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Korean J Anesthesiol > Volume 71(5); 2018 > Article
Schwenk and Mariano: Designing the ideal perioperative pain management plan starts with multimodal analgesia

Abstract

Multimodal analgesia is defined as the use of more than one pharmacological class of analgesic medication targeting different receptors along the pain pathway with the goal of improving analgesia while reducing individual class-related side effects. Evidence today supports the routine use of multimodal analgesia in the perioperative period to eliminate the over-reliance on opioids for pain control and to reduce opioid-related adverse events. A multimodal analgesic protocol should be surgery-specific, functioning more like a checklist than a recipe, with options to tailor to the individual patient. Elements of this protocol may include opioids, non-opioid systemic analgesics like acetaminophen, non-steroidal anti-inflammatory drugs, gabapentinoids, ketamine, and local anesthetics administered by infiltration, regional block, or the intravenous route. While implementation of multimodal analgesic protocols perioperatively is recommended as an intervention to decrease the prevalence of long-term opioid use following surgery, the concurrent crisis of drug shortages presents an additional challenge. Anesthesiologists and acute pain medicine specialists will need to advocate locally and nationally to ensure a steady supply of analgesic medications and in-class alternatives for their patients’ perioperative pain management.

Introduction

Worldwide, today’s healthcare environment stresses the provision of high-quality care while reducing costs. In the United States (US), federal payments to healthcare providers have been tied to various activities: participation in improvement projects, quality metrics, and resource utilization through pay-for-performance programs such as the Merit-Based Incentive Payment System (MIPS) developed by the Center for Medicare and Medicaid Services (CMS) [1]. This growing trend is taking place in other industrialized countries that face the dilemma of rapidly rising healthcare costs [2] and is, in part, responsible for recent innovations in hospital-based care. In the perioperative setting, implementation of standardized multimodal analgesia (MMA) represents one such innovation.
MMA can be defined as the use of more than one pharmacological class of analgesic medication targeting different receptors along the pain pathway with the goal of improving analgesia while reducing individual class-related side effects [3]. The concept of MMA is not new, but the current need for MMA and minimizing opioid use is clearly evident in light of the opioid epidemic as well as ubiquitous drug shortages facing the US and other countries. MMA is recommended for postoperative pain in many clinical situations and is the key focus of a joint clinical practice guideline from the American Pain Society, American Society of Regional Anesthesia and Pain Medicine (ASRA), and the American Society of Anesthesiologists [4]. Designing an ideal perioperative pain management strategy should always start with MMA, and this article will review the evidence for this recommendation including support for individual components and the role of MMA in addressing the opioid epidemic. In this review, we will examine MMA both in the broader context of perioperative care as well as in its specific application in patients undergoing total knee arthroplasty (TKA), a procedure that has been the focus of substantial attention as some projections predict 3.48 million primary and 268,200 revision TKA procedures will be performed annually by 2030 [5].

Elements of Multimodal Analgesia

Perioperative pain consists of multiple pain subtypes and as such cannot be effectively treated with a single medication. Surgical pain may be nociceptive, neuropathic, mixed, psychogenic, or idiopathic [6], depending on the surgery. Kehlet and Dahl [7] recognized the value of balanced analgesia or MMA over two decades ago when they published one of the earliest papers advocating the use of multiple agents rather than a single agent in treating postoperative pain. A good MMA protocol is a checklist rather than a recipe; it will standardize the categories of analgesics while still allowing for some flexibility in the individual components based on patient comorbidities, allergies, medications, and previous surgical experiences. For example, although gabapentinoids have been shown to be opioid sparing when part of a multimodal protocol [8], they can cause sedation [9], particularly in the elderly, and a protocol that includes gabapentinoids may have limitations on the maximum patient age for the drugs or a dose adjustment. A patient with a sulfa allergy may present for elective TKA which precludes celecoxib; rather than eliminating all cyclooxygenase (COX) inhibitors, an alternative, such as ibuprofen or naproxen, can be given. Anticipating common allergies and side effects in certain populations will help maintain adherence to multimodal protocols.

