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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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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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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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