This document discusses multimodal perioperative pain management strategies and their potential to improve postoperative outcomes. It outlines an integrated approach involving pre, intra, and postoperative care using multiple analgesic techniques including regional anesthesia, acetaminophen, NSAIDs, and low-dose opioids to minimize side effects while providing effective pain relief. When combined with early rehabilitation and mobilization, improved pain control can enhance recovery and accelerate discharge from the hospital. The goal is a seamless multimodal strategy from the preoperative period through to recovery.

1. Multimodal Perioperative Pain
Management and Multimodal
Strategies to Enhance Post
Operative Outcomes
Hamed Umedaly MD FRCPC
Anesthesiologist
Medical Director POPS
Vancouver Acute
University of British Columbia

5. Why ? What's wrong with the
status quo ?
Improved Anesthesia & Pain
management can be achieved !
Improved potential for Recovery ?
Unidimensional approaches limit
outcome
Improvements not realizing optimal
patient outcome ?

6. 4 A’s of Changing Physician
Behavior ( Pathman model)
Aware
Agree
Adopt
Adhere

7. For every complex problem
there is an answer that is
simple, neat
and wrong
H.L Menken 1880-1956

8. Concept of Perioperative Pain
Management and Acute
Rehabilitation
Pre- Op Education Preparation &
Planning
Pre & Intraop Pain Management &
Physiological Stabilization
Post-op pain management and Acute
Rehabilitation
Kehlet 1995-2005

9. Preemptive Pain Management:
Neurobiology
Noxious stimuli initiate cascade of
events peripherally and centrally to
produce PAIN
Sensitization (Dynamic)
Nociceptive stimuli amplified ( Primary
and Secondary Hyperalgesia)
Non painful stimuli produce PAIN
(Allodynia)

13. Preemptive Pain
Management:Prevent
Sensitization ( duration and
Intensity)
Reduce the Nociceptive input (Minimally
invasive surgery,LA, NSAIDS, Opioids)
Attenuate Transmission ( Blocks, Spinal,
Epidural)
Modulate mechanisms that underlie
sensitization ( NMDA blockade, Opioids)

14. Multimodal Pain Management
Pain Neurobiology is a complex of
Dynamic Interrelated systems
Unimodal Analgesia cannot be sufficient
to provide optimal pain management
Additive & Synergistic effects of Multiple
modes should improve outcome

15. 4 principles of Multimodal Pain
Management
Multiple Mechanisms/ Sites of action
Avoid Opioid Dominance
Opioid Sparing vs side effects
Multimodal / Lower Doses / Reduce
adverse effects
Treat and Prevent Toxicity / Side effects
i.e PONV /Delirium/Pruritis

16. VA Quality Improvement
Study N=300
~ 40 % of joint arthroplasty have PONV
if untreated
Joint Arthroplasty patients are at high
risk of PONV
~ 10 % of have PONV if Risk Reduction
Strategy and Prophylaxis ( combination
therapy)

17. Consensus Guidelines for
Managing PONV
Evaluate Risk ( Patient, Anesthetic Surgical)
Strategies to reduce baseline risk (Modify
Anesthetic Technique)
Antiemetic prophylaxis
Moderate Risk: Monotherapy 5 HT3 Receptor
antagonist
High risk: Combination therapy
Gan A&A 2003

18. art64_fig11.gif

20. Acetaminophen
Synergy with Opioids / Opioid sparing
Synergy with NSAID’s
Inexpensive
Routes PO / PR
Use 3-4 g/24 hr short term<2 wks

21. Model for Post surgical Chronic Pain
Physiological
Preop Maintaining
Psychological Factors
factors Acute pain Chronic Pain
Physiological ( Nociceptive and
Factors Affective Components)
Acute injury Psycho/social
(Surgery) Maintaining
Factors

23. Multimodal pain management
and Outcomes
Multiple PRCT’s in 10 yrs
Improved Pain Scores and Patient
Satisfaction
Decreased use of PCA and Parenteral
Analgesia
BUT no change in LOS/Outcome