Non-opioid systemic analgesics

Non-opioid analgesics are the cornerstone on which to build a successful perioperative MMA regimen (Table 1). In addition to the absence of opioid side effects, many of these agents are highly effective in reducing postoperative pain and allowing for faster mobilization and meeting milestones. The first medication, acetaminophen, is one that has been in clinical use for decades with a proven track record of safety when used in appropriate doses. Many current multimodal protocols include acetaminophen [8,10,11], and its opioid-sparing effects and absence of contraindications outside of severe liver disease make it appealing. Though not adequate alone for painful procedures such as TKA, it is definitely a useful and inexpensive component of the protocol. Current evidence does not support the use of intravenous (IV) acetaminophen over oral (PO) acetaminophen universally [12], but for specific indications (e.g., long procedures or patients not able to take PO medications) the IV formulation is a good option.
Non-steroidal anti-inflammatory drugs (NSAIDs) represent another class of medication that is highly effective for perioperative pain management and should be considered for MMA protocols. NSAIDs exert their effects through inhibition of COX and prostaglandin synthesis [8]. Despite concerns about the increased risk of postoperative bleeding with NSAIDs, a meta-analysis has revealed that ketorolac does not increase the risk of perioperative bleeding [13]. In a systematic review, the combination of ibuprofen 400 mg and paracetamol (i.e., acetaminophen) 1000 mg had a number needed to treat of only 1.5 to achieve 50% postoperative pain relief or greater [14]. Caution should be exercised in patients with renal disease and gastrointestinal ulcers [8]. In addition, all NSAIDs increase the risk of cardiovascular events, including myocardial infarction [15]. In patients in whom gastrointestinal ulcers are of particular concern, a COX-2 selective inhibitor may be substituted for a non-selective agent to decrease this risk [16].
Another class of analgesics commonly used in MMA protocols is the gabapentinoids, which include gabapentin and pregabalin. As anti-convulsants they exert their clinical effects via interaction with voltage-gated calcium channels [17]. Meta-analyses have demonstrated that gabapentin [18] and pregabalin [19] improve postoperative pain when part of a MMA regimen but are associated with sedation. In particular, elderly patients are vulnerable to this side effect, and consideration should be given to lowering the dose or avoiding them altogether. For patients who may have symptoms that suggest neuropathic pain, such as pain with a burning quality, these agents may be particularly useful.
Other agents to consider in MMA protocols include N-methyl-D-aspartate (NMDA) antagonists, with focus on ketamine and magnesium in particular. Ketamine has a clear opioid-sparing effect in the perioperative period [20] and may even reduce long-term opioid consumption in opioid-tolerant patients [21] as well as persistent postsurgical pain when used intravenously [22]. It is increasingly being featured in MMA protocols as an opioid alternative [23]. Although reviews have not consistently shown an increased incidence of side effects compared to controls [20,24], ketamine has the potential to cause psychomimetic effects and this should be factored into treatment decisions. Its benefits are maximized during painful surgery, including TKA, and opioid-tolerant patients may particularly benefit. ASRA has recently published guidelines for the use of ketamine in acute pain management [25].
Magnesium has produced mixed results as a postoperative analgesic when used alone [26,27] but has demonstrated synergism when combined with morphine or ketamine [26]. It is thought to exert its effects via spinal NMDA receptors and appears to be more effective when used intrathecally rather than intravenously [26]. Nevertheless, it is an inexpensive addition to a multimodal regimen that may be considered especially if there are contraindications or allergies that limit the use of other non-opioid agents.

Local Anesthetics

Regional anesthesia and analgesia techniques

Any discussion of MMA and opioid-sparing techniques must include regional anesthesia, which is the use of local anesthetics to anesthetize discreet areas of the body. Regional anesthesia provides superior pain control compared to traditional opioid-based strategies in many types of surgery, including TKA [28], shoulder surgery [29], foot and ankle surgery [30], and colorectal surgery [31] and can decrease nausea and vomiting as well as the time spent in the post-anesthesia care unit [32]. Regional anesthesia includes both neuraxial (spinal and epidural) anesthesia and peripheral nerve blocks. For surgical procedures amenable to regional anesthesia, such as upper or lower extremity surgery, incorporating blocks can be a highly effective method of minimizing opioids and providing excellent analgesia. Nerve blocks do carry a risk of complications, including nerve injury, bleeding, infection, and rebound pain, and these should be weighed against the potential benefits. Nerve block duration can be prolonged by either placing a continuous nerve block (i.e., perineural catheter) [33] or adding adjuvants to the perineural mixture. Although not approved for this indication in the US, perineural dexamethasone has been shown to extend the duration of brachial plexus block by 6–8 h [34] and sciatic nerve block by 13 h [35]. Dexmedetomidine can prolong blocks as well, with a mechanism likely similar to clonidine, although bradycardia may be an issue [36].
Continuous peripheral nerve blocks offer an alternative to adjuvants to extend the effects of nerve blocks if trained staff are available and a system is in place to care for the patients who receive them. For TKA, one study concluded that single-injection adductor canal block (ACB) is non-inferior to continuous ACB regarding pain and opioid consumption in 48 h [37]. This is encouraging for those practices that do not have resources in place for continuous nerve block follow-up. Another recent study has concluded that a continuous femoral nerve block may not decrease pain or opioid consumption compared to single-injection femoral nerve block after TKA [38]. That being said, continuous peripheral nerve blocks tend to result in less nausea, fewer opioids, and greater satisfaction with pain management overall than alternative techniques [39]; they also allow for individual titration of effect, prolongation of analgesia when needed, and patient-controlled analgesia. Although the addition of perineural adjuvants like dexamethasone may raise concern for neurotoxicity based on animal studies [40], this has not been consistently borne out in human studies [41]. Therefore, the choice of adjuvant or catheter-based technique should be specific to the practice and may be made based on the training of personnel, experience, and logistics.

