Anaes · Acute pain & multimodal analgesia
Acute pain & multimodal analgesia
Also known as Acute pain service · Multimodal analgesia · Opioid-sparing · PCA · Fascial plane blocks · Postoperative pain
Exam-exhaustive acute pain: WHO-style ladder adapted to acute surgical pain, multimodal components with doses, PCA principles, regional integration, and brief opioid-tolerant patient strategy.
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Red flags
- Uncontrolled acute pain causes atelectasis, ileus, DVT risk, delayed mobilisation, and chronic postsurgical pain — treat function, not only the number.
- PCA background infusions in opioid-naïve patients increase respiratory depression risk — usually avoid.
- Opioid-tolerant patients need baseline continuation + multimodal + regional/ketamine — not moralising dose cuts.
- Epidural haematoma/abscess and LAST are regional emergencies — know the pathways.
- Multimodal means different mechanisms — not three opioids.
Meet the patient
A 68-year-old man is day one after open colectomy. His pain is 8 out of 10 on movement, he cannot cough or mobilise, and the ward nurse has been pressing his PCA button for him — proxy pressing that breaks the core PCA safety rule (taught safety rule — the LAST advisory [1] owns no PCA claim). The question the acute pain service asks on review is the one that changes the trajectory: is this an opioid-dose problem, or a multimodal-gap problem?[1]
The answer is almost always the latter. The PCA bolus was increased twice overnight with no improvement, because the foundation — regular paracetamol, NSAID, regional technique — was never laid. Multimodal means different mechanisms, not three opioids (taught framework).[1]
References3ShowHide
- [1]Neal JM et al. The Third American Society of Regional Anesthesia and Pain Medicine Practice Advisory on Local Anesthetic Systemic Toxicity: Executive Summary 2017 Reg Anesth Pain Med, 2018.PMID 29356773
- [2]Horlocker TT et al. Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Fourth Edition) Reg Anesth Pain Med, 2018.PMID 29561531
- [3]Gan TJ, et al. Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting Anesth Analg, 2020.PMID 32467512