Journal Reading

DESIGNING THE IDEAL PERIOPERATIVE

PAIN MANAGEMENT PLAN STARTS WITH
MULTIMODAL ANALGESIA
(JOURNAL 2)

The revised International Association for the Study

of Pain definition of pain: concepts, challenges,
and compromises
(journal 1)
Keywords:
•Definition,
•Terminology,
•Revision,
•IASP
INTRODUCTION

 the International Association for the Study of Pain

(IASP) definition of pain has become accepted globally
by health care professionals and researchers in the pain
field, and has been adopted by several professional,
governmental, and nongovernmental organizations,
including the World Health Organization.

Pain can range widely in intensity, quality, and duration and has
diverse pathophysiologic mechanisms and meanings.
INTRODUCTION

 IASP definition acknowledges that although tissue injury

is a common antecedent to pain, pain can be present
even when tissue damage is not discernible.

 The strengths of this definition include its recognition of

the multidimensional aspects of pain, its brevity, and its
simplicity.
 PAIN
An aversive sensory and emotional experience typically
caused by, or resembling that caused by, actual or
potential tissue injury.

Notes
 (1) Pain is always a subjective experience that is
influenced to varying degrees by biological,
psychological, and social factors.
 (2) Pain and nociception are different phenomena: the
experience of pain cannot be reduced to activity in
sensory pathways.
 (3) Through their life experiences, individuals learn the
concept of pain and its applications.
 PAIN

 (4) A person’s report of an experience as pain should be accepted

as such and respected.
 (5) Although pain usually serves an adaptive role, itmay have
adverse effects on function and social and psychological well-
being.
 (6) Verbal description is only one of several behaviors to express
pain; inability to communicate does not negate the possibility
that a human or a nonhuman animal experiences pain.
REVISION
 REVISION
 (1) the definition of pain should be simple and practical
(wording is cumbersome, reading level should be modified
to facilitate translation to other languages);
 (2) the definition should better capture the personal
experience of pain (“aversive” as a descriptor of pain, impact
of pain on quality of life, and subjectivity of pain);
 (3) the definition should provide more specificity regarding
the various components of pain (pain comes in many forms
and pain is influenced by many factors); and
 (4) the definition’s reference to tissue injury should be better
aligned with modern conceptualizations of pain (tissue injury
as a cause of pain, pain as an interpretation, and pain
resembling tissue injury).
 REVISED IASP DEFINITION OF PAIN (2020).

Pain
An unpleasant sensory and emotional experience associated
with, or resembling that associated with, actual or potential
tissue damage.

Notes
 Pain is always a personal experience that is influenced to
varying degrees by biological, psychological, and social
factors.
 Pain and nociception are different phenomena. Pain cannot be
inferred solely from activity in sensory neurons.
 REVISED IASP DEFINITION OF PAIN (2020).

Notes
 through their life experiences, individuals learn the concept of pain.

 A person’s report of an experience as pain should be respected.*

 Although pain usually serves an adaptive role, it may have adverse

effects on function and social and psychological well-being.
 Verbal description is only one of several behaviors to express pain;
inability to communicate does not negate the possibility that a
human or a nonhuman animal experiences pain.
Keywords:
Acute pain management;
Ketamine;
Multimodal analgesia;
Non-opioid analgesics;
Regional anesthesia
 INTRODUCTION
In the perioperative setting,implementation of standardized
multimodal analgesia (MMA) represents one such
innovation.

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.

This multimodal analgesia technique has been shown to improve

recovery and patient outcomes after outpatient treatment
 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, depending on the surgery.
ELEMENTS OF MULTIMODAL
ANALGESIA

Non-opioid systemic analgesics

 consists of non-narcotic drugs and dont act within CNS

and based on their chemical structure Analgesia Non-
Opioid divide into two group : antipyretic analgesia and
NSAID
ELEMENTS OF MULTIMODAL
ANALGESIA
Non-opioid systemic analgesics
 The use of non-opioid analgesics is able to relieve or eliminate
pain without affecting the central nervous system, or lowering
consciousness, and also does not cause addiction.

 Non-steroidal anti-inflammatory drugs (NSAIDs) represent another

class of medication that is highly effective for perioperative pain
management.

NSAIDs exert their effects through inhibition of COX and prostaglandin

synthesis .
In addition, all NSAIDs increase the risk
of cardiovascular events, including myocardial infarction
 ELEMENTS OF MULTIMODAL
ANALGESIA
Non-opioid systemic analgesics
Non-opioid analgesics are the cornerstone on which to build a successful
perioperative MMA regimen (Table 1)

 acetaminophen, is one that has been in clinical use for

decades with a proven track record of safety when used in
appropriate doses.
 Non-opioid systemic analgesics

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.

gabapentin and pregabalin

 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.
 Non-opioid systemic analgesics
Other agents to consider in MMA protocols include N-methyl-D-aspartate
(NMDA) antagonists, with focus on ketamine,

Ketamine has a clear opioid-sparing effect in the perioperative period and

may even reduce long-term opioid consumption in opioid-tolerant patients

 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.
 opioid ( MAIN ELEMENT)
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.
 Local Anesthetics

Regional anesthesia and analgesia techniques

Regional anesthesia, it is use of local anesthetics to anesthetize

discreet areas of the body.

Regional anesthesia includes both neuraxial (spinal and

epidural) anesthesia and peripheral nerve blocks
 Local Anesthetics
Regional anesthesia and analgesia techniques

•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) or adding adjuvants to the perineural mixture. perineural
dexamethasone has been shown to extend the duration of brachial plexus block by
6–8 h and sciatic nerve block by 13 h

Although the addition of perineural adjuvants like dexamethasone may raise

concern for neurotoxicity based on animal studies, this has not been
consistently borne out in human studies.
 Local Anesthetics

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 and cesarean section, but the magnitude of
analgesia and opioid sparing appears to be small and short-lived.
 Local Anesthetics
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 and
analgesia during the first 48 h after spine surgery.

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
 Local Anesthetics
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.

Commonly used oral perioperative opioids include hydrocodone, oxycodone,

and tramadol.
 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.