Local infiltration analgesia

Some surgeons may prefer the injection of local anesthetics directly into the vicinity of the wound for certain surgeries rather than regional anesthesia for various reasons, including concerns over motor weakness, the need to check nerve function postoperatively, or system-related issues. Wound infiltration techniques have been shown to provide some analgesia for laparoscopic cholecystectomy [42] and cesarean section [43], but the magnitude of analgesia and opioid sparing appears to be small and short-lived. Nevertheless, if peripheral or neuraxial blocks are not an option, wound infiltration may provide some benefit especially when included as part of an overall perioperative MMA strategy.
For TKA, local anesthetics and other medications may be injected directly around the joint to improve pain control with or without the addition of peripheral nerve blocks although the combination of the two may be advantageous [44,45]. Periarticular infiltration analgesia may be comparable to femoral nerve block for the first 48 h after TKA, although femoral nerve block reduces opioid consumption to a greater degree [46]. Periarticular multimodal ‘cocktails’ typically consist of a dilute local anesthetic in addition to medications such as NSAIDs, epinephrine, and opioids [47,48]. While local anesthetic infiltration is commonly performed by surgeons [49], a newer ultrasound-guided technique known as the IPACK (infiltration between the popliteal artery and the capsule of the knee) facilitates performance by the anesthesiologist [50].

Intravenous local anesthetics

Intravenous local anesthetics, specifically lidocaine, may have a role in MMA protocols as well as Enhanced Recovery after Surgery (ERAS) protocols. Limited evidence suggests that lidocaine infusions reduce pain and opioid consumption as well as expedite return of bowel function after abdominal surgery [51] and analgesia during the first 48 h after spine surgery [52]. A meta-analysis in breast surgery found that acute postoperative pain was not improved with lidocaine infusions, but the risk of developing persistent postsurgical pain was reduced [53]. However, inclusion of a small number of studies limits this review. Lidocaine attenuates a number of pro-inflammatory molecules [54], and this is one proposed mechanism for its perioperative analgesic effects. As a generic drug, it is not expensive and should be considered as a component of ERAS protocols for abdominal surgery if epidural analgesia is contraindicated or not desired [55].

Opioid analgesics

Opioids have long been the standard perioperative analgesics of choice, a trend largely based on their simplicity, predictability, and familiarity. However, in light of the current opioid epidemic and greater awareness of opioid-related adverse events, attention has shifted from opioids to non-opioid analgesics as the foundation for perioperative pain management. The concept of reserving opioids for moderate or severe pain after alternatives have failed is not new and in fact was a cornerstone of the World Health Organization’s analgesic ladder that was first proposed in 1986 then recently updated with renewed emphasis on non-opioids as first-line for non-cancer pain [56]. As recent data reveal, MMA protocols for total joint arthroplasty (TJA) continue to include opioids as a component [57], and they are unlikely to be eliminated completely from the perioperative experience. However, the ever-expanding array of non-opioid agents has deepened the clinical armamentarium and given perioperative physicians the ability to minimize opioid exposure. Commonly used oral perioperative opioids include hydrocodone, oxycodone, and tramadol. Hydrocodone exists in several combination formulations and oxycodone is produced both in combination with acetaminophen and alone. Although commonly viewed as less likely to be abused because of its lower μ-opioid receptor affinity, tramadol has been highlighted in a 2017 report by the Centers for Disease Control and Prevention (CDC) for its association with long-term opioid use as well as a recent spike in emergency room visits [58]. Therefore, substituting tramadol for other opioids after surgery is likely not a significant improvement in safety or addiction potential.

