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Multimodal Analgesia

Yusni Puspita
Department of Anaesthesiology and Intensive
Sriwijaya University
“Pain is an unpleasant sensory and emotional
experience associated with actual or potential
tissue damage and described in terms of such
21st century understanding of

• We now know that pain is a complex construct

with sophisticated transmission pathways in
the nervous system.
Physiology of Pain : Acute Pain Processing
• Transduction : pain is generated from local
inflammation and nerve damage caused by trauma or
temperature change. Cellular ion transfers generate an
action potential
• Transmission: Process in which the pain message
moves from the peripheral nervous system to the
dorsal horn, then along sensory tracts to the brain
• Perception: The signals are sent up the spinal cord to
the brain where they are perceived as pain.
• Modulation: Involves off-cells that inhibit pain related
information to the brain and on-cells that facilitate the
transmission of pain-related signals to the brain

Transduction Transmission Descending Perception

Local anesthetics Local anesthetics Opioids Opioids
(topical) (regional anesthesia)

NSAIDs, Cox 2 Opioids Acetaminophen NMDAr antagonists


Opioids Alpha2-agonists Cox 2 inhibitors General anesthetic

Antihistamines Gabapentinoids SNRIs Acetaminophen

Capsaicin NMDAr antagonists NMDAr antagonists

Multimodal Analgesia
• Multimodal analgesia, a concept first
articulated by Kehlet and Dahl

• Is now the foundation for the management of

acute postoperative pain
What is Multimodal Analgesia?
• The use of a number of drugs, analgesic or
adjuvant, in combination to achieve the best
pain relief in acute or chronic pain.
Multimodal Analgesia
• Different drugs act at different areas

• Intervening in all 3 areas more effective

• Reducing the total dose of any one drug and

therefore reducing unwanted effects.
What are the modes?
Reducing nociceptive input
• Peripherally acting drugs
– Local Anaesthetics
• Local infiltration
• Nerve blocks
• Spinal/Epidural blockade
• Cyloxygenase inhibition mixed action or specific.
What are the modes?
• Drugs acting in the spinal cord Opiates
NMDA receptor antagonists
What are the modes?
Drugs acting centrally
• Opiates
– Opiate receptors present in brain stem thalamus
and cortex
• Paracetamol
– Is conjugated with arachadonic acid to
Narachonoylphedamine a CB2 receptor agonist
and a TRVP receptor agonist
What are the modes?
Drugs which act on descending pathways
• Tramadol

• Clonidine

• 5HT3 antagonists
Multimodal Analgesia Protocol
Multimodal Analgesia Protocol
Goal of Analgesia
• Improve perioperative outcomes
• Achieve early mobilization
• Decrease postoperative complications
• Better address
• genetic differences in pain medication metabolism
• peripheral pain sensitization
• central sensitization
• ineffectiveness in pain control (tolerance and
opioid induced hyperalgesia)
Consequences of inadequate pain control

• Acute pain causes potensially detrimental

• physiologic responses:
• Tachycardia
• Hypertension
• Venous stasis
• Hypercoagulability
• Decrease alveolar ventilation
• Hyperglycemia
• Immunosuppression
• Cognitive dysfunction
• Ultimately these can lead to increased morbidity
• Persistent post-surgical pain (PPP) or chronic
• postsurgical pain (CPSP)
Pain Management Plan

Should be Individualized
• Patient
• Mechanism of pain
• Location of pain
• Type of surgical approach
• Expected duration of pain
• Less pain
• Fewer side effects
• Fewer complications
• Faster recovery
• Fewer days in Hospital
Robert Smith :

“There are no safe anaesthetic drugs, there are

no safe anaesthetic techniques, there are only
safe anaesthetists”