Multimodal Analgesia for Postoperative Pain Management

Abstract

The experience of pain is complex, multifaceted, and “an unpleasant sensory and emotional experience,” as defined in part by the International Association for the Study of Pain. It is a personal, subjective experience that involves sensory, emotional and behavioral factors associated with actual or potential tissue injury (Rawal). The differential behavior response to surgical incision can be influenced by many variables including global (i.e., personality, gender, age, cultural background, pre-existing pain syndromes, genetic makeup, kind and type of surgical approach, cultural background) and specific (i.e., fear, anxiety, depression, anger, and coping) psychological factors (Eccleston, 2001). Only by considering all concomitant factors can physicians provide optimal treatment. Millions of surgeries are performed on an annual basis, necessitating the frequent use of acute postoperative pain management. There are many types of surgery and, with few exceptions, all are painful. Fear of uncontrolled pain is among the primary concerns of many patients who are about to undergo surgery. One of the most important factors in determining when a patient can be safely discharged from a surgical facility, and that also has a major influence on the patient’s ability to resume his/her normal activities of daily living, is the adequacy of postoperative pain control. Pain is a predictable part of the postoperative experience. Unrelieved postoperative pain may result in clinical and psychological changes that increase morbidity and mortality as well as costs and that decrease quality of life (Carr& Goudas, 1999). The guidelines for acute pain management in the perioperative setting published in 1992 and 1995 (Acute Pain, 1992; American Pain, 1995; Practice Guidelines, 1995) promoted aggressive treatment of acute pain and educate patients about the need to communicate unrelieved pain. Nonetheless these guidelines appear to have had little influence on practice patterns or on improved pain control for patients. In a study of Warfield and Kahn (Warfield&Kahn, 1995) they found three of four patients reported experiencing pain after surgery, and 80% of these patients rated pain after surgery as moderate to extreme. Since their study, newer drugs, techniques and protocols for postoperative pain management have been developed, and minimally invasive surgical techniques, such as endoscopic procedures, are used more frequently. These changes in practice patterns thought that they could affect the management of postoperative pain and patient attitudes about pain. But in a recent study (Apfelbaum, 2003) that assessed patients’ postoperative pain experience and