Multimodal Analgesic Strategy Research Articles

Practical Review of Abdominal and Breast Regional Analgesia for Plastic Surgeons: Evidence and Techniques.

Summary:Regional analgesia has been increasing in popularity due to its opioid- sparing analgesic effects and utility in multimodal analgesia strategies. Several regional techniques have been used in plastic surgery; however, there is a lack of consensus on the indications and the comparative efficacy of these blocks. The goal of this review is to provide evidence-based recommendations on the most relevant types of interfascial plane blocks for abdominal and breast surgery. A systematic search of the PUBMED, EMBASE, and Cochrane databases was performed to identify the evidence associated with the different interfascial plane blocks used in plastic surgery. The search included all studies from inception to March 2020. A total of 126 studies were included and used in the synthesis of the information presented in this review. There is strong evidence for using the transversus abdominis plane blocks in both abdominoplasties as well as abdominally-based microvascular breast reconstruction as evidenced by a significant reduction in post-operative pain and opioid consumption. Pectoralis (I and II), serratus anterior, and erector spinae plane blocks all provide good pain control in breast surgeries. Finally, the serratus anterior plane block can be used as primary block or an adjunct to the pectoralis blocks for a wider analgesia coverage of the breast. All the reviewed blocks are safe and easy to administer. Interfascial plane blocks are effective and safe modalities used to reduce pain and opioid consumption after abdominal and breast plastic surgery.

A Review of Peripheral Nerve Blocks for Cesarean Delivery Analgesia

(Reg Anesth Pain Med. 2020;45:52–62) Peripheral nerve blocks are used in nonobstetrical surgery as part of a multimodal analgesic strategy. These blocks have been associated with reduced opioid requirements, better quality of recovery, and reduced hospital utilization. Yet, peripheral nerve blocks are not routinely performed for cesarean delivery. This review article discussed several peripheral nerve block options for cesarean delivery, including lumbar sympathetic paravertebral (PVB), transversus abdominis plane (TAP), quadratus lumborum (QL), ilioinguinal-iliohypogastric (II-IH), continuous wound infiltration (CWI), and erector spinae plane blocks.

Achieving pain control with opioid-sparing multimodal analgesic strategy – doing more with less by enhanced recovery after thoracic surgery protocol: A Review

In the last decade, the implementation of enhanced recovery protocol for patients undergoing thoracic surgical procedures, either by thoracotomy or thoracoscopy, has gained significant recognition. Such protocols have been developed following the enhanced recovery after surgery (ERAS) guiding principles, yet have been tailored with attention to the unique nuances of thoracic surgical patients. Over the last 5 years, a body of literature has been published attesting to the success of the enhanced recovery after thoracic surgery (ERATS) protocol, with reported improvements of measurable outcome metrics. This mini-review focuses on postoperative pain control using the innovative strategy of opioid-sparing multimodal analgesics of the ERATS care pathway.

Peripheral nerve blockade and novel analgesic modalities for ambulatory anesthesia.

Despite peripheral nerve blockade offering analgesic benefits and improving patient satisfaction, it has not been well adopted in ambulatory anesthesia. In this review, we aim to summarize the evidence underlying peripheral nerve blockade, local anesthetic adjuncts, continuous peripheral nerve blockade and novel analgesic modalities, with the objective to provide recommendations on postoperative analgesia optimization after peripheral nerve blockade in an ambulatory setting. Barriers to the widespread use of peripheral nerve blockade in ambulatory anesthesia could include lack of education and training, and increased anesthetic induction time. Strategies that have demonstrated promise to increase duration of action and attenuate rebound pain phenomenon after peripheral nerve blockade include multimodal analgesia, local anesthetic adjuncts and continuous infusion of local anesthetic. Dexamethasone has been demonstrated to be the most effective local anesthetic adjunct. Continuous peripheral nerve blockade is a reasonable alternative but at the expense of additional costs and logistical reorganization. There is currently insufficient data to promote the ambulatory use of liposomal bupivacaine, cryoanalgesia and percutaneous peripheral nerve stimulation. Educational programs and parallel processing may promote peripheral nerve blockade in an ambulatory setting, improving the patient experience in the postoperative period. Intravenous dexamethasone should be considered wherever appropriate as part of a multimodal analgesic strategy to optimize postoperative pain control.

