Multimodal Analgesia for
Postoperative Pain Management
A. Husni Tanra
Department of Anesthesiology, IC and Pain
Management
Faculty of Medicine, Hasanuddin University
Makassar
Meet The Expert, Solo May 6, 2016
What the Patients say for their
anesthesiologists?
Before 1990, most patients say
IM WORRIED THAT I WONT
WAKE UP AFTER THE OPERATION
After 1990, Due to the safe of
anesthesia, those words are not
oftenly be hear
IM WORRIED TO HAVE PAIN
Pain Conitinues to be Undertreated
Patients (%)
100
90
80
70
60
50
40
30
20
10
0
77
83
1995
2003
Patients worst pain
49 47
19
Any pain
23 21
13
Slight
pain
Warfield & Kahn. Anesthesiology 1995;83:1090
Apfelbaum et al. Anesth Analg 2003;97:534
18
8
Moderate
pain
Severe
pain
Extreme
pain
Traditional Postoperative Pain Management
Using Monomodality drug
10 mg morphine, IM and PRN
done by SURGEON.
Multimodal Analgesia has
undergone a revolution in the
last 20 years.
Courtesy S.A. Schug
Kehlet & Dahl The value of
Multimodal or Balanced Analgesia in
Postop pain (AA) 1993
Prof. Henrik Kehlet, MD, PhD.
Department of Surgical Gastroenterology, Hvidovre University Hospital, Hvidovre Denmark
What is multimodal analgesia?
Is a combination of two or
more analgesics that act
at different mechanisms,
produce additive or
synergistic analgesia
Main goals of Multimodal Analgsia is to reduce the amount of Opio
pain
Strong pain needs strong
analgesic
strong
analgesic
is
opioid
Opioid is really good and effective to treat pain at rest!
BUT:
Not so good to treat pain on movement
Significant adverse effects
Nausea
Vomiting
Constipation
Sedation, drowsiness, confusion
Potential risk of Opioid Induced Ventilatory Impairment
(OIVI)
Opioid in Postoperative pain
Opioids are needed to treat severe pain
BUT they are impairing recovery and
rehabilitation!
THEREFORE opioid;sparing techniques are
needed!
Paracetamol
in Opioid Sparing Effects
I.V. paracetamol in these studies
was administered as a bioequivalent dose of propacetamol .
Number of CMEs on day 1 after
laparoscopic cholecsytectomy
Opioid Dose and Clinically
Meaningful
Once threshold
reached,
every further 34
mg
Opioid
Related
Adverse
Events
increase will be
associated with 1 (CME)
clinically meaningful opioidrelated symptom
> 3 events
Reduction in
clinically meaningful
opioid related ADE
2 events
1 event
No event
33%
0
ADE = adverse drug
event
5
10
15
20
Morphine equivalent dose in 24 hours (mg)
25
Zhao et al, J Pain Symp Manag
2004;28:35
Benefits of Multimodal
Analgesia
Opioids
Potentiating
/Synergic
Paracetamol
NSAIDs, &
Coxibs
nerve blocks
REDUCED DOSES
of each
analgesic
IMPROVED
EFFECACY
due
to synergistic or
additive effects
REDUCE SIDE
EFFECTS
of
each drug
Kehlet H et al. Anesth Analog. 1993;77:1048-1056.
COMBINE DRUGS MAY HAVE
3 EFFECTS
1. Synergetic .............
2+2>4
2. Additive ................
2+2=4
Why we need multimodal
analgesia for posoperative
pain?
Most of the pain
multifaceted and
sources.
is a
multiple-
No
single
analgesic
is
perfect
and
no
No single analgesic is perfect and no
single
analgesic
can
treat
all
types
of
pain.
single analgesic can treat all types of pain.
Multimodal Analgesia is
potentiating in efficacy,
reduced doses, minimal adverse
effect. Improve the outcome.
