Multimodal Perioperative Management

The analgesic benefits of controlling postoperative pain are generally maximized when a multimodal strategy to facilitate the patient's convalescence is implemented.^{[47] [48]} Postoperative pain treatment may not be enough to provide major improvements in some outcomes because it is unlikely that unimodal intervention can be effective in addressing a complex problem such as perioperative outcomes.^{[18] [49]} Principles of a multimodal strategy include control of postoperative pain of the patient to allow early mobilization, early enteral nutrition, education, and attenuation of the perioperative stress response through the use of regional anesthetic techniques^[18] and a combination of analgesic agents (i.e., multimodal analgesia).^[50] The use of epidural anesthesia and analgesia is an integral part of the multimodal strategy because of the superior analgesia^{[51] [52]} and physiologic benefits^{[19] [23]} conferred by epidural analgesia.

A multimodal strategy to control postoperative pathophysiology and facilitate rehabilitation results in accelerated recovery and decreased length of hospitalization.^[47] Patients undergoing major abdominal or thoracic procedures and who participate in a multimodal strategy have a reduction in hormonal and metabolic stress, preservation of total-body protein, shorter times to extubation, lower pain scores, earlier return of bowel function, and earlier fulfillment of intensive care unit discharge criteria.^{[53] [54] [55]} The multimodal approach may even reduce the length of hospitalization for patients undergoing colon resection from a median of 6 to 10 days to 2 days.^[56] By integrating the most recent data and techniques from surgery, anesthesiology, nociceptive neurobiology, and pain treatment, the multimodal approach may be seen as an extension of "clinical pathways" or "fast tracks" by revising traditional care programs into effective postoperative rehabilitation pathways.^[47] This approach may decrease perioperative morbidity, decrease the length of hospital stay, and improve patient satisfaction without compromising safety. However, the widespread implementation of these programs requires multidisciplinary collaboration, change in the traditional principles of postoperative care, additional resources, and expansion of the traditional acute pain service, which may be difficult in the current economic climate.^{[18] [47] [57]}