Multimodal Analgesia, the Opioid Epidemic, and the Crisis of Drug Shortages

Evidence is accumulating that the risk of long-term opioid use after surgery increases with the length of initial prescription. Sun et al. [59] have reported that the risk of chronic opioid use in opioid-naïve patients after surgery is increased compared to that of non-surgical patients. In 8 of the 12 surgery types studied, including TKA, patients have an increased risk of filling either 10 or more prescriptions or more than 120 days’ worth, excluding the first 90 days. Brummett et al. [60] have also studied opioid-naïve patients who underwent a variety of surgeries, excluding orthopedic surgery, and similarly report an elevated risk among all surgical patients for long-term opioid use (defined as a prescription filled between 90 and 180 days). Interestingly, their reported rates of chronic use do not vary between minor and major surgical procedures. At the same time, the CDC has warned that the risk of long-term opioid use spikes at both 5 and 30 days in the initial prescription window [58]. Given the risk of long-term use that surgery itself introduces combined with the risk associated with prescriptions beyond a few days, efforts to reduce unnecessary opioid prescribing are warranted and already underway. Certainly, much of the focus is on opioid prescribing patterns, which we will not discuss here, but the implementation of MMA into routine perioperative care whenever possible is a step in the right direction.
Hebl et al. [11] have demonstrated that a TKA MMA protocol featuring a peripheral nerve block can produce meaningful benefits including decreases in length of stay and decreased opioid consumption. A large database study in patients who underwent TJA reports that, with each non-opioid agent added to a perioperative multimodal regimen, patients show a stepwise decrease in opioid consumption, opioid prescriptions, and length of stay [57]. Similar patterns have been noted outside of TJA as well. In a study of minor aesthetic plastic surgery procedures, switching from an opioid-based strategy to a non-opioid one does not compromise analgesia but does reduce nausea and vomiting and recovery time [61].
The concept of opioid-free surgery has been introduced and trialed at select institutions, although overall adoption has been slow and inconsistent [62]. Some proposed indications for opioid-free surgery include obesity, obstructive sleep apnea, chronic obstructive pulmonary disease, complex regional pain syndrome, cancer, and opioid tolerance [63]. Although conceptually it is logical that opioid-free surgery would reduce opioid-related complications and improve the perioperative patient experience, few outcome data have been published. When incorporated into an ERAS protocol, opioid-free surgery does not significantly reduce opioid prescribing patterns at discharge, even when pain scores and opioid use are low prior to discharge [64]. Clearly, there is still work to be done in determining the effect of opioid-free surgery on important outcomes and then accomplishing that goal in clinical practice. Any efforts to this end will rely heavily on MMA.
An additional challenge in managing perioperative pain today is that of ongoing drug shortages. Virtually every hospital and practice in the US has experienced this to some degree in recent years, and it can significantly alter a patient’s treatment. The causes of drug shortages are multifactorial and include quality and regulatory issues, company decisions to change strategy or discontinue manufacturing of a drug, or a shortage of raw materials [65]. Because three pharmaceutical companies manufacture 70% of the injectable medications used in the US and some perioperative medications are almost exclusively made by one company [65], shortages can have major, far-reaching effects on MMA strategies. Creating protocols that have some flexibility, such as substituting gabapentin for pregabalin or using alternative NSAIDs if one is not available, will prevent entire classes of drugs from being omitted in the perioperative period. This may not always be possible for agents with unique mechanisms of action, but for others it gives prescribing clinicians some options.
Anesthesiologists must also be creative at times when preferred drugs are not available and may need to turn to older drugs that are no longer commonly used. In one example from Canada, the local anesthetic chloroprocaine, a short-acting agent suitable for shorter procedures that was developed decades ago, was not readily available because of a lack of regulatory approval; anesthesiologists turned to prilocaine, an alternative intermediate-acting local anesthetic [66]. Although a lack of clinical studies comparing prilocaine to the more commonly used ropivacaine initially impeded its use, eventually studies were performed that justified the production and use of the older drug prilocaine [66]. This example may be particularly relevant for other generic drugs that are produced by one or a limited number of companies. Reliance on a single agent in any drug class used in perioperative pain management is no longer acceptable now that drug shortages are so common, and additional clinical studies of alternative drugs are needed to support their use. All anesthesiologists must develop a strong working relationship with their pharmacy colleagues in every practice location to develop a solid plan in terms of medication supply and alternatives in this era of frequent drug shortages so patients can continue to receive consistently high quality pain management in the perioperative period. Longer term solutions will require the involvement of professional societies and engagement of legislators.

Conclusions

In summary, evidence today supports the routine use of multimodal analgesia in the perioperative period to eliminate the over-reliance on opioids for pain control and to reduce opioid-related adverse events. A multimodal analgesic protocol should be surgery-specific, functioning more like a checklist than a recipe, with options to tailor to the individual patient. Elements of this protocol may include opioids, non-opioid systemic analgesics like acetaminophen, NSAIDs, gabapentinoids, ketamine, and local anesthetics administered by infiltration, regional block, or the intravenous route. While implementation of multimodal analgesic protocols perioperatively is recommended as an intervention to decrease the prevalence of longterm opioid use following surgery, the concurrent crisis of drug shortages presents an additional challenge. Anesthesiologists and acute pain medicine specialists will need to advocate locally and nationally to ensure a steady supply of analgesic medications and in-class alternatives for their patients’ perioperative pain management.

