Chapter 156. Multimodal Postoperative Analgesia

Lisa Doan, MD

Multimodal analgesia consists of using various modalities to reduce pain, thus providing more effective analgesia while reducing doses and side effects.

Use regional techniques when possible:
- Continuous or single-injection peripheral nerve blocks (see chapter 163)
- Epidural infusions (see chapter 162)
Nonopioid analgesics (see chapter 157)
Opioid analgesics (see chapter 159):
- IV PCA (see chapter 158)
Adjuvant medications (see also Chapters 160 and 161):

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Adjuvant Medications Used for Multimodal Analgesia

Drug

Dosing

Common side effects

Comments

Gabapentin (Neurontin)

Start at 300 mg qhs, can be titrated to 2,400 mg per day divided in three doses

Dizziness, somnolence, peripheral edema

Adjust doses in patients with renal insufficiency. Doses should be tapered when discontinuing therapy

Pregabalin (Lyrica)

Start at 50 mg qhs, can be titrated to 300 mg per day divided three times daily

Confusion, dizziness, somnolence, edema, weight gain

Similar mechanism of action as gabapentin. Doses should be adjusted in patients with renal insufficiency. Doses should be tapered when discontinuing therapy

Ketamine

0.1–0.5 mg/kg/h IV

Hallucinations, vivid dreams, drowsiness

Especially useful in opioid-tolerant patients

These medications, while not FDA-approved to treat acute pain, are commonly used off-label for that purpose.

1. American Society of Anesthesiologists Task Force on Acute Pain Management. Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology. 2004 Jun;100(6):1573–1581. [PubMed: 15166580]

2. Bell RF, Dahl JB, Moore RA, Kalso EA. Perioperative ketamine for acute postoperative pain. Cochrane Database Syst Rev. 2006 Jan;1:CD004603. [PubMed: 16437490]

3. Durkin B, Page C, Glass P. Pregabalin for the treatment of postsurgical pain. Expert Opin Pharmacother. 2010 Nov;11(16);2751–2758. [PubMed: 20977407]

4. Ho KY, Gan TJ, Habib AS. Gabapentin and postoperative pain: a systematic review of randomized controlled trials. Pain. 2006 Dec;126(1–3):91–101. [PubMed: 16846695]

5. Loftus RW, Yeager MP, Clark JA, et al. Intraoperative ketamine reduces perioperative opiate consumption in opiate-dependent patients with chronic back pain undergoing back surgery. Anesthesiology. 2010 Sep;113:639–646. [PubMed: 20693876]

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Chapter 156. Multimodal Postoperative Analgesia

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