Multimodal Approaches to Minimizing Side Effects

As more complex procedures are performed with minimally invasive surgical approaches (e.g., laparoscopic adrenalectomy and nephrectomy, arthroscopic knee and shoulder reconstructions), the ability to effectively control postoperative side effects may make the difference between performing a given procedure on an inpatient or ambulatory basis. The introduction of multimodal approaches to perioperative care has led to improved surgical outcomes.^[525] For routine antiemetic prophylaxis, the most cost-effective combination consists of low-dose droperidol (0.5 to 1 mg) and dexamethasone (4 to 8 mg).^[179] Interestingly, dexamethasone appears to facilitate earlier discharge independent of its effects on PONV.

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A multimodal (or "balanced") approach to providing postoperative analgesia is also essential in the ambulatory setting.^{[5] [41] [529]} Not surprisingly, pain has been found to be a major factor complicating recovery and delaying discharge after ambulatory surgery.^[260] The addition of low-dose ketamine (75 to 150 µg/kg) to a multimodal analgesic regimen improved postoperative analgesia and functional outcome after painful orthopedic surgery procedures. ^{[253] [274] [444] [530]} Acetazolamide (5 mg/kg IV) reduces referred pain after laparoscopic surgery with CO₂ insufflation.^[531] In addition, when compared with the conventional CO₂ technique, reduced pain and shorter convalescence were achieved after minilaparoscopic cholecystectomy simply by using a gasless technique.^[35] The use of nitrous oxide for pneumoperitoneum was also associated with less postoperative pain than the standard CO₂ technique was.^[532]

After outpatient surgery, pain must be controllable with oral analgesics (e.g., acetaminophen, ibuprofen, acetaminophen with codeine) before patients are discharged from the facility. Although the potent rapid-acting opioid analgesics (e.g., fentanyl, sufentanil) are commonly used to treat moderate to severe pain in the early recovery period, these compounds increase the incidence of PONV and may contribute to delayed discharge after ambulatory surgery.^{[127] [260]} As a result of the concern regarding opioid-related side effects, interest has increasingly focused on the use of potent NSAIDs (e.g., diclofenac, ketorolac), which can effectively reduce the requirements for opioid-containing oral analgesics after ambulatory surgery and lead to earlier discharge home.^[533] Other less expensive oral nonsteroidal analgesics (e.g., ibuprofen, naproxen)^{[534] [535]} may be acceptable alternatives to fentanyl and the parenteral nonselective NSAIDs if administered in a preemptive fashion. Recently, premedication with the COX-2 inhibitors (e.g., celecoxib, rofecoxib, valdecoxib, parecoxib) has become more popular because they are devoid of potential adverse effects on platelet function.^[123]

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One of the keys to facilitating the recovery process is the routine use of local anesthetics as part of a multimodal regimen.^[127] The use of local anesthetics for perioperative analgesia during MAC, as well as adjuncts to general and regional anesthesia, can provide excellent analgesia during the early recovery and postdischarge periods.^{[480] [492] [493]} Even simple wound infiltration and instillation techniques have been shown to improve postoperative analgesia after a variety of lower abdominal, peripheral extremity, and even laparoscopic procedures. A wide array of peripheral extremity blocks have also been used to minimize postoperative pain.^{[393] [541]} More recently, the use of continuous local anesthetic delivery systems has been found to improve pain control after major ambulatory orthopedic surgery by extending peripheral nerve blocks.^{[395] [397] [398]} Patient-controlled local anesthetic delivery has also been described for improving pain relief after discharge home.^{[402] [542]}

For laparoscopic procedures, abdominal pain can also be minimized by the use of a local anesthetic at the portals and topical application at the surgical site. Shoulder pain is also common after laparoscopic surgery, and this pain has been reported to be reduced with subdiaphragmatic instillation of local anesthetic solutions.^[543] After arthroscopic knee surgery, instillation of 30 mL of 0.5% bupivacaine into the joint space reduces postoperative opiate requirements and permits earlier ambulation and discharge.^[544] The addition of morphine (1 to 2 mg), ketorolac (15 to 30 mg), clonidine (0.1 to 0.2 mg), and/or triamcinolone (10 to 20 mg) to the intra-articular local anesthetic solution can further reduce pain after arthroscopic surgery.^{[545] [546] [547] [548]} Finally, simple electroanalgesic techniques (e.g., transcutaneous or percutaneous electrical nerve stimulation) can also be used as part of a multimodal treatment regimen.^[549] Future growth in the complexity of surgical procedures being performed on an ambulatory basis will require further improvements in our ability to provide effective postoperative pain relief outside the surgical facility.