour genomic alterations, and survival differences in people with lung adenocarcinoma. Br J Anaesth. 2021;127(1):75-84. DOI: https://doi.org/10.1016/j.bja.2021.03.030
Bohl DD, Louie PK, Shah N, Mayo BC, Ahn J, Kim TD, Massel DH, et al. Multimodal versus patient-controlled analgesia after an anterior cervical decompression and fusion. Spine. 2016;41(12):994-8. DOI: https://doi.org/10.1097/BRS.0000000000001380
Van Tulder M, Becker A, Bekkering T, Breen A, del Real MT, Hutchinson A, et al. COST B13 Working group on guidelines for the management of acute low back pain in primary Care. European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J. 2006;15(2):169. DOI: https://doi.org/10.1007/s00586-006-1071-2
Friedman BW, Dym AA, Davitt M, Holden L, Solorzano C, Esses D, et al. Naproxen with cyclobenzaprine, oxycodone/acetaminophen, or placebo for treating acute low back pain: a randomized clinical trial. JAMA. 2015;314(15):1572-80. DOI: https://doi.org/10.1001/jama.2015.13043
Tiippana EM, Hamunen K, Kontinen VK, Kalso E. Do surgical patients benefit from perioperative gabapentin/pregabalin? A systematic review of efficacy and safety. Anesthesia Analgesia. 2007;104(6):1545-56. DOI: https://doi.org/10.1213/01.ane.0000261517.27532.80
Shetty AP, Subramanian B, Kanna RM, Rajasekaran S. A prospective randomized study to analyze the efficacy of balanced pre-emptive analgesia in spine surgery. Spine J. 2019;19(4):569-77. DOI: https://doi.org/10.1016/j.spinee.2018.10.010
Garcia RM, Cassinelli EH, Messerschmitt PJ, Furey CG, Bohlman HH. A multimodal approach for postoperative pain management after lumbar decompression surgery: a prospective, randomized study. Clin Spine Surg. 2013;26(6):291-7. DOI: https://doi.org/10.1097/BSD.0b013e318246b0a6
Lohsiriwat V. Opioid-sparing effect of selective cyclooxygenase-2 inhibitors on surgical outcomes after open colorectal surgery within an enhanced recovery after surgery protocol. World J Gastrointes Oncol. 2016;8(7):543. DOI: https://doi.org/10.4251/wjgo.v8.i7.543
Loftus RW, Yeager MP, Clark JA, Brown JR, Abdu WA, Sengupta DK, et al. Intraoperative ketamine reduces perioperative opiate consumption in opiate-dependent patients with chronic back pain undergoing back surgery. J Am Society Anesthesiol. 2010;113(3):639-46. DOI: https://doi.org/10.1097/ALN.0b013e3181e90914
Young A, Buvanendran A. Recent advances in multimodal analgesia. Anesthesiol Clin. 2012;30(1):91-100. DOI: https://doi.org/10.1016/j.anclin.2011.12.002
De Oliveira GS, Almeida MD, Benzon HT, McCarthy RJ. Perioperative single dose systemic dexamethasone for postoperative pain: a meta-analysis of randomized controlled trials. J Am Society Anesthesiol. 2011;115(3):575-88. DOI: https://doi.org/10.1097/ALN.0b013e31822a24c2
Clement JC, Besch G, Puyraveau M, Grelet T, Ferreira D, Vettoretti L, et al. Clinical effectiveness of single dose of intravenous dexamethasone on the duration of ropivacaine axillary brachial plexus block: the randomized placebo-controlled ADEXA trial. Regional Anesthesia Pain Med. 2019;44(3):89. DOI: https://doi.org/10.1136/rapm-2018-100035
Murphy GS, Szokol JW, Avram MJ, Greenberg SB, Shear TD, Deshur MA, et al. Clinical effectiveness and safety of intraoperative methadone in patients undergoing posterior spinal fusion surgery: a randomized, double-blinded, controlled trial. Anesthesiol. 2017;126(5):822-33. DOI: https://doi.org/10.1097/ALN.0000000000001609
Farag E, Ghobrial M, Sessler DI, Dalton JE, Liu J, Lee JH, et al. Effect of perioperative intravenous lidocaine administration on pain, opioid consumption, and quality of life after complex spine surgery. Anesthesiol. 2013;119(4):932-40. DOI: https://doi.org/10.1097/ALN.0b013e318297d4a5
Hansen RN, Pham AT, Böing EA, Lovelace B, Wan GJ, Miller TE. Comparative analysis of length of stay, hospitalization costs, opioid use, and discharge status among spine surgery patients with postoperative pain management including intravenous versus oral acetaminophen. Curr Med Res Op. 2017;33(5):943-8. DOI: https://doi.org/10.1080/03007995.2017.1297702
Mörwald EE, Poeran J, Zubizarreta N, Cozowicz C, Mazumdar M, Memtsoudis SG. Intravenous acetaminophen does not reduce inpatient opioid prescription or opioid-related adverse events among patients undergoing spine surgery. Anesthesia Analgesia. 2018;127(5):1221-8. DOI: https://doi.org/10.1213/ANE.0000000000003344
Thepsoparn M, Sereeyotin J, Pannangpetch P. Effects of combined lower thoracic epidural/general anesthesia on pain control in patients undergoing elective lumbar spine surgery: a randomized controlled trial. Spine. 2019;4:67-9.