Conflicts of Interest

Dr. Schwenk has received consulting fees from Avenue Therapeutics (New York, NY, USA). This company had no input into any aspect of the present project or manuscript. Dr. Mariano does not have any conflicts of interest to declare.

Table 1.
Commonly Used Perioperative Systemic Non-opioid Multimodal Analgesics in Adults
Drug Route (s) Preoperative dose Intraoperative dose Postoperative dose
Acetaminophen IV/PO 1000 mg (> 50 kg) 1000 mg 1000 mg q6h
Celecoxib PO 400 mg N/A 200 mg q12h
Gabapentin PO 300–1200 mg N/A 300–800 mg q8h
Ketamine IV N/A 0.25–0.5 mg/kg bolus 0.25 mg/kg/h infusion
Ibuprofen IV/PO 600–800 mg N/A 600 g q6h
Pregabalin PO 75–150 mg N/A 75 mg q12h

IV: intravenous, N/A: not applicable, PO: by mouth.

References

1. Carter Clement R, Bhat SB, Clement ME, Krieg JC. Medicare reimbursement and orthopedic surgery: past, present, and future. Curr Rev Musculoskelet Med 2017; 10: 224–32.
crossref pmid pmc pdf
2. Wilson KJ. Pay-for-performance in health care: what can we learn from international experience? Qual Manag Health Care 2013; 22: 2–15.
crossref pmid
3. Goldberg SF, Pozek JJ, Schwenk ES, Baratta JL, Beausang DH, Wong AK. Practical management of a regional anesthesia-driven acute pain service. Adv Anesth 2017; 35: 191–211.
crossref pmid
4. Chou R, Gordon DB, de Leon-Casasola OA, Rosenberg JM, Bickler S, Brennan T, et al. Management of postoperative pain: a clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain 2016; 17: 131–57.
crossref pmid
5. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007; 89: 780–5.
pmid
6. Welchek CM, Mastrangelo L, Sinatra RS, Martinez R. Qualitative and quantitative assessment of pain. Acute Pain Management. Edited by Sinatra RS, de Leon-Cassasola OA, Ginsberg B, Viscusi ER: New York, Cambridge University Press. 2009, pp 147–71.

