The conventional analgesics may be supplemented with adjuvant drugs that have different

mechanisms of action. Postoperative pain management is often limited by side effects such as

nausea and vomiting. These agents can act synergistically to improve analgesia and reduce the

dose of conventional analgesic required.

Clonidine

A 2 adrenergic agonist (oral, IV, epidural, or spinal — typically 1–3mcg/kg) is sometimes given

preoperatively and has a number of useful actions including an opioid-like analgesia without

some of the characteristic opioid-ergic side effects.

• Sedation and anxiolysis.

• Anaesthetic-sparing and opioid-sparing effect.

• Decreases arterial blood pressure and heart rate.

• Does not produce respiratory depression, itching, or urinary retention.

• Prevents postoperative shivering.

• Decreases nausea and vomiting.

• Lasting postoperative analgesic effect.

• Does prolong postoperative ileus.

Dexamethasone

A glucocorticoid which has been used extensively to reduce swelling following surgery and has

been found to be analgesic for some procedures.

• Some types of postoperative pain are reduced, e.g. tonsillectomy.

• There is strong evidence for a reduction in postoperative nausea and vomiting (PONV).

• Reduced convalescence time.

• Attenuates infl ammatory responses (C-reactive protein, interleukin-6).

• Opioid-sparing effect has been demonstrated.

• Although prolonged use of steroids is associated with morbidity, the available evidence

suggests that a single dose is relatively safe.

Ketamine (IV, IM, or SC)

Ketamine is a NMDA antagonist with a useful pharmacodynamic profile as an anaesthetic or

analgesic agent. The NMDA receptor is involved in sensitization of pain circuits and therefore

the antagonist is rationally employed as an analgesic adjuvant. Ketamine in subanaesthetic doses

is effective in reducing morphine requirements in the fi rst 24h after surgery and also reduces

PONV. Adverse effects are typically mild but can manifest as psychomimetic symptoms. The

role of ketamine for postoperative analgesia can be useful for challenging cases (particularly by

low-dose infusion) but its routine use is still debatable.

Gabapentin/pregabalin

These antiepileptic medications were initially only indicated for the treatment of pain with a

neuropathic component. However, recent studies in the perioperative setting have demonstrated a

consistent opioid-sparing effect with some reduction in side effects. There is also hope that there

may be a corresponding reduction in chronic pain that accompanies their perioperative use but

this has not yet been substantiated.