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Postoperative Multimodal Analgesia Pain Management With Nonopioid Analgesics and TechniquesA Review

Educational Objective To identify the advantages and disadvantages of nonopioid techniques commonly included in the enhanced recovery after surgery protocol.
1 Credit CME
Abstract

Importance  Amid the current opioid epidemic in the United States, the enhanced recovery after surgery pathway (ERAS) has emerged as one of the best strategies to improve the value and quality of surgical care and has been increasingly adopted for a broad range of complex surgical procedures. The goal of this article was to outline important components of opioid-sparing analgesic regimens.

Observations  Regional analgesia, acetaminophen, nonsteroidal anti-inflammatory agents, gabapentinoids, tramadol, lidocaine, and/or the N-methyl-d-aspartate class of glutamate receptor antagonists have been shown to be effective adjuncts to narcotic analgesia. Nonsteroidal anti-inflammatory agents are not associated with an increase in postoperative bleeding. A meta-analysis of 27 randomized clinical trials found no difference in postoperative bleeding between the groups taking ketorolac tromethamine (33 of 1304 patients [2.5%]) and the control groups (21 of 1010 [2.1%]) (odds ratio [OR], 1.1; 95% CI, 0.61-2.06; P = .72). After adoption of the multimodal analgesia approach for a colorectal ERAS pathway, most patients used less opioids while in the hospital and many did not need opioids after hospital discharge, although approximately 50% of patients received some opioid during their stay.

Conclusions and Relevance  Multimodal analgesia is readily available and the evidence is strong to support its efficacy. Surgeons should use this effective approach for patients both using and not using the ERAS pathway to reduce opioid consumption.

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Article Information

Corresponding Author: Elizabeth C. Wick, MD, Department of Surgery, University of California, San Francisco, 513 Parnassus Ave, Room S549, San Francisco, CA 94143 (elizabeth.wick@ucsf.edu).

Accepted for Publication: March 4, 2017.

Published Online: May 31, 2017. doi:10.1001/jamasurg.2017.0898

Author Contributions: Dr Wick had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: Wick.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: Wick, Grant.

Administrative, technical, or material support: Wick, Grant.

Study supervision: Wick, Wu.

Conflict of Interest Disclosures: None reported.

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