Ultrasound-Guided Rectus Sheath Block Combined with Butorphanol for Single-Incision Laparoscopic Cholecystectomy: What is the Optimal Dose of Ropivacaine?

PurposeIn recent years, ultrasound-guided rectus sheath block (RSB) has been widely used in postoperative analgesia of abdominal operation. However, there is no uniform standard for the optimal dose of local anesthetics (LA) under ultrasound-guided rectus sheath block. This study aimed to determine the dose of ropivacaine combined with butorphanol that is effective in 50% (ED50) and 95% (ED95) of subjects for successful pain-free ultrasound-guided RSB in single-incision laparoscopic cholecystectomy (SILC).Patients and MethodsTwenty-four patients scheduled to undergo single-incision laparoscopic cholecystectomy received an ultrasound-guided RSB. The initial dose of ropivacaine injected was 1.7 mg/kg, which was subsequently increased or decreased by 0.2 mg/kg, depending on whether the previous patient was free from pain (numeric rating scale (NRS) score of incisional pain at rest within 12 h after operation ≤ 3). All patients were treated with butorphanol 0.02 mg/kg as preemptive analgesia. The ED50 and ED95 were calculated using a probit regression model.ResultsThe ED50 and ED95 of ropivacaine combined with butorphanol in ultrasound-guided rectus sheath block for analgesia in SILC, which were calculated by the probit regression model, were 0.719 mg/kg (95% confidence interval (CI), 0.553 mg/kg−0.873 mg/kg) and 0.967 mg/kg (95% CI, 0.835 mg/kg−1.91 mg/kg), respectively.ConclusionAs part of a multimodal analgesia strategy, a dose of 0.719 mg/kg ropivacaine provided successful RSB under ultrasound guidance in 50% of the patients who underwent SILC. A dose of 0.967 mg/kg would be successful in 95% of patients.

Multimodal oral analgesia strategy after ambulatory arthroscopic shoulder surgery: case series using adaptive therapeutic approaches by sequential analysis

Pain control and quality of recovery (QoR) at home remains a challenge after ambulatory shoulder arthroscopy. This study aims to assess the QoR and pain relief using a sequential implementation strategy for rescue analgesic drugs. After institutional review board approval, patients (>18 years, American Society of Anesthesiology [ASA] score 1-3 stable) scheduled for ambulatory surgery under general anesthesia with a single-shot interscalene nerve block were enrolled. After discharge, patients received standard information regarding the postoperative recovery and care consisting of a multimodal analgesic regime (acetaminophen and ketoprofen for 5 days). The first 48 postoperative hours allowed us to compare 3 different rescue drug regimes with a control group, in sequential order: tramadol (control group), tramadol + nefopam, immediate-release oxycodone (IR), and extended-release oxycodone (ER). The primary endpoint was the QoR 40 score at 48 hours after surgery. Secondary endpoints were pain relief and adverse events over a 7-day period. An intention-to-treat statistical analysis was performed with sequential analysis (as an interim analysis) every 20 patients. Results were recorded as medians and interquartiles (25-75). We analyzed 109 patients with similar characteristics among groups. The QoR 40 scores were similar for the tramadol group (168 [161-172]), the tramadol + nefopam group (161 [151-173], P = .09), and the IR group (164 [153-169], P = .17), but higher for the ER group (176 [167-181], P = .03). Concerning adverse events, drugs were interrupted more frequently in the tramadol + nefopam group (36 %). In the ER group, a higher quality of postoperative relief was attained in the domains of pain and sleep. The present study shows that a combination of IR and ER oxycodone over a short period of time (<48 hours) is associated with a better QoR at home after ambulatory shoulder surgery.