Pain is always associated with surgery,
but how far these doctors concern about it
Pathophysiology of
Surgical Trauma
Inflammato
ry
Soup
Surgical
Injury
Peripheral
Nerve
Injury
Peripheral
Sensitisation
of
Nociceptors
Central
Sensitisation
of Dorsal
Horn
Primary
hyperalgesi
a
Secondary
Hyperalgesi
a
Long-Term
Potentiatio
n
Chroni
cPain
After surgery Pain Sensitization:
Hyperalgesia and Allodynia
HYPERALGESIA
10
Pain intensity
8
6
4
2
Sensitised
pain response
Pain intensity
for stimulus X
sensitised
pain response
Normal
pain response
Injury
Pain intensity
for stimulus
X
normal
pain
response
ALLODYNIA
X
Stimulus intensity
Clinical Features of
Postoperative Pain
HYPERALGESI
Primary
Hyperalgesia
ALLODYNIA
CLINICAL PAIN
(PATHOPHYSIOLO
GICAL PAIN )
Secondary
Hyperalgesia
Vanished
after healing
Chronic
Pain
Basic Principle of Postop
Pain Management is
prevent the occurrence of
Peripheral
and
Central
sanitization
reduced the process ofNeuroplasticity
Preventive
Multimoda
l
Analgesia
By Giving
Antihyperalgesic
& Antiallodynic
drugs
Anti-hyperalgesic Therapy:
Opioid-Sparing
Sensitised
pain response
Opioid
Opioid
Pain intensity
~30%
reduction
Partially desensitised
pain response
Normal
pain
response
Antihyper
algesic
X
Stimulus intensity
KETAMIN as
Antihyperalgesic
Low-dose ketamine (0.1- 0.15
mg/Kg )is not really an analgesic,
but better described as:
anti-hyperalgesic
anti-allodynic
tolerance-protective of
opioid
Opioid-induced
Hyperalgesia
Coutersy by Prof. S. A. Schug
Philosophy of Multimodal
Analgesia
Not only just giving 2 or more drugs which
different mechanism, but;
One drug should be effective at
peripheral sensitization and other at
central sensitization.
Combine drugs must be synergetic or
addictive.
Must be proven by laboratory or clinical
data.
Target Point of Analgesic Drugs
Ketamin
Paracetamol
Percepti
on
Opioids
Gabapentinoid
s
Clonidine
CNS
Modulatio
n
Transducti
on
DR
G
Modulatio
n
COXIBs
Corticosteroi
ds
NSAIDs
COXIBs
Local
Anesthetic
Transducti
on
Transmiss
ion
Local
anesthetics
Modify by
ANALGESIC DRUGS
NONOPIOIDSOPIOIDS ADJUVANTS
Paracetamol
NSAID
(nonselective)
Coxib (selective
NSAID)
Mild Opioid
( codeine & tramadol
)
Strong Opioid
( Morphine &
Fetanyl )
Steroid
(dexamethason)
Alpha2 agonist
(Clonidine)
Ketamine (NMDA
Multimodal Analgesia
OPIOIDS
NEURAXIAL BLOCKS
PERIPHERAL NERVE
BLOCKS
MULTIMODAL
ANALGESIA
NON-OPIOID
ANALGESICS
ADJUVANTS
What is the most
regiments
Opioid
doses of each analgesic
Improved
Potentiation
Paracetamol
NSAIDs or Coxibs
Nerve blocks
Ketamine
Dexamethazone
Alpha;2 Agonists
Gabapentinoids
anti;nociception
due to synergistic/additive
effects
severity of side;effects of
each drug
Kehlet & Dahl. Anesth Analg 1993;77:1048
Playford et al. Digestion. 1991;49:198
Paracetamol
Paracetamol is very safe drug as
long as it is given within
recommended doses
4 gr/day,
children
20-40
1.(Adult
Can <
be
given Infant
to alland
age
from
mg/kgBW)
Infant to Elderly
2. From pregnant to Lactating
Woman
Qualitative Review of Paracetamol,
NSAIDs-or their Combination in
postoperative pain.
