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An increasing number of complex operations are being performed on an outpatient basis for which the use of conventional opioid-based IV patient-controlled analgesia (IVPCA) and central neuraxial (spinal and epidural) analgesia are not practical techniques for pain management. For that and other reasons, effective treatment of acute postsurgical pain presents unique challenges for practitioners.1 This expansion of outpatient surgery requires a perioperative analgesic regimen that is highly effective, has minimal side effects, is intrinsically safe, and can be easily managed away from the hospital or surgical center.2

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Clinical Pearl
  • Adequacy of postoperative pain control is one of the most important factors in determining when a patient can be safely discharged from a surgical facility and has a major influence on the patient's ability to resume the normal activities of daily living.
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Adequacy of postoperative pain control is one of the most important factors in determining when a patient can be safely discharged from a surgical facility and has a major influence on the patient's ability to resume the normal activities of daily living.3 Perioperative analgesia has traditionally been provided by opioid analgesics. However, extensive use of opioids is associated with a variety of perioperative side effects [eg, ventilatory depression, drowsiness and sedation, postoperative nausea and vomiting (PONV), pruritus, urinary retention, ileus, constipation] that can delay hospital discharge.4 Intraoperative use of large bolus doses or continuous infusions of potent opioid analgesics may actually increase postoperative pain as a result of their rapid elimination or the development of acute tolerance.5 In addition, it has been suggested by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) that excessive use of postoperative opioid analgesics leads to decreased patient satisfaction. Partial opioid agonists (eg, tramadol) are also associated with increased side effects (eg, nausea, vomiting, ileus) and patient dissatisfaction compared with those reported for both opioid6 and nonopioid7,8 analgesics.

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  • Multimodal, or “balanced,” analgesic techniques involving the use of smaller doses of opioids in combination with nonopioid analgesic drugs [eg, local anesthetics, ketamine, acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDs)] are becoming increasingly popular approaches to preventing pain after surgery.
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Therefore, in order to minimize the adverse effects of analgesic medications, anesthesiologists and surgeons are increasingly turning to nonopioid analgesic techniques as adjuvants for managing pain during the perioperative period. Multimodal, or “balanced,” analgesic techniques involving the use of smaller doses of opioids in combination with nonopioid analgesic drugs [eg, local anesthetics, ketamine, acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDs)] are becoming increasingly popular approaches to preventing pain after surgery (Table 77–1).9–11 This review will discuss recent evidence supporting the use of nonopioid analgesic drugs and techniques for facilitating the recovery process during the perioperative period.

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Table 77-1. Commonly Used Nonopioid Drugs and Nonpharmacologic Techniques for Minimizing Pain after Ambulatory Surgerya 

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