This review lays out the rationale and evidence for multimodal (balanced) analgesia in postoperative pain. It asks whether combining analgesics acting at different sites beats single-drug treatment. The focus is on moderate-to-severe pain and relief during function, not just at rest.
The core teaching: total pain relief allowing normal function cannot come from one drug without major side effects or monitoring burden. The fix is to attack pain at multiple points along the nociceptive pathway. Peripheral (NSAID, local anesthetic), spinal (epidural local anesthetic plus opioid), and central levels combine for additive or synergistic effect at lower individual doses.
The decision rule for major surgery: a low-dose epidural bupivacaine-opioid infusion is the most effective and reliable base. Add local anesthetic to opioid, not the other way around, and dose lower in the lumbar space to avoid motor block and orthostatic hypotension.
The most testable concept is assessing pain during movement. A regimen that looks equal at rest can be clearly superior during cough and mobilization, and mobilization is what drives recovery. This paper is a conceptual foundation for modern enhanced recovery protocols, though the authors note the outcome data were still scarce in 1993.
This review lays out the rationale and evidence for multimodal (balanced) analgesia in postoperative pain. It asks whether combining analgesics acting at different sites beats single-drug treatment. The focus is on moderate-to-severe pain and relief during function, not just at rest.
The core teaching: total pain relief allowing normal function cannot come from one drug without major side effects or monitoring burden. The fix is to attack pain at multiple points along the nociceptive pathway. Peripheral (NSAID, local anesthetic), spinal (epidural local anesthetic plus opioid), and central levels combine for additive or synergistic effect at lower individual doses.
The decision rule for major surgery: a low-dose epidural bupivacaine-opioid infusion is the most effective and reliable base. Add local anesthetic to opioid, not the other way around, and dose lower in the lumbar space to avoid motor block and orthostatic hypotension.
The most testable concept is assessing pain during movement. A regimen that looks equal at rest can be clearly superior during cough and mobilization, and mobilization is what drives recovery. This paper is a conceptual foundation for modern enhanced recovery protocols, though the authors note the outcome data were still scarce in 1993.