Multimodal Analgesia in the Perioperative Period of Major Surgeries: An In-depth Analysis

Author(s): Sean Kincaid, Justine How, Devendra K Agrawal

The successful management of postoperative pain remains a significant challenge to patient recovery following high-risk surgeries, often leading to the overuse of opioids and increasing dangers for developing chronic postsurgical pain (CPSP). CPSP is defined as pain persisting for at least 3 months after surgery, beyond the expected healing window. CPSP can develop after any type of surgery, but especially very traumatic ones- where nerve injury, inflammation, and abnormal central sensitization cause acute postoperative pain to transition into chronic pain. Multimodal analgesia (MMA) is an integrated pain management approach that employs a wide range of drug interventions with the end goal of achieving a synergistic effect in pain reduction and recovery. This method is used to reduce the necessity for opioids due to their addictive properties and other detrimental side effects. Anchored in Enhanced Recovery After Surgery (ERAS) protocols, MMA is a tailored approach that takes into consideration various pain pathways, such as nociceptive, neuropathic, and inflammatory. These methods can widely differ across various surgical categories, as each patient and procedure present distinct complications to address. Current studies offer a vast array of interventions with shifting impacts on recovery, though there is general agreement on certain specific, consistently effective approaches. This review critically reviewed the most widely accepted MMA strategies across orthopedic, thoracic, abdominal, breast, and amputation procedures, while also identifying areas for further optimization. Overall, the multimodal analgesia reduces opioid intake in the postoperative setting and benefits patients undergoing multiple procedures. However, there is a need for integrative, patient-tailored algorithms supported by predictive analytics and perioperative data to personalize MMA plans. Further investigations using high-quality, procedure-specific randomized controlled trials are warranted to evaluate short-term analgesic success and long-term quality-of-life metrics.