Essential elements of anaesthesia practice in ERAS programs.

Enhanced recovery pathways vary amongst institutions but include key components for anesthesiologists, such as haemodynamic optimization, use of short-acting drugs (and monitoring), postoperative nausea and vomiting (PONV) prophylaxis, protective ventilation, and opioid-sparing multimodal analgesia. After critical appraisal of the literature, studies were selected with particular attention being paid to meta-analyses, randomized controlled trials, and large prospective cohort studies. For each item of the perioperative treatment pathway, available English literature was examined and reviewed. Patients should be permitted to drink clear fluids up to 2h before anaesthesia and surgery. Oral carbohydrate loading should be used routinely. All patients may have an individualized plan for fluid and haemodynamic management that matches the monitoring needs with patient and surgical risk. Minimizing the side effects of anaesthetics and analgesics using short-acting drugs with careful perioperative monitoring should be encouraged. Protective ventilation with alveolar recruitment maneuvers is required. Preventive use of a combination with 2-3 antiemetics in addition to propofol-based total intravenous anaesthesia (TIVA) is most likely to reduce PONV. While the ideal analgesia regimen remains to be determined, it is clear that a multimodal opioid-sparing analgesic strategy has significant benefits. Careful evaluation of single patient and planning of the anesthetic care are mandatory to join the ERAS philosophy. Optimal fluid management, use of short-acting drugs, prevention of PONV, protective ventilation, and multimodal analgesia are the cornerstones of the anaesthesia management within ERAS protocols.

Intrathecal morphine is associated with reduction in postoperative opioid requirements and improvement in postoperative analgesia in patients undergoing open liver resection

BackgroundOur study aimed to test the hypothesis that the addition of intrathecal morphine (ITM) results in reduced postoperative opioid use and enhanced postoperative analgesia in patients undergoing open liver resection using a standardized enhanced recovery after surgery (ERAS) protocol with multimodal analgesia.MethodsA retrospective analysis of 216 adult patients undergoing open liver resection between June 2010 and July 2017 at a university teaching hospital was conducted. The primary outcome was the cumulative oral morphine equivalent daily dose (oMEDD) on postoperative day (POD) 1. Secondary outcomes included postoperative pain scores, opioid related complications, and length of hospital stay. We also performed a cost analysis evaluating the economic benefits of ITM.ResultsOne hundred twenty-five patients received ITM (ITM group) and 91 patients received usual care (UC group). Patient characteristics were similar between the groups. The primary outcome - cumulative oMEDD on POD1 - was significantly reduced in the ITM group. Postoperative pain scores up to 24 h post-surgery were significantly reduced in the ITM group. There was no statistically significant difference in complications or hospital stay between the two study groups. Total hospital costs were significantly higher in the ITM group.ConclusionIn patients undergoing open liver resection, ITM in addition to conventional multimodal analgesic strategies reduced postoperative opioid requirements and improved analgesia for 24 h after surgery, without any statistically significant differences in opioid-related complications, and length of hospital stay. Hospital costs were significantly higher in patients receiving ITM, reflective of a longer mandatory stay in intensive care.Trial registrationRegistered with the Australian New Zealand Clinical Trials Registry (ANZCTR) under ACTRN12620000001998.

Postoperative opioid-free analgesia in elective bowel resection: Changes over time.

In the pain management evolution, opioid-free analgesia and multimodal analgesia strategies have emerged as feasible in many surgical settings including colorectal surgery. This was a retrospective cohort study including patients having undergone elective bowel resection between February 2012 and June 2018 aiming to evaluate whether there was reduction in opioid use after implementation of opioid-free analgesia in one medical centre. Trend analysis was conducted using Joinpoint regression employing nine-month intervals. The primary outcome for each interval was the proportion of patients receiving postoperative opioid-free analgesia, defined as forgoing all opioid analgesics after the day of surgery. This study showed a significant increasing trend in opioid-free analgesia in elective bowel resection from 0 to 42.5% over 4.5 years.

