Multimodal postoperative pain management

The mechanisms of persistent postoperative pain, rationale for multimodal pain therapy, and limitations of currently available analgesic agents and administration routes and techniques are described.

Persistent postoperative pain can cause long-term disability. It is the result of complex neurohormonal effects that can be prevented using preemptive analgesic therapy. Multimodal pain therapy can result in additive or synergistic analgesic effects and minimize adverse drug effects. Limitations of systemic opioid analgesics given by patient-controlled analgesia include adverse effects, a short duration of action, and nocturnal hypoxemia. Limitations of local anesthetics include unwanted motor blockade, which can interfere with postoperative mobilization and rehabilitation efforts. Inadvertent administration of analgesics into subarachnoid, subdural, or vascular spaces is a potential problem with the epidural route. Use of this route may be limited by the perioperative use of prophylactic anticoagulation.

Research is needed to identify analgesic agents and administration techniques with greater efficacy and safety than those currently available.