Multimodal Analgesia for Perioperative Pain Management

Abstract

Postoperative pain is an important problem which is a common condition in patients and can become chronic if left untreated. Ineffective pain management in the postoperative period may increase stress response and may cause vital changes on endocrine, respiratory, cardiovascular, gastrointestinal, and musculoskeletal systems and patient psychology. Side effects from the use of high-dose medication for pain management also increases complications. Multimodal analgesia applications aim to reduce the side effects that may occur with the use of high doses of a single agent by creating additive or synergistic effects by using analgesics with different mechanisms of action together. Therefore, protocols have been developed that aim to minimize complications, eliminate pain, accelerate recovery, encourage early ambulation and thus reduce the length of hospital stay. These include the Enhanced Recovery After Surgery protocols, which include multimodal analgesia and procedure-specific protocols. The aim of this review is to highlight the most optimal patient and procedure-specific perioperative pain management strategies in the light of available evidence.

Keywords

• Postoperative pain
• multimodal analgesia
• ERAS
• procedure-specific postoperative pain management

Perioperatif Ağrı Yönetiminde Multimodal Analjezi

Abstract

Postoperatif ağrı, hastalarda yaygın olarak görülen ve tedavi edilmediği takdirde kronikleşebilen önemli bir sorundur. Postoperatif dönemdeki etkisiz ağrı kontrolü, stres cevabı artırıp endokrin, solunum, kardiyovasküler, gastrointestinal, kas iskelet sistemleri bozukluklarına ve hasta psikolojisi üzerinde önemli değişikliklere yol açmaktadır. Ağrı kontrolünde yüksek doz ilaç kullanımından kaynaklanan yan etkiler de komplikasyonları artırmaktadır. Multimodal analjezi uygulamaları farklı etki mekanizmalarına sahip analjeziklerin birlikte kullanımıyla additif veya sinerjistik etki oluşturarak, tek ajanın yüksek doz kullanımıyla oluşabilecek yan etkileri azaltmayı amaçlar. Bu bağlamda komplikasyonlarını en aza indirmeyi, ağrıyı ortadan kaldırmayı, iyileşmeyi hızlandırmayı, erken ambulasyona teşvik etmeyi ve böylece hastanede kalış süresini azaltmayı amaçlayan protokoller geliştirilmiştir. Multimodal analjezi uygulamalarını içeren Cerrahi Sonrası Hızlandırılmış İyileşme protokolleri ve prosedür spesifik protokoller bunlardan bazılarıdır. Bu derlemenin amacı mevcut kanıtlar ışığında hasta ve prosedür spesifik olarak en optimal perioperatif ağrı yönetimi stratejilerini vurgulamaktır.

Keywords

• Postoperatif ağrı
• multimodal analjezi
• ERAS
• prosedür spesifik postoperatif ağrı yönetim

References

1. 1. Schug SA, Bruce J. Risk stratification for the development of chronic postsurgical pain. Pain Rep. 2017;2:e627.
2. 2. Yang MMH, Hartley RL, Leung AA, et al. Preoperative predictors of poor acute postoperative pain control: a systematic review and meta-analysis. BMJ Open. 2019;9:e025091.
3. 3. Wu CL, Raja SN. Treatment of acute postoperative pain. Lancet. 2011;377:2215-2225.
4. 4. O’Neill A, Lirk P. Multimodal Analgesia. Anesthesiol Clin. 2022;40:455-468.
5. 5. Rømsing J, Møiniche S. A systematic review of COX-2 inhibitors compared with traditional NSAIDs, or different COX-2 inhibitors for post-operative pain. Acta Anaesthesiol Scand. 2004;48:525-546.
6. 6. Karaaslan A, Gok S, Basaran R. The preoperative use of gabapentinoids for the treatment of acute postoperative pain following lumbar spine fixation surgery, World Neurosurg. 2023:178:e57-e64.
7. 7. Tian C, Malhan RS, Deng SX, et al. Benefits of dexmedetomidine on postoperative analgesia after bariatric surgery. Minerva Anestesiol. 2022;88:173-183.
8. 8. Tavanaei R, Rezaee-Naserabad SS, Alizadeh S, et al. Analgesic Effects of Preoperative Combination of Oral Pregabalin and Intravenous Magnesium Sulfate on Postoperative Pain in Patients Undergoing Posterolateral Spinal Fusion Surgery: A 4-arm, Randomized, Double-blind, Placebo-controlled Trial. J Neurosurg Anesthesiol. 2024;36:134-141.