Paracetamol as a basic component of a modern approach to adequate perioperative analgesia

The problem of adequate perioperative anesthesia is one of the most pressing in the current health care system, given its medical, humanistic and socio-economic aspects. Currently, the standard of postoperative analgesia is multimodal analgesia (MMA). One of the major and required components of MMA is paracetamol, which has antipyretic and analgesic effects with limited peripheral anti-inflammatory activity. Most authors consider intravenous paracetamol as a base drug in a multimodal analgesia strategy for a variety of surgical interventions, which reduces the need for opioids and reduces the side effects of the latter, which in turn significantly affects the results of treatment and the length of hospital stay.Numerous studies in many countries have created a broad evidence base for the clinical use of this drug. Due to its pharmacokinetic and pharmacodynamic properties, it has been shown that intravenous paracetamol has several advantages over oral and rectal forms: early and more effective onset of analgesia and stable maintenance of the therapeutic dose of paracetamol are explained by the formation of a faster and higher peak in the concentration of the drug. The side effects of using paracetamol can be compared with placebo. The mechanism of action of the drug is different from the mechanism of action of NSAIDs, however, is still not fully understood. It may possibly involve inhibition of cyclooxygenase, cannabinoid, or nitric oxide pathways in the central nervous system. Intravenous paracetamol is a safe and effective first-line drug for the treatment of moderate pain in the perioperative period.

Oral vs intravenous acetaminophen as a constituent of multimodal analgesia after coronary artery bypass graft surgery: A randomized, blinded trial

Background &amp; Aim: This trial aimed to compare the pain relief and side effects of Oral Acetaminophen (OA) and Intravenous Acetaminophen (IVA) after CABG surgery. Methods &amp; Materials: This parallel-group, triple-blinded, randomized trial was conducted on 113 CABG patients from September 2017 through February 2018. The samples were selected through blocked randomization and allocated into two groups using computer-generated. The participants administered 1gr oral (OA group, n=57) or intravenous Acetaminophen (IVA group, n=56) every 6h for the first 24h following surgery; also, pain controlled in both group with Morphine multimodal analgesia strategy. Pain intensity measurement by VAS was followed after extubating the endotracheal tube at the 0, 1, 6, 12, 18 and 24 hours during the rest and deep breathing. The Morphine consumption and the incidence of nausea and vomiting in the first 24h were assessed. Data were analyzed using SPSS software and Chi-square, t-test, mixed ANOVA and ANCOVA test. Results: The pain score in the IVA group was found to be statistically significantly lower than the OA group at rest (P&lt;0.001) and during deep breathing (P&lt;0.001) in the first 24h. There was no statistically significant difference between groups regarding the cumulative Morphine consumption (P=0.056). The use of IVA was associated with a reduction in frequencies of nausea and vomiting incidents (P=0.029). Conclusion: Administration of IVA for the management of postoperative pain in CABG patients significantly reduced pain score and incidence of nausea and vomiting compared to OA. Any reduction in cumulative Morphine consumption did not accompany the lower pain.

The extent of cranio-caudal spread within the erector spinae fascial plane space using computed tomography scanning in a neonatal cadaver.

The erector spinae plane block (ESP) is a novel approach for blockade of the spinal nerves in infants, children, and adults. Until recently, the gold standard for truncal procedures includes the paravertebral and epidural blocks. However, the exact mechanism by which this blockade is achieved is subject to debate. 2.3mL (1mL/kg) of iodinated contrast dye was injected bilaterally into the erector spinae fascial plane of a fresh unembalmed preterm neonatal cadaver (weighing 2.3kg), to replicate the erector spinae plane block and to track the cranio-caudal spread of the contrast dye using computed tomography. The "block" was performed at vertebral level T8 on the right-hand side and at vertebral level T10 on the left-hand side. Contrast dye was spread over three dermatomal levels from T6 to T9 on the right-hand side, while on the left-hand side, the spread was seen over four dermatomal levels from T9 to T11/12. Contrast dye also spread over the costotransverse ligament, into the paravertebral space and further lateral from the lateral border of the erector spinae muscle into the intercostal space. However, no spread was seen in the epidural space. The erector spinae plane block is a versatile technique that can be part of the multimodal postoperative analgesic strategy for truncal surgery. In this study, contrast material dye was tracked over four vertebral levels in the paravertebral space (suggesting an approximate volume of 0.5-0.6mL per dermatome).