7. Kehlet H, Dahl JB. The value of “multimodal” or “balanced analgesia” in postoperative pain treatment. Anesth Analg 1993; 77: 1048–56.
crossref pmid
8. Wick EC, Grant MC, Wu CL. Postoperative multimodal analgesia pain management with nonopioid analgesics and techniques: a review. JAMA Surg 2017; 152: 691–7.
crossref pmid
9. Doleman B, Heinink TP, Read DJ, Faleiro RJ, Lund JN, Williams JP. A systematic review and meta-regression analysis of prophylactic gabapentin for postoperative pain. Anaesthesia 2015; 70: 1186–204.
crossref pmid
10. Elia N, Lysakowski C, Tramèr MR. Does multimodal analgesia with acetaminophen, nonsteroidal antiinflammatory drugs, or selective cyclooxygenase-2 inhibitors and patient-controlled analgesia morphine offer advantages over morphine alone? Meta-analyses of randomized trials. Anesthesiology 2005; 103: 1296–304.
crossref pmid
11. Hebl JR, Dilger JA, Byer DE, Kopp SL, Stevens SR, Pagnano MW, et al. A pre-emptive multimodal pathway featuring peripheral nerve block improves perioperative outcomes after major orthopedic surgery. Reg Anesth Pain Med 2008; 33: 510–7.
crossref pmid
12. Jibril F, Sharaby S, Mohamed A, Wilby KJ. Intravenous versus oral acetaminophen for pain: systematic review of current evidence to support clinical decision-making. Can J Hosp Pharm 2015; 68: 238–47.
crossref pmid pmc
13. Gobble RM, Hoang HL, Kachniarz B, Orgill DP. Ketorolac does not increase perioperative bleeding: a meta-analysis of randomized controlled trials. Plast Reconstr Surg 2014; 133: 741–55.
crossref pmid
14. Derry CJ, Derry S, Moore RA. Single dose oral ibuprofen plus paracetamol (acetaminophen) for acute postoperative pain. Cochrane Database Syst Rev 2013; (6): CD010210.
crossref
15. Fosslien E. Cardiovascular complications of non-steroidal anti-inflammatory drugs. Ann Clin Lab Sci 2005; 35: 347–85.
pmid
16. Rostom A, Muir K, Dubé C, Jolicoeur E, Boucher M, Joyce J, et al. Gastrointestinal safety of cyclooxygenase-2 inhibitors: a Cochrane Collaboration systematic review. Clin Gastroenterol Hepatol 2007; 5: 818–28.
crossref pmid
17. Tiippana EM, Hamunen K, Kontinen VK, Kalso E. Do surgical patients benefit from perioperative gabapentin/pregabalin? A systematic review of efficacy and safety. Anesth Analg 2007; 104: 1545–56.
crossref pmid
18. Hurley RW, Cohen SP, Williams KA, Rowlingson AJ, Wu CL. The analgesic effects of perioperative gabapentin on postoperative pain: a meta-analysis. Reg Anesth Pain Med 2006; 31: 237–47.
crossref pmid
19. Dong J, Li W, Wang Y. The effect of pregabalin on acute postoperative pain in patients undergoing total knee arthroplasty: a meta-analysis. Int J Surg 2016; 34: 148–60.
crossref pmid
20. Laskowski K, Stirling A, McKay WP, Lim HJ. A systematic review of intravenous ketamine for postoperative analgesia. Can J Anaesth 2011; 58: 911–23.
crossref pmid
21. Loftus RW, Yeager MP, Clark JA, Brown JR, Abdu WA, Sengupta DK, et al. Intraoperative ketamine reduces perioperative opiate consumption in opiate-dependent patients with chronic back pain undergoing back surgery. Anesthesiology 2010; 113: 639–46.
crossref pmid
22. McNicol ED, Schumann R, Haroutounian S. A systematic review and meta-analysis of ketamine for the prevention of persistent postsurgical pain. Acta Anaesthesiol Scand 2014; 58: 1199–213.
crossref pmid
23. Mitra S, Carlyle D, Kodumudi G, Kodumudi V, Vadivelu N. New advances in acute postoperative pain management. Curr Pain Headache Rep 2018; 22: 35.
crossref pmid pdf
24. Bell RF, Dahl JB, Moore RA, Kalso E. Peri-operative ketamine for acute post-operative pain: a quantitative and qualitative systematic review (Cochrane review). Acta Anaesthesiol Scand 2005; 49: 1405–28.
crossref pmid
25. Schwenk ES, Viscusi ER, Buvanendran A, Hurley RW, Wasan AD, Narouze S, et al. Consensus guidelines on the use of intravenous ketamine infusions for acute pain management from the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists. Reg Anesth Pain Med 2018; 43: 456–66.
crossref pmid pmc
26. Helander EM, Menard BL, Harmon CM, Homra BK, Allain AV, Bordelon GJ, et al. Multimodal analgesia, current concepts, and acute pain considerations. Curr Pain Headache Rep 2017; 21: 3.
crossref pmid pdf
27. Murphy JD, Paskaradevan J, Eisler LL, Ouanes JP, Tomas VA, Freck EA, et al. Analgesic efficacy of continuous intravenous magnesium infusion as an adjuvant to morphine for postoperative analgesia: a systematic review and meta-analysis. Middle East J Anaesthesiol 2013; 22: 11–20.
pmid
