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Multimodal Analgesia

Origin
The concept of multimodal analgesia was born in the 1990’s and was driven by teams involved in analgesic strategies. Such teams included those of JB Dahl, H Kehlet or GP Joshi. The concept is based on the following facts:

  1. Some pains cannot be relieved by one analgesic only, especially since nociceptive mechanisms differ from one surgical procedure tanother.
  2. Opioids have adverse effects mostly because of the doses, and these effects are all the more present as the drug is prescribed alone. Moreover, opiates dnot relieve pain in dynamic conditions.
  3. Associating analgesics that act at different sites of action increases the analgesic effect, and thus, decreases the pain score at rest, and for some drugs associations, on movement.
  4. Combining analgesics acting at different levels reduces drug consumption, in particular opioids consumption, with a decrease in adverse effects.


Objective

Multimodal analgesia is an efficient strategy in the treatment of postoperative pain(1).
This approach consists in associating several analgesics in order tobtain synergistic or additive analgesic effects. This technique leads tan optimal analgesia, with a decrease in adverse effects due tthe decrease in doses of analgesic drugs (2).

“Multimodal analgesia is about associating analgesic drugs and techniques that have different and complementary sites of action, which leads tadditive, and even synergistic interactions”.
Chauvin M. Multimodal analgesia.
In “Les essentiels”. 47th congress of anesthesia and reanimation. 2005.

1

Definition
ADDITIVE EFFECT = effect equal tthe sum of each effect of the products taken individually.

SUPRA-ADDITIVE (SYNERGISTIC) EFFECT = effect bigger than the sum of each effect of the products taken individually.
INFRA-ADDITIVE EFFECT = effect smaller than the sum of each effect of the products taken individually.
Chauvin M. Multimodal analgesia. “Les essentiels”. Elsevier. 2005 : 295-308

  1. Huang N, Cunningham F, LauritCE, et al. Can we dbetter with postoperative pain management.
    Am J Surg 2001; 182: 440-48
  2. Kehlet H, Dahl JB. The value of « multimodal » or « balanced analgesia » in postoperative pain treatment.
    Anesth Analg 1993; 77: 1048-5

The concept of multimodal analgesia is well-established in medical practice, and is recommended by scientific societies such as:

  • The American Society of Anesthesiologists (1)
  • The American Pain Society (2)
  • The SFAR: French Society of Anesthesia and Reanimation (3)
  • The Latinoamerican confederation of anesthesiologists (4)
  1. American Society of Anesthesiologists Task Force on Acute Pain Management. Practice guidelines for acute pain management in the perioperative setting : an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology. 2004 ; 100 : 1573-1581.
  2. Gordon DB, Dahl JL, Miaskowski C et coll. American Pain Society recommendations for improving the quality of acute and cancer pain management. Arch Intern Med. 2005 ; 165 : 1574-1580.
  3. http://www.sfar.org/douleurpratique.html
  4. http://www.clasa-anestesia.org/


Evaluation of postoperative pain

Pain is a subjective and multifactorial phenomenon, with sensory and emotional components, the measure of which is difficult.

Quantitative and qualitative self-evaluation is the most adapted method of evaluation during the postoperative period.

Example of one-dimensional self-evaluation scales:

  1. The simple verbal evaluation scale (SVS), from 0 (npain) t5 points (extreme pain)
  2. The numeric evaluation scale (NES), from 0 (absence of pain) t10 or 100 points (worst possible pain)
    • Favorite tool for old patients or nurses
  3. The visual analog scale (VAS) is a small plastic 10-cm ruler with a millimetric scale. One side is for the caregiver, the other for the patient. Its extremities are marked “absence of pain” and “worst possible pain”.
    Measurement is fast, easy, valid and reproducible.

2
(1) M. Navez, Évaluation de la douleur de l’enfant et de l’adulte, Conférences d’actualisation 2003,
p. 335-355. 2003 Elsevier.

It is important tuse tools that have been validated in order ttake intaccount the pain of a patient and tundertake necessary actions.
Scales are a tool for follow-up and evaluation
of the treatment.
3

Objectives of the evaluation of pain:

  • Determine the treatment (choosing a molecule)
  • Adapt the treatment (efficient posology)
  • Provide clear and relevant information tother caregivers
  • Improve caregiver / patient relationship in order tbuild trust and favor collaboration

Key points

  • The concept of multimodal analgesia is now an indispensible prerequisite for optimizing postoperative care
  • Acupan, with its unique mechanism of action, plays a central role in multimodal analgesia.
  • The most studied molecules associated with Acupan are NSAIDs/morphine/paracetamol
  • Pain must be systematically evaluated postoperatively and for that, there are validated scales. Evaluation is associated with a better global care of the patient
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