24. Beyond Multimodal Pain
Management: A Multimodal
Strategy to Enhance
Postoperative Recovery
Multimodal Rehabilitation model
Integrated (Patient,
Nurse,PT/OT.Pharmacist, Surgeon,
Anesthesiologist)
Use the Improved pain management to
accelerate recovery discharge & Really
Improve outcome

25. Multimodal Recovery
Wellness model
Perioperative model ( seamless)
Architecture from Bed oriented wards
to Activity Oriented Units
“Postoperative Rehabilitation Unit”
Now lets look at Outcome

26. Opioid Tolerance:
Reality Check
Increasing incidence of Opioid Tolerant
Patients presenting for Surgery
CPS & APS approve the use of Opioids
for Chronic Non malignant Pain
i.e Osteoarthritis

27. Opioid Tolerance
(Chronic Pain)
Morphine equivalence
> 30 mg/ day for > I month
Central sensitization ; afferent nociceptive
facilitatation
Primary and secondary hyperalgesia
Allodynia
Opioid mu receptor down regulation

28. Opioid Tolerance : Features
Tolerance to:
pain management,
respiratory depression
Sedation
Non Nociceptive Suffering ( anxiety)
Renders Perioperative Pain
Management Challenging

29. Opioid Tolerance in the
Perioperative Period
Its too late postop ( in the PACU )
Start preop ( identify , plan , preop Opioid ,
Acetaminophen, NSAID,
+/- Clonidine
Continue Intraop ( Opioid , Local, Regional ,
Ketamine)
Extend strategy Postop (Opioid , Regional ,
+/- Ketamine, NSAIDs, Acetaminophen

30. Opioid Tolerance: Multimodal
Strategies
Use Neuraxial Blockade/ Regional
Anesthesia/Analgesia with LA
NSAID’s
Acetaminophen at max dose ( 1.5-2 g
load and 4 g/day)
Low dose Ketamine intra +/- postop
Treat Non Nociceptive Suffering

31. Opioid Tolerance
Identify
Discuss Complexity and Potential
Toxicity with Patients
Resume PO Opioid asap at higher dose
and provide breakthrough

32. Strategy and Goals
Integrated
Pre, Intra & post operative Care
Seamless
Multimodal pain management
Treat Pain with activity
Avoidance of routine PCA Opioid
Improve pain management and outcomes

33. Perioperative vs Postoperative
Preop: Recognition, Assessment, Discussion,
Plan, Pre emptive
Intraop: Modification of Surgical approach
Anesthesia and Pain Management Strategy
Post Op: Multimodal Pain Management and
Intervention

34. VA Approach: Preop
Consultation and preparation
Identify Risk of Difficult to manage
pain
High dose Acetaminophen
+/- NSAID
Low dose long acting Opioid
(Oxycodone CR 10 mg)

35. VA Approach:”Intraop”
Intrathecal LA(Spinal) and low dose
Opioid( PF Morphine 100 ug)
+/- GA or Epidural for Revisions or
Opioid Tolerance
Preincision LA
LA in capsule and closure
PONV prophylaxis
Fast track PACU

36. VA Approach:
”Post op”
Full reg dose Acetaminophen
+/- NSAID
Reg low dose long acting Opioid
(Oxycodone CR) plus breaktrough prn
opioid ( Oxycodone IR)
PCA only for unsatisfactory pain control
“Fast track” early mobilization

37. Rehabilitation / Recovery
Achieve best pain control with minimal
side effects
Use that pain control to achieve early :
Recovery
Mobilization
Function

38. Ambulatory or Short stay Hip
Replacement
Minimally Invasive approach
85 % with same day DC
N= 100
Duwelius JBJS 2000

39. Short Stay Total Knee
Arthroplasty
Spinal Anesthesia
Multimodal pain management
Femoral Nerve LA Catheter Infusion
Anesthesia and Analgesia Jan 2006

40. MIS Surgery:Purported
Benefits
Surgical Invasiveness
Better Pain Management
Improved Rehabilitation Protocols
?Higher Complication rate with MIS
Woolson JBJS 2004, Ogonda JBJS 2005
Wright J.Artroplasty 2004

41. Periop Pain Management
Talk about it “Can and should focus on
pain”
Work on Periop Strategies and utilize
them to enhance satisfaction /outcome
Manage PONV