Integrating complementary medicine in the perioperative period: a simple, opioid-sparing addition to your multimodal analgesia strategy?

The current US opioid health-related crisis underscores the importance for perioperative physicians to optimize various approaches to pain management. Multimodal techniques and enhanced recovery after surgery (ERAS) protocols are frequently...

864 Perioperative Multimodal Analgesia Reduces Opioid Use Following Skin Grafting in Burn Patients

Abstract Introduction Burn injuries cause severe pain and patients often require high doses of opioid medications. Pain management is particularly challenging during dressing changes and following skin grafting procedures. Non-opioid analgesic medications and multimodal analgesic strategies have been promoted to improve pain management and decrease opioid use. Methods We performed a retrospective chart review to identify burn patients who underwent autologous skin grafting procedures between January 2011 and June 2018. We included patients who underwent were 18–80 years old and were inpatients for at least 24 hours before and after their procedure. We excluded patients who remained intubated in PACU, had surgery the day prior or had active opioid prescriptions prior to their hospitalization. We evaluated the effect of different non-opioid analgesic medications on opioid use following a skin grafting procedure. The primary outcome measure of this study compared opioid use 24 hours before skin grafting to 24 hours after skin grafting. Results We found that most patients (69%) reported severe pain (NRS ≥7) immediately after autologous skin grafting. On average, patients required an additional 54 mg of oral morphine equivalents (ME) in the 24 hours after the procedure compared to the 24 hours before. The use of perioperative non-opioid analgesia varied between patients (Acetaminophen 29%, gabapentin 29%, ketamine 33% and all three 8%). Patients who received either gabapentin or a combination of acetaminophen, gabapentin and ketamine had a smaller increase in their opioid use than patients who did not receive the medications (-24 ME, CI -46, -3 and -40 ME, CI -75, -5 respectively). Conclusions Burn patients who received perioperative acetaminophen, gabapentin and ketamine required relatively less opioid following their skin grafting procedure. Applicability of Research to Practice These results support the use of multimodal analgesia for perioperative analgesia in burn patients.

Analysis of clinical efficacy and safety of intravenous use of diclofenac for the prevention of postoperative pain: current status and strategic aspect

The aim of the work is to analyze and systematize the literature data regarding the current state and strategic aspect of intravenous use of diclofenac for the prevention of postoperative pain, namely clinical efficacy and safety.Materials and methods. Studies were conducted using databases on the Internet: PubMed; Food and Drug Administration, European Medicines Agency. It has used retrospective, logical, research methods, content analysis.Results. Conducted clinical data analysis indicates that diclofenac sodium, when administered intravenously, has an opioid-saving effect, is effective in patients experiencing acute postoperative pain, or as part of a multimodal analgesic strategy to achieve perioperative pain control. This increases the possibility of relief of pain and promotes accelerated rehabilitation after surgery, reduces the need for opiates. The incidence of side effects with intravenous diclofenac was similar to that seen with other treatments. New opportunities of the strategic aspect of intravenous use of diclofenac is related to the use of Dyloject, Hospira Inc., USA, which has improved solubility, shorter administration time than infusion. The incidence of thrombophlebitis on treatment with Dyloject was less pronounced compared to Voltarol.Conclusions. Thus, the experience of clinical intravenous use of diclofenac sodium for the prevention of postoperative pain has confirmed its efficacy, favorable safety profile and the ability to reduce the need for opiates. The promising strategic aspect is the creation of domestic diclofenac sodium preparations for intravenous administration, which have improved solubility, shorter administration time than infusions and have no additional safety risk

Chest Trauma: Current Recommendations for Rib Fractures, Pneumothorax, and Other Injuries.

