Multimodal pain management strategies for office-based and ambulatory procedures.

Abstract

OFFICE-BASED SURGICAL PROcedures account for up to 25% of all elective surgical procedures performed in the United States. Ambulatory surgical proceduresnowmakeup70%of the total volume of hospital-based elective surgical procedures. More major surgical procedures are being performed on an ambulatory or 23-hour hospital stay basis including intra-abdominal, intrathoracic, and major orthopedic procedures. Postoperative pain, nausea, and vomiting are the most common factors leading to delays in outpatient discharge and admissions to the hospital following ambulatory surgery. An understanding of the pharmacologic concepts and pain management techniques for those office-based procedures performedwithin the scopeof aprimarycare practice, and for patients undergoing hospital-based ambulatory (outpatient) surgical procedures, is a crucial component in the continuing education of the primary care physician. Opioid analgesics are the historical choice of primary analgesic medications for postoperative pain. It has been well documented that opioid analgesics are commonly associated with nausea, vomiting, sedation, dysphoria, pruritus, constipation, urinary hesitancy, and respiratory depression. Multimodal analgesia, or balanced analgesia, refers to the use of more than one medication or class of medication, or the use of more than one analgesic technique to produce analgesia through multiple mechanisms. Multimodal analgesic strategies for postoperative pain management, including the use of combinations of local anesthetic neural blockade techniques and nonopioid analgesic medications supplemented with opioid analgesics, have been shown to improve postoperative analgesia and reduce postoperative opioid requirements and opioid-related adverse effects. Multimodal postoperative pain management is applicable and equally important to both the pediatric and adult patient populations.