A Commonsense Patient-Centered Approach to Multimodal Analgesia Within Surgical Enhanced Recovery Protocols

Figures & data

Figure 1 A simple paradigm for applying a multimodal analgesic strategy taking into consideration the source, transmission, and processing of the expected surgical pain; *= Routine and should be available to all patients unless contraindicated; †=Not routine and given only as indicated.

Box 1 Sample Perioperative Multimodal Analgesic Regimen Included in an Enhanced Recovery Protocol for Total Knee Arthroplasty Patients

Before Surgery

Counsel the patient on inpatient fall prevention and expected pain trajectory. Assess each patient’s medical and substance abuse history, pain medication history, drug allergies, and intolerances to analgesic medications. Give acetaminophen 1000 mg and celecoxib 400 mg by mouth if no contraindications exist. Insert an adductor canal catheter under ultrasound guidance in the regional anesthesia induction area (“block room”); add infiltration between the popliteal artery and capsule of the knee (IPACK) block if the surgeon does not routinely perform local infiltration analgesia at the end of surgery. If applicable, continue the patient’s chronic outpatient analgesics on the day of surgery and postoperatively. For the chronic pain or opioid-tolerant patient, consider giving a single dose of gabapentin 300–600 mg by mouth (lower dose in elderly and renal insufficiency).

During Surgery

Recommend and perform spinal anesthesia (local anesthetic only) unless refused by the patient or contraindicated (then proceed with general anesthesia). For the patient who does not receive spinal anesthesia, intravenous opioids may be administered as needed based on reactivity to painful stimuli. For the opioid-tolerant patient who receives general anesthesia, consider intraoperative low-dose ketamine infusion (0.5 mg/kg bolus followed by 0.25 mg/kg/hr infusion). Encourage surgeons to perform local infiltration analgesia (ropivacaine 0.2% 150 mL with epinephrine 2.5 mcg/mL and ketorolac 30 mg) before closure; if not an option, perform IPACK block preoperatively.

After Surgery

Provide routine cryotherapy with or without compression based on institutional practice. Prescribe scheduled acetaminophen 1000 mg by mouth every 6 hrs unless contraindicated (reduce the dose in patients with impaired liver function). Prescribe scheduled celecoxib 200 mg by mouth twice a day for up to 5 days then continue as needed (avoid if history of gastric ulcer or renal insufficiency). Short-acting oxycodone may be prescribed on a scheduled basis 5–10 mg every 6 hrs for the first 1–2 days after surgery; replace with the patient’s preoperative opioid regimen when applicable. For breakthrough pain relief, prescribe short-acting oxycodone tablets (e.g., 5 mg) by mouth and hydromorphone intravenously (e.g., 0.2 mg) every 4 hrs as needed. Initiate perineural infusion of ropivacaine 0.2% (basal rate 6 mL/hr; patient-controlled bolus 5 mL, lockout 30 min) via adductor canal catheter immediately after surgery. Provide daily monitoring of the patient’s pain experience, achievement of functional goals, and overall recovery through hospital discharge and adjust medications and interventions as needed. Counsel the patient on outpatient opioid use and safe storage following discharge and recommend provision of a tapering schedule for prescribed outpatient opioids based on the patient’s prior 24 hr opioid use; continue non-pharmacologic interventions and non-opioid analgesics on an as-needed basis. For the patient taking opioids chronically before surgery, communicate the discharge analgesic plan with the outpatient prescribing physician.