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Management of postoperative pain has improved in the last few decades. In 2000, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) officially recognized patients’ rights in pain management and implemented standards for assessment, monitoring, and treatment of pain1; in 2004, the American Society of Anesthesiologists established the Pain Task Force and published clinical practice guidelines to promote standardization of procedures and the use of multimodal analgesia2; and in 2010, the Department of Health and Human Services and the Institute of Medicine agreed to promote the recognition of pain as a significant public health problem. Now, pain management has become a focus of the healthcare system and an important ethical responsibility of the medical profession. Opioids remain the primary analgesic agent for treating moderate and severe pain after surgery; however, opioid-related side effects may compromise quality of recovery.

Preventive analgesia is a method of attenuating the central sensitization that results from a painful insult and the inflammatory reaction that develops after the insult.3 For effective prevention of central sensitization and reduction of postoperative and chronic pain,4,5 aggressive multimodal analgesic interventions should be used during the perioperative period. Maximum benefit occurs when pain interventions are extended into the postoperative phase.6

Multimodal analgesia (Figure 70–1) involves the administration of two or more analgesic agents by one or more routes. The different agents should exert their effects via different analgesic mechanisms and ideally act synergistically at different sites in the nervous system, thereby providing superior analgesia with fewer side effects. Multimodal analgesia can include regional analgesia with local anesthetics, acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and opioids.7 The combination of several nonopioid analgesics with opioids delivered by patient-controlled analgesia (PCA) offers advantages over opioids alone.8,9 Multimodal pain-control strategies for certain procedures could become an integral part of clinical pathways to provide effective postoperative analgesia and rehabilitation.8,9

Figure 70–1.

Possible sites for intervention.

The broader concept of PCA is not restricted to intravenous opioid use. In fact, any analgesic delivered by any route (epidural, peripheral nerve catheter, subcutaneous, or transdermal) can be administered under patient control (with or without a continuous background infusion). This technique is based on delivering a preprogrammed dose of drug when the patient pushes a demand button through a microprocessor-controlled infusion pump.10


In 1963, Roe11 was the first to demonstrate that postoperative narcotics are necessary and that small intravenous (IV) doses of opioids provide more effective pain relief than do conventional intramuscular (IM) injections. In 1968, Sechzer,12 the true pioneer of PCA, evaluated the analgesic response to small IV doses of opioid administered by a nurse at the patient’s request. In 1971, the first apparatus for delivering ...

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