42. The Future
Perioperative infusion of Continuos
Regional Anesthesia(PICRA)
PCOA
Antineuropathic agents
( gabapentin/pre gabalin)
Microsphere impregnated Local
anesthetic agents

43. A Multimodal Strategy to
Enhance Postoperative
Recovery: Conclusions
Integrated Perioperative approach
Enhanced Perioperative Pain
management
Perioperative stress response and Organ
Dysfunction reduction ( eg blood loss,
PONV )
Utilize to achieve Fast Track Recovery
and Enhance Outcome

44. Divinum est sedare dolorum
Blessed are those who treat pain.
-Galen

53. COX 2 Inhibiters : Background
Inducible vs Constitutive enzymes
No apparent GI or Renal Sparing
Platelet Aggregation Sparing
( Thromboxane inhibition)

54. Cyclooxygenase Isoforms
Cox-1 Cox-2
Constitutive, and found in Predominately inducible
most tissues - enzyme in many tissues -
“housekeeping”. Inducible 10- to 20-fold by inflam
2- to 4-fold by inflammatory stimuli or cancer
stimuli
Stimulates PGI2 production
in endothelium
Only isoform present in
platelets TxA2
Main isoform in gastric Constitutive in CNS, fem.
mucosa Cytoprotective reproductive tract, and
kidney
PG’s

55. COX 2 Inhibiters : When ?
Pain Management Challenging and Intraop
Bleeding an Issue
Pain Management responsive to NSAIDS
(Bone, Gyne etc and potential for intraop
/post op bleeding)
Concurrent Anticoagulation or LMW Heparin
Epidural insitu and pain outside covered
dermatomes

56. Cardiovascular and Platelet
Effects
Platelets:
- ASA: irreversibly acetylates Cox-1,
selectively inhibits TxA2 formation
- Nonselective NSAIDs: Inhibit TxA2 and
PGI2 to a similar degree. Effect is reversible
during the dosing interval
- COXIBS: Inhibit (reversibly) Prostacyclin
formation which mediates platelet inhibition

57. CLASS and VIGOR studies
CLASS:
- Celebrex Long-term Arthritis Safety Study
VIGOR:
- VIoxx Gastrointestinal Outcomes Research
Very large (n = >4,000 and >8,000), multicenter,
double-blind, randomized trials (no placebo arm)
examining efficacy and safety of Celecoxib and
Rofecoxib

58. CLASS VIGOR
- 28% with RA, 72% OA - 100% with RA
- compared coxib Vs - compared coxib (2x max
ibuprofen & diclofenac dose) Vs naproxen
- ASA allowed for Cardiac - ASA not allowed
prophylaxis (21%)
- sig lower rates of upper GI
- no difference in ulcer events and GI bleeding
frequency,but fewer with vioxx
symptomatic ulcers
- sig higher rates of
- no sig difference in MI thrombotic events and MI
frequency with Rofecoxib, altho’ CV
mortality rates similar

59. Why do Cox-2s Increase
SAEs??
Not completely explained by the trials
Increase of thrombotic CV events more
than cancels reduction in complicated
ulcer risk

61. COX 2 Inhibiters : Cost
COX 2 $ 1.25/day
Rofecoxib and Valdecoxib once daily
dosing
Nonselective po nonselective COXIB
$30-60 cents (eg Diclofenac)
IV nonselective COXIB (~$ 8.00 day)
(eg Ketorolac)

62. COX 2 Inhibiters : Add to
formulary ?
Minimal cost
Selective Use When Indicated
Avoid use when known or risk factors
for CAD
Platelet sparing really only benefit

63. The Future
IV Acetaminophen = “Propacetamol
will be available in Canada “soon”
IV Parecoxib
immediately converted to Valdecoxib
Nitric Oxide-donating NSAIDs
NO functions as an endogenous mediator
of gastric mucosal health and defence

65. Multimodal Perioperative Pain
Management and Multimodal
Strategies to Enhance Post
Operative Outcomes
Hamed Umedaly MD FRCPC
Anesthesiologist
Medical Director POPS
Vancouver Acute