Chin KJ, Lewis S. Opioid-free analgesia for posterior spinal fusion surgery using erector spinae plane (ESP) blocks in a multimodal anesthetic regimen. Spine. 2019;44(6):379-83. DOI: https://doi.org/10.1097/BRS.0000000000002855
Melvin JP, Schrot RJ, Chu GM, Chin KJ. Low thoracic erector spinae plane block for perioperative analgesia in lumbosacral spine surgery: a case series. Canadian J Anesthesia. 2018;65(9):1057-65. DOI: https://doi.org/10.1007/s12630-018-1145-8
Reynolds RA, Legakis JE, Tweedie J, Chung Y, Ren EJ, BeVier PA, Thomas RL, Thomas ST. Postoperative pain management after spinal fusion surgery: an analysis of the efficacy of continuous infusion of local anesthetics. Global Spine J. 2013;3(1):7-13. DOI: https://doi.org/10.1055/s-0033-1337119
Ulutas M, Secer M, Taskapilioglu O, Karadas S, Akyilmaz AA, Baydilek Y, et al. General versus epidural anesthesia for lumbar microdiscectomy. J Clin Neurosc. 2015;22(8):1309-13. DOI: https://doi.org/10.1016/j.jocn.2015.02.018
Ezhevskaya AA, Mlyavykh SG, Anderson DG. Effects of continuous epidural anesthesia and postoperative epidural analgesia on pain management and stress response in patients undergoing major spinal surgery. Spine. 2013;38(15):1324-30. DOI: https://doi.org/10.1097/BRS.0b013e318290ff26
Schmidt PC, Ruchelli G, Mackey SC, Carroll IR. Perioperative gabapentinoids: choice of agent, dose, timing, and effects on chronic postsurgical pain. Anesthesiol. 2013;119(5):1215-21. DOI: https://doi.org/10.1097/ALN.0b013e3182a9a896
Kim JC, Choi YS, Kim KN, Shim JK, Lee JY, Kwak YL. Effective dose of peri-operative oral pregabalin as an adjunct to multimodal analgesic regimen in lumbar spinal fusion surgery. Spine (Phila Pa 1976). 2018;5:78-9.
Pandey CK, Navkar DV, Giri PJ, Raza M, Behari S, Singh RB, et al. Evaluation of the optimal preemptive dose of gabapentin for postoperative pain relief after lumbar diskectomy: a randomized, double-blind, placebo-controlled study. J Neur Anesthesiol. 2005;17(2):65-8. DOI: https://doi.org/10.1097/01.ana.0000151407.62650.51
Ho KY, Gan TJ, Habib AS. Gabapentin and postoperative pain–a systematic review of randomized controlled trials. Pain. 2006;126(1-3):91-101. DOI: https://doi.org/10.1016/j.pain.2006.06.018
Terracina S, Robba C, Prete A, Sergi PG, Bilotta F. Prevention and treatment of postoperative pain after lumbar spine procedures: a systematic review. Pain Practice. 2018;18(7):925-45. DOI: https://doi.org/10.1111/papr.12684
Francisco AA, De Oliveira SM, Steen M, Nobre MR, De Souza EV. Ice pack induced perineal analgesia after spontaneous vaginal birth: Randomized controlled trial. Women Birth. 2018;31(5):334-40. DOI: https://doi.org/10.1016/j.wombi.2017.12.011
MacLachlan C, Shipton EA, Wells JE. Perioperative pain correlates and prolonged postoperative pain predictors: demographic and psychometric questionnaires. Pain Therapy. 2015;4:119-33. DOI: https://doi.org/10.1007/s40122-015-0037-7
Mathiesen O, Dahl B, Thomsen BA, Kitter B, Sonne N, Dahl JB, et al. A comprehensive multimodal pain treatment reduces opioid consumption after multilevel spine surgery. Europ Spine J. 2013;22:2089-96. DOI: https://doi.org/10.1007/s00586-013-2826-1
Grasu RM, Cata JP, Dang AQ, Tatsui CE, Rhines LD, Hagan KB, et al. Implementation of an enhanced recovery after spine surgery program at a large cancer center: a preliminary analysis. J Neurosurg Spine. 2018;29(5):588-98. DOI: https://doi.org/10.3171/2018.4.SPINE171317
Singh K, Bohl DD, Ahn J, Massel DH, Mayo BC, Narain AS, et al. Multimodal analgesia versus intravenous patient-controlled analgesia for minimally invasive transforaminal lumbar interbody fusion procedures. Spine. 2017;42(15):1145-50. DOI: https://doi.org/10.1097/BRS.0000000000001992
Jain N, Phillips FM, Weaver T, Khan SN. Preoperative chronic opioid therapy: a risk factor for complications, readmission, continued opioid use and increased costs after one-and two-level posterior lumbar fusion. Spine. 2018;43(19):1331-8. DOI: https://doi.org/10.1097/BRS.0000000000002609
Jain N, Brock JL, Phillips FM, Weaver T, Khan SN. Chronic preoperative opioid use is a risk factor for increased complications, resource use, and costs after cervical fusion. Spine J. 2018;18(11):1989-98. DOI: https://doi.org/10.1016/j.spinee.2018.03.015
Buvanendran A, Thillainathan V. Preoperative and postoperative anesthetic and analgesic techniques for minimally invasive surgery of the spine. Spine. 2010;35(26):274-80. DOI: https://doi.org/10.1097/BRS.0b013e31820240f8
Downloads
Published
How to Cite
Issue
Section
