Multimodal analgesia techniques and postoperative rehabilitation

Although the management of postoperative pain poses some unique challenges for the practitioner, an important reason for suboptimal pain management is the inadequate or improper application of available information and analgesic therapies. Multimodal analgesia techniques, including regional analgesic techniques, acetaminophen, nonspecific NSAIDs or COX-2-specific inhibitors, and opioids, have become standard practice. The choice of analgesic combinations should depend not only on their analgesic efficacy but also on the side effect profile of these combinations. Thus, even if a certain analgesic regimen provides superior pain relief, it may not be clinically beneficial if it is also associated with more adverse events. Although it is clear that multimodal analgesia techniques improve postoperative pain relief, there are insufficient data on the optimal multimodal regimen for a particular patient undergoing a particular surgical procedure. Nevertheless, regional analgesia techniques have evolved as a critical component of a multimodal approach to achieving the goal of dynamic pain relief with improved outcomes. Other nonopioid analgesics (eg, acetaminophen and nonspecific NSAIDs or COX-2-specific inhibitors) should be used, assuming there are no contraindications, at their ceiling doses, administered on a round-the-clock schedule of dosing. Opioids should be used as "rescue" analgesics on an as-needed basis because opioid-related side effects can retard patients' postoperative recovery. In addition, nonpharmacologic interventions should become a standard component of multimodal analgesia techniques. However, there is a need for the development of an evidence-based approach to reliable, comprehensive, individualized analgesic plans for specific surgical procedures. Finally, because surgical morbidity is multifactorial, a multimodal approach to perioperative care is required to achieve a significant improvement in postoperative outcome and reduce convalescence. Therefore, it is important that a multidisciplinary approach be used to manage postoperative care as a continuum from the preoperative period through the convalescence period.