Role of Multimodal Analgesia in the Evolving Enhanced Recovery after Surgery Pathways
Abstract
:1. Introduction
2. Postoperative Pain Management (PPM)
3. Epidural Analgesia (EDA)
4. Multimodal Analgesia
5. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) and Paracetamol (Acetaminophen)
6. Conclusions
Author Contributions
Conflicts of Interest
References
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Type of Surgery | Preoperative Analgesia | Intraoperative Analgesia | Postoperative Analgesia |
---|---|---|---|
Open colorectal cancer surgery Bertoglio et al., 2012 [25] | None | Fentanyl 2–5 mcg/kg/h | Ropivacaine 0.2% 10 mL/h through preperitoneal catheter (above the peritoneum within the musculofascial layer) Ketolorac 30 mg × 3 IV Acetaminophen 1 g × 4 PO |
Open gynaecology/oncology surgery Kalogera et al., 2013 [26] | Celecoxib 400 mg × 1 PO Acetaminophen 1 g × 1 PO Gabapentin 600 mg × 1 PO | Opioids IV at discretion of anesthesiologist supplemented with ketamine, ketorolac, or both. After incision closure: injection of bupivacaine at incision site | Oxycodone 5–10 mg as required PO, max 6 doses/day Acetaminophen 1 g × 4 PO Ketorolac 15 mg × 4 IV on Day 1, then Ibuprofen 800 mg × 4 PO Hydromorphone for rescue analgesia |
Primary total knee arthroplasty McDonald et al., 2011 [27] | 2 h before surgery: Temazepam 10–20 mg × 1 Dexamethasone 10 mg × 1 Gabapentin 300 mg × 1 Acetaminophen 1 g × 1 | Spinal anesthesia with 2.75–3.2 mL 0.5% Bupivacaine. 200 mL intra-articular 0.2% Ropivacaine (at the end of surgery). | Gabapentin 300 mg × 2 Acetaminophen 1 g × 4 Ibuprofen 400 mg × 3 Oxycodone 5–10 mg 2–4 hourly as required Three bolus doses of 40 mL Ropivacaine (0.2%), each via intra-articular catheter at 4 h post-surgery, 2300 h, and 0800 h the following morning. Intra-articular catheter then removed. |
Hip hemiarthoplasty for fractured neck of femur Talboys et al., 2015 [28] | Preoperatively, patients are prescribed a dose of acetaminophen of 1 gram (g) PO and tramadol M/R 50–100 mg × 2. A fascia iliaca compartment block (FICB) comprising of 30 mL of levobupivacaine 0.25% is given in the emergency department. | A single shot of spinal bupivacaine (2.5–3.0 mL); no intrathecal opiates are used.IV dexamethasone 8 mg and diclofenac 75 mg. Perioperatively, the surgeon infiltrates the joint with 150–200 mL of ropivicaine 0.2%. A periarticular catheter is then set up to deliver an infusion of the LA: an initial 20 mL bolus followed by an infusion rate of 8 mL/h (with 5 mL bolus every 20 min). | Gabapentin 300 mg twice daily for 5 days Acetaminophen 1 g × 4 Ibuprofen 400 mg × 3 for 1 week When required, tramadol M/R 50–100 mg × 2 Severe breakthrough pain is managed with Oramorph liquid 5–10 mg every 2 hours. |
Open abdominal aortic surgery Renghi et al., 2013 [29] | Proparacetamol 2 g × 1 Fentanyl 100 mcg × 1 | Fascia of the parietal peritoneum was infiltrated subcutaneously with 20 mL of levobupivacaine (0.5%) | At the end of surgery, subfascial and subcutaneous placement of a double-multiperforated catheter was performed, and an infusion of levobupivacaine, 0.25% at 4 mL/h, was started. Ibuprofen 600 mg × 3 PO Ketorolac 30 mg IV for rescue analgesia |
Laparoscopic colorectal surgery Hubner et al., 2015 [20] | None | Fentanyl at discretion of anesthesiologist | Morphine PCA Paracetamol 1 g × 4 PO Metamizole 500 mg × 4 PO |
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Gelman, D.; Gelmanas, A.; Urbanaitė, D.; Tamošiūnas, R.; Sadauskas, S.; Bilskienė, D.; Naudžiūnas, A.; Širvinskas, E.; Benetis, R.; Macas, A. Role of Multimodal Analgesia in the Evolving Enhanced Recovery after Surgery Pathways. Medicina 2018, 54, 20. https://doi.org/10.3390/medicina54020020
Gelman D, Gelmanas A, Urbanaitė D, Tamošiūnas R, Sadauskas S, Bilskienė D, Naudžiūnas A, Širvinskas E, Benetis R, Macas A. Role of Multimodal Analgesia in the Evolving Enhanced Recovery after Surgery Pathways. Medicina. 2018; 54(2):20. https://doi.org/10.3390/medicina54020020
Chicago/Turabian StyleGelman, David, Arūnas Gelmanas, Dalia Urbanaitė, Ramūnas Tamošiūnas, Saulius Sadauskas, Diana Bilskienė, Albinas Naudžiūnas, Edmundas Širvinskas, Rimantas Benetis, and Andrius Macas. 2018. "Role of Multimodal Analgesia in the Evolving Enhanced Recovery after Surgery Pathways" Medicina 54, no. 2: 20. https://doi.org/10.3390/medicina54020020