Multimodal analgesia techniques for ambulatory surgery

Multimodal analgesia techniques, including regional analgesia, acetaminophen, nonspecific NSAIDs or COX-2-specific inhibitors, and opioids, have become standard practice. Oral nonopioid analgesics (eg, acetaminophen and nonspecific NSAIDs or COX-2-specific inhibitors) should be administered as "round-the-clock" scheduled dosing, assuming there are no contraindications. Opioids should be used sparingly and only as "rescue" analgesics because opioid-related side effects can delay postoperative recovery. Although preemptive or preventative analgesia remains controversial, it is crucial that the timing of the analgesic administration is such that the therapeutic effects occur before emergence from anesthesia. Because of significant variations in the degree of postoperative pain, analgesic technique should be individualized. Similarly, the choice of analgesic modality should be specific to the surgical procedure. The number and type of analgesic combinations could be determined based on the possibility of the patient in developing significant postoperative pain and the extensiveness of the surgical procedure. The choice of analgesic combinations should not only depend on their analgesic efficacy, but also on the overall side effect profile of these combinations. However, there are insufficient data on the optimal multimodal regimen for a particular patient undergoing a particular surgical procedure. Given the inherent adverse effects of opioid as well as nonopioid analgesics, nonpharmacologic interventions should become a standard component of multimodal analgesia. Future analgesic techniques may include analgesics adjuncts such as specific NMDA receptor antagonists, anti-convulsants (eg, gabapentin and pregabalin), and nicotinic cholinergic receptors agonists. Nicotinic receptors have been demonstrated to modulate inflammatory pain, and treatment with a single dose of nicotine nasal spray immediately before emergence from anesthesia has been shown to significantly reduce pain scores and opioid requirements without increasing side effects such as tachycardia and hypertension. In addition, noninvasive drug delivery methods (eg, iontophoresis) have potential advantages in an outpatient setting and thus may be increasingly used in the future. Finally, there is a need for development of a protocol-based approach to reliable, comprehensive, individualized analgesic plans for specific surgical procedures, which can be useful for standardizing pain management and reducing variation in practice. 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 both anesthesiologists and surgeons join together to manage postoperative care as a continuum from the preoperative period through the convalescence period.