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How I Mix My Multimodal Cocktail
A dash of NSAIDs, a splash of IV acetaminophen, and a shot of regional or local anesthesia will send your patients home free of pain.
Paul White
Publish Date: March 31, 2015   |  Tags:   Anesthesia
reduce patient pain TREAT 'EM AND STREET 'EM Are you doing all you can to send patients home quickly with reduced pain?

As the outpatient surgery population grows, the interest in developing a pain management plan that's safe and effective and accelerates recovery has become a top priority for many. So, what's the plan? There's no gold standard, but the best pain management techniques involve a multimodal or "balanced" approach.

If your providers are still relying on opioid analgesics to treat and prevent post-operative pain because they believe it's the best solution, think again. Opioids come with many unwanted side effects that affect virtually every organ system in the body — producing hypoventilation, hypotension, sedation, nausea and vomiting, pruritis, urinary retention and ileus, as well as acute opioid tolerance. Opioid-related complications are harmful, especially in at-risk populations like the elderly. When coupled with the rapid pace of outpatient surgery, use of classic opioids like morphine and meperidine can be a serious detriment to an efficient and pleasant recovery.

Since pain involves multiple mechanisms in the brain, spinal cord and peripheral nervous system, it's better to attack surgical-related pain by combining non-opioid analgesics that have additive or synergistic effects. Every doctor has his own favored combination, but the basic idea is similar — reduce pain as much as possible using non-opioid analgesic medications, in particular regional and local anesthesia, with opioids serving primarily as "rescue" medication.

Multimodal plans vary by provider, as each has his own "cocktail," but I've found the best multimodal plans for a quick recovery typically include the use of regional and/or local anesthesia, non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen. Here's a rundown of some of the best options.

Regional and local anesthesia
Often in ambulatory surgery, general anesthesia, not the actual procedure itself, can be the biggest factor in when a patient returns home. Instead, consider the use of local tissue infiltration with local anesthetics in combination with regional anesthesia involving a peripheral nerve block, if appropriate.

combining nerve blocks with NSAIDs A BALANCED APPROACH Combining nerve blocks with NSAIDs and IV acetaminophen can give you a superior pain management plan.

Infiltration of local anesthetic around the surgical incision site should be a component of all of your multimodal pain management plans. There are virtually no side effects and it's a very simple option that effectively reduces incisional pain. Additionally, local infiltration anesthesia alone works well for many superficial procedures, such as knee and shoulder arthroscopies, and breast and hernia surgery.

The benefits are many, especially in terms of its ability to reduce opioid analgesic consumption and limit adverse postoperative side effects, speeding up your patient's recovery. While a simple lidocaine and/or bupivacaine infiltration is highly effective for many procedures, the inclusion of a parenteral NSAID (ketorolac 15 to 30 mg IV, for example) and glucocorticosteroid (dexamethasone 4 to 8 mg IV, for example) can further reduce post-operative pain and tissue inflammation.

Many anesthesia providers also include peripheral nerve blocks as a part of their multimodal plan. Use of ultrasound-guided nerve blocks appears to have improved the effectiveness of nerve block procedures, in particular for more complex surgical procedures. For example, for painful knee replacement procedures, combining a femoral and obturator block has been clinically shown to be effective in reducing overall post-operative pain.

Continuous peripheral nerve blocks have played an increasingly important role in facilitating recovery after painful outpatient orthopedic procedures. While they come with their challenges — they can be difficult to maintain in place when patients ambulate and reimbursement issues can tax your facility resources — they may be worth the trouble. Recent studies have shown that the use of a continuous infusion of a local anesthetic is effective at reducing pain and opioid analgesic requirements, and aids in an earlier discharge for patients undergoing upper or lower extremity procedures.

The effectiveness of continuous nerve blocks can depend on your catheter system, although this is often left up to physician preference and facility budgets. While disposable, non-electronic infusion pain pumps are simple to operate and require less troubleshooting, their accuracy can change over time and may be affected by ambient temperature. There are also downsides to electronic pumps, since they can be cumbersome to operate and can have a short battery life.

NSAIDs and acetaminophen
In addition to regional and/or local anesthesia, you'll also want to consider some other components: namely, acetaminophen and NSAIDs. Acetaminophen is used to treat mild-to-moderate pain, but usually works best when combined with other analgesics. Acetaminophen can be used pre- and/or postoperatively, and comes in various forms including oral, rectal and IV. Recent studies suggest that IV acetaminophen may provide a more rapid and effective analgesic effect compared to standard oral doses.

The combination of acetaminophen and NSAIDs has been shown to offer superior analgesia compared to either one alone. NSAIDs reduce tissue swelling and muscle soreness and are often used alone to treat mild postoperative pain. However, clinical studies have shown that they're effective at treating moderate-to-severe pain when used in combination with other, more potent, non-opioid analgesics. Prescribing NSAIDs (and COX-2 inhibitors) for 3 to 4 days after ambulatory surgery — in combination with acetaminophen — can improve the recovery process and outcomes for your patients.

—\ MULTIMODAL METHODS IV acetaminophen is one option to consider adding to your multimodal pain management plan.

One of the biggest concerns with NSAIDs is the possibility of gastrointestinal and renal complications. However, research has shown that those complications tend to be a result of long-term administration of higher doses, typically for more than 5 days. There's also concern that the use of non-selective NSAIDs can cause increased operative site bleeding, but studies have found that that typically only applies to surgical procedures involving "raw" surface areas like tonsillectomies and plastic surgery. To avoid this complication, have your staff give the first dose of the NSAID after the surgeon has achieved hemostasis or in PACU.

A selective category of NSAIDs, called COX-2 inhibitors, targets only the COX-2 enzyme that stimulates the inflammatory response in the body. You may want to consider this class of NSAIDs for certain at-risk patients, since it causes fewer stomach problems and has a lower risk of perioperative bleeding.

The dwindling use of opioids
Ideally, your plan should include opioids only as "rescue" medications. That means the use of an oral opioid in combination with an NSAID and/or acetaminophen for patients with mild-to-moderate pain, or a small dose of IV fentanyl or hydromorphine for more severe pain before discharge home. With more non-opioid analgesics hitting the market, even more therapeutic options will soon be available to improve recovery for your surgery patients. Given the clearly demonstrated benefits, there's no reason not to shift to a multimodal approach for pain management.

3 Additional Considerations for Your Multimodal Plan

For patients who have chronic pain and are being treated with opioid-containing analgesic medications, consider adding one or more of the following non-opioid analgesics to your multimodal approach:

  • Gabapentin/pregabalin. These gabapentanoid drugs are typically used to treat neuropathic pain. However, they can also reduce pain caused by damage to the nerves during surgery. For those suffering from chronic pain, consider having patients take a dose prior to surgery and again postoperatively, as studies have shown patients who take a dose before and after surgery suffer from less post-op pain. However, note that these do increase postoperative sedation in the elderly population.
  • Steroids. Steroids are also an effective option for patients with chronic pain or for those at an increased risk for PONV. Of the available glucocorticoid steroids, both dexamethasone and betamethasone have been found to provide synergistic effects in combination with other non-opioid analgesics. Some studies have shown that the opioid-sparing effects of these steroids can last up to 72 hours and can lead to shorter recovery times.
  • Ketamine. For those patients undergoing ambulatory surgery who are receiving long-term opioid analgesic therapy for chronic pain conditions, the addition of a small dose of ketamine perioperatively has been shown to improve pain control. The NMDA receptor antagonist works to block pain signals and doesn't depress breathing as much as other anesthetic and opioid analgesic medications.

— Paul F. White, PhD, MD, FANZCA