Multimodal Analgesia

Multimodal Analgesia

David Ray Velez, MD

Table of Contents

Definition
Basic Approach
Options

Definition

Multimodal Analgesia: The Use of Multiple Different Classes of Medications to Simultaneously Manage Pain

Should Be Used Routinely in the Management of Traumatic Injury and Surgical Pathology to Minimize Narcotic Usage

Basic Approach

Generally Follow a Tiered Approach to Sequentially Escalate Potency Based on Objective Measures

Tier I: Scheduled Non-Narcotics with As Needed/Breakthrough Narcotics

  • Ice and Heat to Affected Tissues
  • Any Appropriate Non-Pharmacologic Adjuncts
  • Scheduled Acetaminophen and NSAID of Choice
  • Consider As Appropriate:
    • Gabapentin
    • Muscle Relaxant
    • Lidocaine Patch
  • Low Dose Oral Narcotic for Moderate-Severe Pain
  • Low Dose IV Narcotic for Breakthrough Pain

Tier II: Locoregional Analgesia

  • Neuraxial Anesthesia (Epidural Catheter)
  • Peripheral Nerve Block
  • Pain Pump (Bupivicaine Infusion)

Tier III: IV Infusion

  • Narcotic Patient Controlled Analgesia (PCA)
  • Ketamine Infusion
  • Lidocaine Infusion

Options

Basic Analgesia (Tylenol and NSAID’s)

  • Acetaminophen (Tylenol) – 1,000 mg PO Every 6-8 Hours
  • Non-Steroidal Anti-Inflammatory Drugs (NSAID’s):
    • Ibuprofen (Motrin/Advil) – 600-800 mg PO Every 6-8 Hours
    • Ketorolac (Toradol) – 15 mg IV Every 6 Hours
    • Celecoxib (Celebrex) – 100-200 mg PO Every 12 Hours
    • *NSAIDs Do NOT Increase Risk of Bleeding or Inhibit Bone/Wound Healing

Adjuvants

  • Muscle Relaxants:
    • Cyclosporine (Flexeril) – 5-10 mg PO Every 8 Hours
    • Methocarbamol (Robaxin) – 500-1,000 PO or IV Every 6-8 Hours
  • Gabapentin (Neurontin) – 100-300 mg PO Three Times Daily
  • Alpha-2 Blocker: Clonidine (Catapres) –0.1-0.6 mg PO Two Times Daily
  • Lidocaine Patch – Changed Every 1-3 Days

Locoregional Analgesia

  • Neuraxial Anesthesia (Epidural Catheter)
  • Peripheral Nerve Blocks:
    • Intercostal Nerve Blocks
    • Paravertebral Block (PVB)
    • Erector Spinae (ESP) Block/Catheter
    • Transversus Abdominis Plane (TAP) Block
  • Pain Pump (Bupivicaine Infusion)

Narcotic Analgesia

  • Oxycodone – 5-15 mg PO Every 4 Hours as Needed
  • Dilaudid – 0.5-1.0 mg IV Every 2-4 Hours as Needed
  • Fentanyl – 25-100 mcg IV Every 1-2 Hours as Needed

Infusions

  • Narcotic Patient Controlled Analgesia (PCA)
  • Ketamine Infusion
  • Lidocaine Infusion

Non-Pharmacologic Adjuncts

  • Ice and Heat to Affected Tissues
  • Exercise with PT/OT
  • Normalize Life
  • Normalize Sleep-Wake Cycle
  • Aromatherapy
  • Massage
  • Spirituality