Multimodal analgesia techniques Part 1

Professor Narinder Rawal, MD, PhD, FRCA (Hon)
Department of Clinical Medicine
Division of Anaesthesiology and Intensive Care
University Hospital
Örebro, Sweden
Multicomponent techniques to improve
postoperative outcome
• Multimodal analgesia
• Enhanced Recovery (ER), Fast-track protocols for a variety
of surgical procedures (in particular colorectal surgery)
• Local Infiltration Anesthesia (LIA)
Rationale for analgesic combinations
 To improve efficacy and reduce toxicity
 Combining analgesics that act at different locations along the pain pathway
 centrally acting (opioid) with peripherally acting (NSAID’s)
 centrally acting with centrally acting but different mode of
action, e.g. opioid and clonidine (2-agonist)
 three types of combination: tramadol (central opioid and monoaminergic
effects) and peripheral (paracetamol or NSAID)
 To increase duration and widen the spectrum of efficacy:
 l.a. + epinephrine
 opioids + NMDA-receptor antagonists (ketamine, dextromethorphan
to  efficacy,  tolerance, prevent central sensitization and hyperalgesia)
 To improve compliance (specially elderly patients)
 Reduce risk of abuse (e.g. combining opioid with antagonist)
Multimodal analgesia – The evidence – I
• 26 articles (21 articles rejected)
• 5 articles (3 meta-analyses, 2 systematic reviews)
• 1st meta-analysis 22 RCTs, 2nd 7 RCTs, 3rd 57 RCTs
• 1st systematic review 22 RCTs, 2nd 9 RCTs
• Comparison between addition of paracetamol or NSAIDs
or coxibs versus placebo to i.v. PCA morphine
• Evaluation of
a) efficacy of analgesia
b) reduction of opioid-related adverse effects
Rathmell JP et al.
Reg Anesth Pain Med 2006;31:1-42
Multimodal analgesia – The evidence – II
• NSAID-based multimodal analgesia improves pain control –
only for multidose, non-specific NSAIDs and coxibs (level A)
• Paracetamol and single dose NSAID (level E)
• NSAID-based multimodal analgesia reduces opioid-related
adverse effects (level E*)
• Evidence for other forms of multimodal analgesia – limited
* Reduced relative risk of some opioid-related AE (PONV, sedation) but not others (pruritus, urinary retention,
resp. dep.) but only with non-selective NSAID
Rathmell JP et al.
Reg Anesth Pain Med 2006;31:1-42
J Clin Anesth 2001;13:524-39
No mention of possible risks of combining
multiple drugs and modalities
• 11 RCT`s, n= 887
• Ketamine + iv opioid PCA vs iv PCA alone
• Improvement= 6 RCT`s, no improvement= 5 RCT`s
• 18 diff. surgical procedures, heterogeniety of studies, small sample size,
5 diff. dosages
• Improvement- thoracic surgery, unclear- orthopedic, abdominal surgery
• Opioid-related side effects decreased in 7 RCT´s, no difference in 4 RCT´s
• Ketmine side effects
- psychotomimetic side effects in 2 RCT´s
- cognitive impairment 1 RCT
- overall increase in AE (dysphoria, nausea, pruritus) 1 RCT
Anesthesiology 2012;116:248-73
Multimodal techniques for pain management
The following drugs should be considered:
• COX-2 selective NSAID´s(Coxibs)
• Nonselective NSAID´s
• Acetaminophen (paracetamol)
• Calcium channel antagonists (gabapentin/pregabalin)
• Unless contraindicated,all patients should receive an around-the-clock regimen of
NSAID´, Coxibs or acetaminophen
• Regional blockade with local anesthetics-part of multimodal analgesia
• Individualize the choice of medication, dose, route,and duration of therapy
LIA technique (knee, hip replacement)
 Intraoperative infiltration of surgical area
ropivacaine 0.2 % 150 mL (300 mg)
ketolorac 30 mg
adrenaline 0.5 mg
 Intraarticular catheter (withdrawn morning after surgery)
 Pressure bandage + icepack for 4-6 h (to prolong analgesia)
 Anaesthesia: spinal with high GA
 Surgical technique: conventional
 Early mobilization within 3-5 h