Purpose of ReviewThis article provides an overview of the common and important chest injuries that the anesthesiologist may encounter in patients following trauma including blunt injury, pneumothorax, hemothorax, blunt aortic injury, and blunt cardiac injury.Recent FindingsRib fractures are frequently associated with chest injury and are associated with significant pain and other complications. Regional anesthesia techniques combined with a multimodal analgesic strategy can improve patient outcomes and reduce complications. There is increasing evidence for paravertebral blocks for this indication, and the myofascial plane blocks are a popular emerging technique. Recent changes to recommended management of tension pneumothorax are also described.SummaryChest trauma is commonly encountered, and anesthesiologists have the potential to significantly improve morbidity and mortality in this group of patients.

Multimodal Analgesia for Shoulder Rotator Cuff Surgery Pain: The Role of Naldebain® and Ultrasound-Guided Peripheral Nerve Blocks Combination

Multimodal analgesia (MMA) strategy is widely used for anesthesia and perioperative pain management. MMA provides continuous and satisfactory postoperative pain management, subsequently prevents patients from the development of chronic postsurgical pain (CPSP). We report a 55-year-old female patient with impingement syndrome and provide an MMA protocol for rotator cuff surgery with satisfactory pain management, which combines oral nonopioid analgesics, long-acting dinalbuphine sebacate (Naldebain ER Injection) and ultrasound-guided peripheral nerve blocks. This protocol modifies the timing of long-acting dinalbuphine sebacate injection, thus decreases dinalbuphine sebacate associated side effects. The ultrasound-guided nerve block provides enough time for long-acting dinalbuphine sebacate to reach the therapeutic level. Moreover, multiple oral analgesics act as preventive analgesia, which further enhances postoperative long-acting dinalbuphine sebacate analgesia. We suggest that this MMA protocol can be performed successfully in patients receiving shoulder surgery to provide good pain management and inhibits the consequent CPSP. We believe this MMA protocol may also be used in other types of surgery.

Systemic lidocaine versus ultrasound-guided transversus abdominis plane block for postoperative analgesia: A comparative randomised study in bariatric surgical patients.

Background and Aims:The multimodal analgesia strategies to minimise opioid-related side effects are highly desirable in bariatric surgical procedures. We evaluated the efficacy of ultrasound-guided transversus abdominis plane (USG-TAP) block and intravenous lidocaine for postoperative analgesia in obese patients undergoing laparoscopic bariatric surgery.Methods:We studied 56 patients with body mass index >35 kg/m2. They were randomly allocated to Lidocaine group (Group A) and USG-TAP group (Group B). Group A patients were given intravenous Lidocaine (1.5 mg/kg) bolus followed by (1.5 mg/kg/h) infusion. Group B patients were given ultrasound-guided bilateral TAP block using 20 cc of 0.375% ropivacaine each side. Postoperative numeric rating pain scale score (NRS) hours were compared. Other parameters compared were total fentanyl requirement, sedation score, postoperative nausea vomiting (PONV) score and patient satisfaction score. A P value < 0.05 was considered statistically significant.Results:The patient in the Group A had lower resting NRS score (P < 0.05) postoperatively and less fentanyl consumption (P < 0.001) than in Group B. The difference in the sedation scores (P = 0.161) and PONV (P = 0.293) score was found to be statistically insignificant between Group A and B. The difference between the two groups was statistically significant with respect to patient satisfaction score with majority of patients having an excellent patient satisfaction score in Group A as compared to Group B.Conclusion:Intravenous Lidocaine as part of multimodal analgesic technique in obese patients undergoing laparoscopic bariatric surgery improves pain score and reduces opioid requirement as compared to USG-TAP Block.