9. 9. Tejedor A, Bijelic L, Polanco M, et al. Intravenous lidocaine infusion compared to thoracic epidural analgesia in cytoreductive surgery with or without heated intraperitoneal chemotherapy. A retrospective case-cohort study. Eur J Surg Oncol. 2023;49:597-603.
10. 10. Mestdagh FP, Lavand’homme PM, Pirard G, et al. Pain management after elective craniotomy: A systematic review with procedure-specific postoperative pain management (PROSPECT) recommendations. Eur J Anaesthesiol. 2023;40:747-757.
11. 11. Maeßen T, Korir N, Van de Velde M, et al. Pain management after cardiac surgery via median sternotomy: A systematic review with procedurespecific postoperative pain management (PROSPECT) recommendations. Eur J Anaesthesiol. 2023;40:758-768.
12. 12. Dost B, Kaya C, Turunc E, et al. Erector spinae plane block versus its combination with superficial parasternal intercostal plane block for postoperative pain after cardiac surgery: a prospective, randomized, double-blind study. BMC Anesthesiol. 2022;22:295.
13. 13. Roofthooft E, Joshi GP, Rawal N, et al. PROSPECT guideline for elective caesarean section: Updated systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia. 2021;76:587–589.
14. 14. Boules ML, Goda AS, Abdelhady MA, et al. Comparison of Analgesic Effect Between Erector Spinae Plane Block and Transversus Abdominis Plane Block After Elective Cesarean Section: A Prospective Randomized Single-Blind Controlled Study. J Pain Res. 2020;13:1073-1080.
15. 15. Mostafa M, Nasr MA, Fawzy M, et al. The analgesic effect of transmuscular quadratus lumborum block versus erector spinae plane block for women undergoing elective Caesarean section: A randomized controlled trial. Br J Pain. 2023;17:438-446.
16. 16. Feray S, Lubach J, Joshi GP, et al. PROSPECT guidelines for videoassisted thoracoscopic surgery: A systematic review and procedurespecific postoperative pain management recommendations. Anaesthesia. 2022;77:311-325.
17. 17. Leviel F, Fourdrain A, Delatre F, et al. S erratus anterior plane block alone, paravertebral block alone and their combination in video-assisted thoracoscopic surgery: The THORACOSOPIC double-blind, randomized trial. Eur J Cardiothorac Surg. 2024;65:ezae082.
18. 18. Waelkens P, Alsabbagh E, Sauter A, et al. Pain management after complex spine surgery: A systematic review and procedure-specific postoperative pain management recommendations. Eur J Anaesthesiol. 2021;38:985-994.
19. 19. Ma K, Bebawy JF, Hemmer LB. Multimodal Analgesia and Intraoperative Neuromonitoring. J Neurosurg Anesthesiol. 2023;35:172-176.
20. 20. Jacobs A, Lemoine A, Joshi GP, et al. PROSPECT guideline for oncological breast surgery: a systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia. 2020;75:664-673.
21. 21. Hozien AI, Helmy AM, Koptan HM, et al. Analgesic Effect of Addition of Pectointercostal Block to Serratus Anterior Plane Block in Breast Surgeries: A Randomized, Controlled Trial. Pain Physician. 2023;26:E679-E685.
22. 22. Garcia V, Wallet J, Leroux-Bromberg N, et al. Incidence and characteristics of chronic postsurgical pain at 6 months after total mastectomy under pectoserratus and interpectoral plane block combined with general anesthesia: A prospective cohort study. Reg Anesth Pain Med. 2024;49:36