50 % discharged day after surgery (almost all others on day 2)
 Pain management: paracetamol, NSAID’s, weak opioids
 Antithrombotic treatment: only aspirin!
• RCT, TKA, n=102, surgery under spinal anaesthesia
• EDA group: bupi 0.1% + fentanyl + epinephrine for 48h vs
• LIA group: ropi 150mg + epinephrine 0.5mg (150ml), intraarticular catheter (lateral side,
epidural 18G)
- LIA group: intraarticular ketolorac 30mg + morphine 5mg
- LIAiv group: intravenous ketorolac 30mg + morphine 5mg
• LIA group: injections repeated at 22-24h, rescue PCA, oxycodone after PCA stopped
• LIA with intraarticular ketorolac and morphine (vs EDA) associated with:
- lower pain scores at rest from 24h after surgery until discharge
- lower cumulated morphine consumption (80mg vs 101mg)
- superior knee function
- faster mobilization
- earlier discharge (3.5 vs 5.5 days)
”LIA with local adjuvants compared with epidural analgesia results in reduced opioid
consumption, faster mobilization, and earlier readiness for hospital discharge. Ketolorac and
morphine are more efficient when given locally than systemically”.
CWI vs other regional techniques
1. CWI vs Neuraxial techniques
- vs epidural c.section
- vs epidural THA
- vs epidural TKA
- vs epidural TKA
- vs i.t morphine TKA
- vs i.t morphine THA
- vs epidural prostatectomy
- vs epidural for c.section
- vs epidural open colorectal
-vs epidural open colorectal
equally effective
Ranta PO Int J Obstet Anesth 2006
CWI better, ↓LOS
Andersen KV Acta Orthop 2007
CWI better
Andersen KV Acta Orthop 2010
CWI better, ↓LOS
Spreng KJ
Br J Anaesth 2010
CWI better
Essving P
Anesth Analg 2011
CWI better Rikalanen-Salmi R Acta Anaesth Scand 2012
epidural better
Fant F
Br J Anaesth 2011
CWI better, ↓LOS
O´Neill P
Anesth Analg 2012
CWI better, ↓LOS
Bertoglio S
Anesth Analg 2012
EDA better, ↓LOS
Jouve P
Anesthesiology 2013
2. CWI vs Femoral nerve block for TKA
-
CWI better (not blinded)
Femoral better
Equally effective
Equally effective (analgesia,rehab, satisfaction)
Toftdahl K
Acta Orthop 2007
Carli F
Br J Anaesth 2010
Affas F
Acta Orthop 2011
Ng F Y
J Arthroplasty 2012
3. CWI vs paravertebral block
- radical mastectomy
CWI better
Sidiropoulou T Anesth Analg 2008
4. CWI vs interscalene block for arthroscopic shoulder surgery
- 4/6 studies- interscalene better (in 1 study analgesia lasted 6h)
LIA – unanswered questions
• Which drugs or drug combinations are essential ?
• Is intraarticular catheter necessary? for THA?
TKA?
• Is there a local NSAID effect ?
• Is LIA more effective for TKA vs THA?
• Role of surgical and infiltration technique, ice
packs, pressure bandage etc?
Recommended interventions for ERAS – open colorectal surgery
• Preoperative counselling
• Epidural analgesia
• Preoperative feeding
• Short transverse incision
• Synbiotics
• No routine use of drains
• No bowel preparation
• Enforced postoperative mobilization
• No premedication
• Enforced postoperative oral feeding
• Fluid restriction
• No systemic morphine (opioid) use
• Perioperative high oxygen concentrations
• Standard laxatives
• Active prevention of hypothermia
• Early removal of bladder catheter
•
•
•
•
6 RCTs, n= 452
Number of ERAS elements 4-12 (12, 4, 12, 8, 10, 9)
Number of recommended evidence-based elements = 17
Epidural technique used in 5/6 studies
“The results from the present meta-analysis suggest that the
implementation of four or more elements of the ERAS pathway
leads to a reduction in length of hospital stay by more than
2 days and an almost 50% reduction in complication rates in
patients undergoing major open colonic/colorectal surgery”
Problems with ER programs for colorectal
surgery
• 17 components recommended but hardly any 2 protocols
similar
• Several metaanalyses, no clear answers to following
questions:
- How many components essential ?
- “4 or more components adequate”- which 4?
- Are all components equally beneficial ?
- Is epidural technique necessary?
Fast-track surgery versus conventional recovery
strategies for colorectal surgery
“ The (low) quality of the trials and lack of sufficient
other outcome parameters do not justify
implementation of fast-track surgery as a standard of
care”
Spanjerberg WR et al
Cochrane Database Syst Rev 2011;2;CD 007635
Evidence-based methods* to reduce
postoperative ileus
1. Thoracic epidural analgesia- reduces postoperative ileus by 24-37 h
• Liu SS,Wu CL Anesth Analg 2007;104:689-702
• Marret E et al Br J Surg 2007;94:665-73
2. Intravenous lidocaine
• Sun Y et al
• Vigneault L et al
Dis Colon Rectum 2012;2012;55:1183-94
Can J Anesth 2011;58:22-37
• Mccarthy GC et al Drugs 2010;18:1149-63
• Marret E et al
Br J Surg 2008;95: 1331-8
3. Chewing gum therapy
• Fitzgerald JEF, et al World J Surg 2009;33:2557-2566
• De Castro SM et al Dig Surg 2008;25:39-45
• Chan MK et al
Dis Colon Rect 2007;50:2149-57
4. Systemic prokinetic drugs ( Alvimopan- peripheral mu receptor antagonist)
• *Traut U et al Cochrane Database of Systematic Reviews 2008 issue 1
*Metaanalysis or systematic reviews
Epidural technique for postoperative pain – the
evidence (PROSPECT www.postoppain.org)
Surgical procedure
PROSPECT recommendation
• Thoracotomy
Yes (or paravertebral -grade A)
• Breast surgery
No
• Lap. cholecystectomy
No
• Lap. colon resection
No (yes for open resection)
• Abdominal hysterectomy
No
• Hip replacement
No
• Knee replacement
No
• Abdominal prostatectomy
No
Audits are performed annually and the results presented at meetings of
different surgery sections (picture: department of general surgery)

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