28. Paul JE, Arya A, Hurlburt L, Cheng J, Thabane L, Tidy A, et al. Femoral nerve block improves analgesia outcomes after total knee arthroplasty: a meta-analysis of randomized controlled trials. Anesthesiology 2010; 113: 1144–62.
crossref pmid
29. Warrender WJ, Syed UAM, Hammoud S, Emper W, Ciccotti MG, Abboud JA, et al. Pain management after outpatient shoulder arthroscopy: a systematicreview of randomized controlled trials. Am J Sports Med 2017; 45: 1676–86.
crossref pmid
30. Elkassabany N, Cai LF, Mehta S, Ahn J, Pieczynski L, Polomano RC, et al. Does regional anesthesia improve the quality of postoperative pain management and the quality of recovery in patients undergoing operative repair of tibia and ankle fractures? J Orthop Trauma 2015; 29: 404–9.
crossref pmid
31. Helander EM, Webb MP, Bias M, Whang EE, Kaye AD, Urman RD. Use of regional anesthesia techniques: analysis of institutional enhanced recovery after surgery protocols for colorectal surgery. J Laparoendosc Adv Surg Tech A 2017; 27: 898–902.
crossref pmid
32. Liu SS, Strodtbeck WM, Richman JM, Wu CL. A comparison of regional versus general anesthesia for ambulatory anesthesia: a metaanalysis of randomized controlled trials. Anesth Analg 2005; 101: 1634–42.
crossref pmid
33. Bugada D, Ghisi D, Mariano ER. Continuous regional anesthesia: a review of perioperative outcome benefits. Minerva Anestesiol 2017; 83: 1089–100.
pmid
34. Kirkham KR, Jacot-Guillarmod A, Albrecht E. Optimal dose of perineural dexamethasone to prolong analgesia afterbrachial plexus blockade: a systematic review and meta-analysis. Anesth Analg 2018; 126: 270–9.
crossref pmid
35. Rahangdale R, Kendall MC, McCarthy RJ, Tureanu L, Doty R Jr, Weingart A, et al. The effects of perineural versus intravenous dexamethasone on sciatic nerve blockade outcomes: a randomized, double-blind, placebo-controlled study. Anesth Analg 2014; 118: 1113–9.
crossref pmid
36. El-Boghdadly K, Brull R, Sehmbi H, Abdallah FW. Perineural dexmedetomidine is more effective than clonidine when added to local anesthetic for supraclavicular brachial plexus block: a systematic review and meta-analysis. Anesth Analg 2017; 124: 2008–20.
crossref pmid
37. Lee S, Rooban N, Vaghadia H, Sawka AN, Tang R. Inferiority trial of adductor canal block for analgesia after total knee arthroplasty: single injection versuscatheter technique. J Arthroplasty 2018; 33: 1045–51.
crossref pmid
38. Dixit V, Fathima S, Walsh SM, Seviciu A, Schwendt I, Spittler KH, et al. Effectiveness of continuous versus single injection femoral nerve block for total knee arthroplasty: a double blinded, randomized trial. Knee 2018; 25: 623–30.
crossref pmid
39. Bingham AE, Fu R, Horn JL, Abrahams MS. Continuous peripheral nerve block compared with single-injection peripheral nerve block: a systematic review and meta-analysis of randomized controlled trials. Reg Anesth Pain Med 2012; 37: 583–94.
crossref pmid
40. Knight JB, Schott NJ, Kentor ML, Williams BA. Neurotoxicity of common peripheral nerve block adjuvants. Curr Opin Anaesthesiol 2015; 28: 598–604.
crossref pmid pmc
41. De Oliveira GS Jr, Castro Alves LJ, Nader A, Kendall MC, Rahangdale R, McCarthy RJ. Perineural dexamethasone to improve postoperative analgesia with peripheral nerve blocks: a meta-analysis of randomized controlled trials. Pain Res Treat 2014; 2014: 179029.
crossref pmid pmc pdf
42. Loizides S, Gurusamy KS, Nagendran M, Rossi M, Guerrini GP, Davidson BR. Wound infiltration with local anaesthetic agents for laparoscopic cholecystectomy. Cochrane Database Syst Rev 2014; (3): CD007049.
crossref
43. Adesope O, Ituk U, Habib AS. Local anaesthetic wound infiltration for postcaesarean section analgesia: A systematic review and metaanalysis. Eur J Anaesthesiol 2016; 33: 731–42.
crossref pmid
44. Kampitak W, Tanavalee A, Ngarmukos S, Amarase C, Apihansakorn R, Vorapalux P. Does adductor canal block have a synergistic effect with localinfiltration analgesia for enhancing ambulation and improvinganalgesia after total knee arthroplasty? Knee Surg Relat Res 2018; 30: 133–41.
crossref pmid pmc pdf
45. Perlas A, Kirkham KR, Billing R, Tse C, Brull R, Gandhi R, et al. The impact of analgesic modality on early ambulation following total knee arthroplasty. Reg Anesth Pain Med 2013; 38: 334–9.
crossref pmid
46. Dong P, Tang X, Cheng R, Wang J. Comparison of the efficacy of different analgesia treatments for total knee arthroplasty: a network metaanalysis. Clin J Pain 2018 Advance Access published on Jun 2, 2018, doi: 10.1097/AJP.0000000000000631.
crossref
47. Tammachote N, Kanitnate S, Manuwong S, Panichkul P. Periarticular multimodal drug injection is better than single anesthetic drug in controlling pain after total knee arthroplasty. Eur J Orthop Surg Traumatol 2018; 28: 667–75.