Efficacy of multimodal analgesic treatment of severe traumatic acute pain in mice pretreated with chronic high dose of buprenorphine inducing mechanical allodynia

Managing severe acute nociceptive pain in buprenorphine-maintained individuals for opioid use disorder management is challenging owing to the high affinity and very slow dissociation of buprenorphine from μ-opioid receptors that hinders the use of full agonist opioid analgesics.In a translational approach, the aim of this study was to use an animal setting to investigate the effects of a chronic high dose of buprenorphine treatment on nociceptive thresholds before and after applying a severe acute nociceptive traumatic surgery stimulus and to screen postoperative pharmacological analgesic strategies.A chronic treatment of mice with a high dose of buprenorphine (BUP HD, 2 × 200 μg/kg/day; i.p.) revealed significant mechanical allodynia. One and two days after having discontinued buprenorphine administration and having induced a severe nociceptive acute pain by a closed tibial fracture, acute administration of morphine at a dose which has analgesic effects in absence of pretreatment (4.5 mg/kg; i.p.), was ineffective to reduce pain in the BUP HD group. However, mimicking multimodal analgesia strategy used in human postoperative context, the combination of morphine (administered at the same dose) with a NMDA receptor antagonist (ketamine) or an NSAID (ketoprofen) produced antinociceptive responses in these animals.The mouse model of closed tibial fracture could be useful to identify analgesic strategies of postoperative pain for patients with chronic exposure to opioids and suffering from hyperalgesia.

Implementation of an Enhanced Recovery Protocol (ERP) is associated with an increase in the perioperative use of non-opioid multimodal analgesia for non-ERP patients

Study objectiveIncorporation of multimodal, non-opioid analgesic medications into patient care pathways has become a common theme of enhanced recovery pathways (ERPs), which have been shown to improve patient outcomes such as complication rates and length of stay. With surgical care episodes, patients also incur a significant risk of persistent postoperative opioid use, whether the surgery is classified as major or minor surgery. One method that has been shown to reduce perioperative opioid administration is a structured non-opioid multimodal analgesic strategy, widely utilized in ERPs. Despite well-defined benefits, the time to translate evidence-based approaches into clinical practice can be prolonged. This study examines the effect of implementation of an Enhanced Recovery Protocol (ERP) on the adoption of intraoperative multimodal analgesia outside of the auspices of an ERP care pathway, describing factors influencing the clinical implementation of non-opioid multimodal analgesia (NOMA) in routine practice. DesignRetrospective cohort analysis. SettingWe identified all surgical cases between January 2013 and December 2016 at Vanderbilt University Medical Center (VUMC). InterventionsNone. MeasurementsUsing both segmented and logistic regression approaches, we compared non-ERP surgical cases before and after the initial ERP education and implementation in April 2014. Outcomes included provider, patient, and procedural factors associated with utilization of non-opioid multimodal analgesia (NOMA) in the immediate perioperative period. Main resultsWe studied 73,560 non-ERP cases. Cases utilizing any element of NOMA increased from 17.06% to 35.21% (X2 = 2358, df = 1, p < 0.01) before and after the initial ERP pathway implementation. Patient factors influencing this increased adoption of multimodal analgesia included lower American Society of Anesthesiologists Physical Status Class, younger age, and Caucasian race. Cases with in-room providers who were residents or trainees (as opposed to nurse anesthetists) or providers who had a greater number of prior ERP pathway cases were more likely to use multimodal. Procedure-specific factors favoring multimodal included use of laparoscopy. The gynecologic, neurosurgical, and orthopedic cases were more likely to utilize multimodal analgesics. ConclusionsFrom 2013 to 2016, NOMA usage in non-ERP patients increased significantly and in association with departmental education and concomitant implementation of an ERP pathway. Factors associated with increased uptake of multimodal analgesia included the presence of trainees, providers with a higher number of previous ERP pathway cases, patients who were younger, healthier, female, Caucasian race, and having specific types of surgery.