Preemptive, preventive, multimodal analgesia: what do they really mean?-Preemptive, preventive, multimodal analgesia: what do they really mean?

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The document addresses the pressing issue of inadequate postoperative pain management, despite existing guidelines and advances in analgesic techniques. Over 86% of postoperative patients in the US experience pain, predominantly moderate to severe, even after they leave the hospital. Inadequate pain control can lead to serious outcomes like increased morbidity, extended hospital stays, and the development of persistent postoperative pain (PPP).<br /><br />To address this, different approaches have been suggested: preemptive analgesia, preventive analgesia, and multimodal analgesia. Preemptive analgesia involves administering pain relief before surgery to prevent central and peripheral sensitization. However, evidence on its effectiveness remains inconsistent, as many studies do not show significant benefits compared to post-incisional analgesia.<br /><br />Preventive analgesia, a broader concept, aims to minimize sensitization from noxious stimuli throughout the perioperative period. It is deemed effective if it reduces pain and analgesic consumption beyond the drug's normal duration of effectiveness, but current findings are mixed.<br /><br />Multimodal analgesia, meanwhile, employs a combination of different analgesics to improve pain control while minimizing side effects. This approach is preferred, involving drugs like opioids, local anesthetics, NSAIDs, and various adjuncts like steroids and NMDA antagonists. The objective is superior pain relief without the drawbacks of single-drug dependence, while also reducing opioid-related adversities.<br /><br />In summary, the document discusses the necessity of better understanding pain mechanisms and using diverse analgesic strategies to improve postoperative pain management. The use of multimodal analgesia is emphasized as the most effective approach, involving a combination of regional analgesia, non-opioid, and opioid analgesics tailored to individual patient needs.

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Author(s): Rosero, Eric B. MD, MSc; Joshi, Girish P. MBBS, MD, FFARCS Summary: To improve postoperative pain management, several concepts have been developed, including preemptive analgesia, preventive analgesia, and multimodal analgesia. This article will discuss the role of these concepts in improving perioperative pain management. Preemptive analgesia refers to the administration of an analgesic treatment before the surgical insult or tissue injury. Several randomized clinical trials have, however, provided equivocal evidence regarding the benefits of preincisional compared with postincisional analgesic administration. Current general consensus, therefore, indicates that use of preemptive analgesia does not translate into consistent clinical benefits after surgery. Preventive analgesia is a wider concept where the timing of analgesic administration in relation to the surgical incision is not critical. The aim of preventive analgesia is to minimize sensitization induced by noxious stimuli arising throughout the perioperative period. Multimodal analgesia consists of the administration of 2 or more drugs that act by different mechanisms for providing analgesia. These drugs may be administered via the same route or by different routes. Thus, the aim of multimodal analgesia is to improve pain relief while reducing opioid requirements and opioid-related adverse effects. Analgesic modalities currently available for postoperative pain control include opioids, local anesthetic techniques [local anesthetic infiltration, peripheral nerve blocks, and neuraxial blocks (epidural and paravertebral)], acetaminophen, nonsteroidal anti-inflammatory drugs, and cyclooxygenase-2-specific inhibitors as well as analgesic adjuncts such as steroids, ketamine, α-2 agonists, and anticonvulsants. Plastic and Reconstructive Surgery: October 2014 - Volume 134 - Issue 4S-2 - p 85S-93S doi: 10.1097/PRS.0000000000000671

Keywords

Eric B. Rosero MD

MSc; Girish P. Joshi MBBS MD FFARCS; Memben

postoperative pain management

analgesic techniques

multimodal analgesia

preemptive analgesia

preventive analgesia

pain control

opioid-related adversities

pain mechanisms

regional analgesia

analgesic strategies