Paracetamol can be the best
alternative to NSAIDs for high risk
patients.
It is appropriate to administer
Acetaminophen with NSAID, additive
or synergistic effects
Intravenous form of paracetamol
has more predictable onset and
duration of actions
Hyllested M, Jones S, Pedersen JL et al (2002) Comparative effect of paracetamol, NSAIDs or
their combination in postoperative pain management: a qualitative review. Br J Anaesth
Review 2010
Paracetamol and NSAIDs (cox1 and cox2)
Combination of paracetamol and an
NSAIDs may offer superior analgesia
compared with either drug alone
(Anesth Analg 2010)
SYSTEMIC REVIEW
NSAIDs vs COXIBs For Postoperative
Pain
Demonstrate Equipotent Analgesic
Efficacy After Minor and Major
Surgical Procedure
NSAIDs
COXIBs
COXIBs Better Alternative
TO NSAIDs in the
perioperative setting
COXIBs associated with:
Reduce gastrointestinal
side effects
Absence of anti-platelet
activity
Romsing J & Moiniche S (2004) A systematic review of COX-2 inhibitors compared with traditional NSAIDs, or different COX-2
inhibitors for post-operative pain. Acta Anaesthesiol Scand 48(5): 52546.
Parecoxib and
Acetominophen
Combination of paracetamol and parecoxib may
useful in patients
who are susceptible to haemorrhagic
complications of NSAIDs
Paracetamol + Tramadol
Tramadol/paracetamol
combination tablets provided
analgesic efficacy with a better
safety profile to tramadol
capsules in patients
postoperative pain following
ambulatory hand surgery.
Sedation can be interpreted as a negative outcome of
gabapentin ,however its can be benefical in the
perioperative setting as an anxiolysis
Choice of Analgesic Technique
(Analgesic Ladder of WFSA)
Pain
Intensity
Opiate
And
NSAID
and
Paracetamol
Oral route available give
orally
NSAID
and
Paracetamol
Pain
decreases
as time
passes
Paracetamol
Conclusions:
Multimodal Analgesia
There is Level I evidence for the effectiveness
of the following components of multimodal
analgesia:
Paracetamol
NSAIDs/Coxibs
Alpha;2;Delta Ligands (pregabalin)
Systemic Local Anaesthetics
Ketamine
Alpha;2 Agonists
(clonidine/dexmedetomidine)
Corticosteroids
Practice Guidelines for Acute Pain Management in the
Perioperative Setting
An Updated Report by the American Society of
Anesthesiologists Task Force on Acute Pain Management 2012
Recommendations for Multimodal
Techniques.
Whenever possible, anesthesiologists should use
multimodal pain management therapy.
Central or nerve blockade with LA should be
considered.
Unless contraindicated, patients should receive an
ATC regimen of COXIBs, NSAIDs, or acetaminophen .
Dosing regimens shoud be optimize efficacy while
minimizing the risk of adverse events.
The choice of medication, dose, route, and
duration of therapy should be individualized.
Anesthesiology 2012; 116:248-7
Multimod
al
Analgesi
a
Improved
Analgesia
Lowered Dose
Reduced
Side
Effects
Early
Mobilization
Early Enteral
Feeding
Rapid Recovery
multimodal
analgesia
low cost
Aggressive preventive
including epidural or nerve block not
produce optimal analgesia but also may
only
prevent
This is not new
Crile
Stated
1913That:
Patients Given
Inhalation
anesthesia still
need to be
protected by
regional
anesthesia,
otherwise they
might suffer
Thank you
very much
Paracetamol
NEW but OLD DRUG
Acetominophen/P
Acetominophen/P
AAP
AAP
Analgesic
Effects
Antipyretic
Effect
No Anti-Inflammation
Effect
Route of Administration
Orally
Rectally
Intravenously available in Indonesia
since 2009
Bertolini A, et al CNS Drugs reviews,
