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This highlights the importance of tailoring analgesic regimens to patient type. For example, elderly patients are more susceptible to the adverse effects of spinal analgesia and require lower doses, as their reduced volume of nerve myelination and cerebrospinal fluid CSF results in greater diffusion of local anesthetics and wider extension of nerve block.
Moreover, such blocks are resource-intensive due to the need for ongoing monitoring. Surgical site infiltration The incorporation of local anesthetics as part of multimodal analgesia decreases opioid requirements and side effects when used at several surgical sites e.
Consideration must be given to the risks resulting from local anesthetics, including cardiac effects e. Allergic reactions are rare but include skin rash, nausea and vomiting, loss of consciousness, fever, and hypotension.
Regional techniques Regional techniques, such as transversus abdominis plane TAP block and paravertebral block PVB, are increasingly incorporated into multimodal analgesic regimens, with good evidence for their efficacy in ERAS protocols.
Addition of the bilateral TAP block to an established enhanced recovery pathway using general anesthesia was found to decrease postoperative opioid requirements and LOS after laparoscopic colorectal surgery.
One study found that, after laparoscopic colorectal surgery, a four-quadrant TAP block with continuous infusion via bilateral posterior TAP catheters 0.
Moreover, PVB use is associated with a shorter LOS, thus supporting its utility in fast-track thoracic surgery, for which TEA is typically considered the optimal technique for post-thoracotomy pain. Systemic analgesia Opioids Opioids are the mainstay of postoperative analgesia for many surgeries.
While they are effective for moderate to severe pain, their usage is limited by dose-related adverse effects, including PONV, urinary retention, ileus, pruritus, and most dangerously, respiratory depression.
Acetaminophen paracetamol Acetaminophen is an effective analgesic for mild to moderate pain.
There is increasing usage of intravenous acetaminophen, which has more favourable pharmacokinetics earlier plasma and CSF peaks than oral and rectal formulations, 44 but is more costly than the latter two. Studies are currently lacking that directly compare oral with intravenous acetaminophen, but thus far, studies of intravenous acetaminophen have been encouraging.
Adding to the value of acetaminophen in multimodal analgesia is its apparent synergistic effect with non-steroidal anti-inflammatory drugs NSAIDs.
For instance, the combination of single-dose acetaminophen 0. The greatest benefit occurred with abdominal surgery. Although the same meta-analysis found that only 12 of 29 eligible studies screened for adverse events, incidences of cardiac and neurologic adverse events were comparable between control and treatment groups in these studies.
Non-steroidal anti-inflammatory drugs and COX-2 inhibitors Non-steroidal anti-inflammatory drugs including cyclooxygenase-2 inhibitors reduce opioid consumption and opioid-related side effects when used in multimodal regimens.