Multimodal analgesia, current concepts, and acute pain considerations

Helander, Erik M., Menard, Bethany L., Harmon, Chris M., Homra, Ben K., Allain, Alexander V., Bordelon, Gregory J., Wyche, Melville Q., Padnos, Ira W., Lavrova, Anna and Kaye, Alan D. (2017) Multimodal analgesia, current concepts, and acute pain considerations. Current Pain and Headache Reports, 21 1: 3. doi:10.1007/s11916-017-0607-y


Author Helander, Erik M.
Menard, Bethany L.
Harmon, Chris M.
Homra, Ben K.
Allain, Alexander V.
Bordelon, Gregory J.
Wyche, Melville Q.
Padnos, Ira W.
Lavrova, Anna
Kaye, Alan D.
Title Multimodal analgesia, current concepts, and acute pain considerations
Journal name Current Pain and Headache Reports   Check publisher's open access policy
ISSN 1534-3081
1531-3433
Publication date 2017-01-01
Sub-type Critical review of research, literature review, critical commentary
DOI 10.1007/s11916-017-0607-y
Open Access Status Not yet assessed
Volume 21
Issue 1
Start page 3
Total pages 10
Place of publication Philadelphia, PA, United States
Publisher Springer Healthcare
Language eng
Abstract Management of acute pain following surgery using a multimodal approach is recommended by the American Society of Anesthesiologists whenever possible. In addition to opioids, drugs with differing mechanisms of actions target pain pathways resulting in additive and/or synergistic effects. Some of these agents include alpha 2 agonists, NMDA receptor antagonists, gabapentinoids, dexamethasone, NSAIDs, acetaminophen, and duloxetine.

Alpha 2 agonists have been shown to have opioid-sparing effects, but can cause hypotension and bradycardia and must be taken into consideration when administered. Acetaminophen is commonly used in a multimodal approach, with recent evidence lacking for the use of IV over oral formulations in patients able to take medications by mouth. Studies involving gabapentinoids have been mixed with some showing benefit; however, future large randomized controlled trials are needed. Ketamine is known to have powerful analgesic effects and, when combined with magnesium and other agents, may have a synergistic effect. Dexamethasone reduces postoperative nausea and vomiting and has been demonstrated to be an effective adjunct in multimodal analgesia. The serotonin-norepinephrine reuptake inhibitor, duloxetine, is a novel agent, but studies are limited and further evidence is needed. Overall, a multimodal analgesic approach should be used when treating postoperative pain, as it can potentially reduce side effects and provide the benefit of treating pain through different cellular pathways.
Formatted abstract
Purpose of Review: Management of acute pain following surgery using a multimodal approach is recommended by the American Society of Anesthesiologists whenever possible. In addition to opioids, drugs with differing mechanisms of actions target pain pathways resulting in additive and/or synergistic effects. Some of these agents include alpha 2 agonists, NMDA receptor antagonists, gabapentinoids, dexamethasone, NSAIDs, acetaminophen, and duloxetine.

Recent Findings: Alpha 2 agonists have been shown to have opioid-sparing effects, but can cause hypotension and bradycardia and must be taken into consideration when administered. Acetaminophen is commonly used in a multimodal approach, with recent evidence lacking for the use of IV over oral formulations in patients able to take medications by mouth. Studies involving gabapentinoids have been mixed with some showing benefit; however, future large randomized controlled trials are needed. Ketamine is known to have powerful analgesic effects and, when combined with magnesium and other agents, may have a synergistic effect. Dexamethasone reduces postoperative nausea and vomiting and has been demonstrated to be an effective adjunct in multimodal analgesia. The serotonin–norepinephrine reuptake inhibitor, duloxetine, is a novel agent, but studies are limited and further evidence is needed.

Summary: Overall, a multimodal analgesic approach should be used when treating postoperative pain, as it can potentially reduce side effects and provide the benefit of treating pain through different cellular pathways.
Keyword Acetaminophen
Alpha 2 agonists
Clonidine
Dexamethasone
Dexmedetomidine
Duloxetine
Ketamine
Magnesium
Multimodal analgesia
NSAIDs
Opioids
Q-Index Code C1
Q-Index Status Provisional Code
Institutional Status UQ

Document type: Journal Article
Sub-type: Critical review of research, literature review, critical commentary
Collections: HERDC Pre-Audit
School of Medicine Publications
 
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