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

Enhanced recovery" in the context of a surgical patient is both a plan and a goal at the same time.The goal is faster convalescence after surgery with positive outcomes and no complications.The plan takes the form of an enhanced recovery protocol (ERP) or clinical pathway specific to a surgical procedure, a concept pioneered by Professor Henrik Kehlet from Denmark decades ago. 1 Over time, this basic concept has evolved and has become arguably too complex.With over twenty elements frequently included in modern ERPs, it is not surprising that consistent implementation and adherence are lacking. 2Not all of these elements are critical, and a study of an ERP for bowel resection has demonstrated that three are particularly important: 1) laparoscopic (minimally invasive) approach; 2) early termination of intravenous fluid; and 3) early mobilization (getting out of bed). 3 This last element is critically dependent on effective pain management.Because the objective of achieving analgesia does not exist in a vacuum and must be balanced with the goal of early mobility, today's standard for pain management in the perioperative period is multimodal analgesia or using more than one analgesic agent with different mechanisms of action. 4While a single analgesic agent has the potential to provide complete postoperative pain management alone, it often comes at a significant cost.Consider these two extremes: continuous spinal anesthesia and opioid-only analgesia.Continuous spinal anesthesia, which may involve an infusion of local anesthetic into the cerebrospinal fluid, is arguably the most effective regional analgesic technique available. 5In the case of lower extremity arthroplasty, a continuous spinal anesthetic will provide complete postoperative pain relief; however, it will also result in complete immobility and prevent the patient from participating in any physical therapy.For the same surgery, opioid-only analgesia may also provide effective pain management, but it may also render the affected patient unconscious, depress respirations, and precipitate nausea, vomiting and constipation, which can also negatively impact postoperative rehabilitation.Additionally, persistent postoperative opioid use has been identified as a common adverse outcome after surgery. 6Given these examples, it is clear why multimodal analgesia has become the cornerstone of all ERPs.Available data suggest that the increasing number of non-opioid analgesic modalities decreases total opioid usage and opioid-related side effects, 7 and different patterns of non-opioid analgesic utilization have been identified among