crossref pmid pdf
48. Kim TW, Park SJ, Lim SH, Seong SC, Lee S, Lee MC. Which analgesic mixture is appropriate for periarticular injection after total knee arthroplasty? Prospective, randomized, double-blind study. Knee Surg Sports Traumatol Arthrosc 2015; 23: 838–45.
crossref pmid
49. Tripuraneni KR, Woolson ST, Giori NJ. Local infiltration analgesia in TKA patients reduces length of stay and postoperative pain scores. Orthopedics 2011; 34: 173.
crossref pmid
50. Thobhani S, Scalercio L, Elliott CE, Nossaman BD, Thomas LC, Yuratich D, et al. Novel regional techniques for total knee arthroplasty promotereduced hospital length of stay: an analysis of 106 patients. Ochsner J 2017; 17: 233–8.
pmid pmc
51. Weibel S, Jokinen J, Pace NL, Schnabel A, Hollmann MW, Hahnenkamp K, et al. Efficacy and safety of intravenous lidocaine for postoperative analgesia and recovery after surgery: a systematic review with trial sequential analysis. Br J Anaesth 2016; 116: 770–83.
crossref pmid pdf
52. Farag E, Ghobrial M, Sessler DI, Dalton JE, Liu J, Lee JH, et al. Effect of perioperative intravenous lidocaine administration on pain, opioid consumption, and quality of life after complex spine surgery. Anesthesiology 2013; 119: 932–40.
crossref pmid
53. Chang YC, Liu CL, Liu TP, Yang PS, Chen MJ, Cheng SP. Effect of perioperative intravenous lidocaine infusion on acute and chronic pain after breast surgery: a meta-analysis of randomizedcontrolled trials. Pain Pract 2017; 17: 336–43.
crossref pmid
54. Herroeder S, Pecher S, Schönherr ME, Kaulitz G, Hahnenkamp K, Friess H, et al. Systemic lidocaine shortens length of hospital stay after colorectal surgery: a double-blinded, randomized, placebo-controlled trial. Ann Surg 2007; 246: 192–200.
crossref pmid pmc
55. Naik BI, Tsang S, Knisely A, Yerra S, Durieux ME. Retrospective case-control non-inferiority analysis of intravenous lidocaine in a colorectal surgery enhanced recovery program. BMC Anesthesiol 2017; 17: 16.
crossref pmid pmc pdf
56. Vargas-Schaffer G, Cogan J. Patient therapeutic education: placing the patient at the centre of the WHO analgesic ladder. Can Fam Physician 2014; 60: 235–41.
pmid pmc
57. Memtsoudis SG, Poeran J, Zubizarreta N, Cozowicz C, Mörwald EE, Mariano ER, et al. Association of multimodal pain management strategies with perioperative outcomes and resource utilization: a population-based study. Anesthesiology 2018; 128: 891–902.
crossref pmid
58. Shah A, Hayes CJ, Martin BC. Characteristics of initial prescription episodes and likelihood of long-term opioid use - United States, 2006-2015. MMWR Morb Mortal Wkly Rep 2017; 66: 265–9.
crossref pmid pmc
59. Sun EC, Darnall BD, Baker LC, Mackey S. Incidence of and risk factors for chronic opioid use among opioid-naive patients in the postoperative period. JAMA Intern Med 2016; 176: 1286–93.
crossref pmid
60. Brummett CM, Waljee JF, Goesling J, Moser S, Lin P, Englesbe MJ, et al. New persistent opioid use after minor and major surgical procedures in us adults. JAMA Surg 2017; 152: e170504.
crossref pmid
61. Nguyen TC, Lombana NF, Zavlin D, Moliver CL. Transition to nonopioid analgesia does not impair pain control after major aesthetic plastic surgery. Aesthet Surg J 2018; 38: 1139–44.
crossref pmid pdf
62. Urman RD, Böing EA, Khangulov V, Fain R, Nathanson BH, Wan GJ, et al. Analysis of predictors of opioid-free analgesia for management of acute post-surgical pain in the United States. Curr Med Res Opin 2018. Advance Access published on Jun 26, 2018, doi: 10.1080/03007995.2018.1481376.
crossref
63. Sultana A, Torres D, Schumann R. Special indications for Opioid Free Anaesthesia and Analgesia, patient and procedure related: including obesity, sleep apnoea, chronic obstructive pulmonary disease, complex regional pain syndromes, opioid addiction and cancer surgery. Best Pract Res Clin Anaesthesiol 2017; 31: 547–60.
crossref pmid
64. Brandal D, Keller MS, Lee C, Grogan T, Fujimoto Y, Gricourt Y, et al. Impact of enhanced recovery after surgery and opioid-free anesthesia on opioid prescriptions at discharge from the hospital: a historical-prospective study. Anesth Analg 2017; 125: 1784–92.
crossref pmid
65. Golembiewski J. Drug shortages in the perioperative setting: causes, impact, and strategies. J Perianesth Nurs 2012; 27: 286–92.
crossref pmid
66. Szerb JJ. Reviving older drugs to deal with anesthesia drug shortages. Can J Anaesth 2015; 62: 1042–4.
crossref pmid


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