What is the recommended analgesia regimen post-reconstruction?

Recommended Analgesia Regimen Post-Reconstruction Surgery

The optimal post-reconstruction analgesia regimen should include a combination of NSAIDs and paracetamol as baseline treatment, supplemented with regional anesthesia techniques and rescue opioids as needed, following a multimodal approach to minimize opioid requirements while providing effective pain control. 1

Multimodal Analgesia Framework

Basic Analgesic Regimen

• First-line medications:
  • NSAIDs (oral or IV): Ibuprofen 10 mg/kg every 8 hours or diclofenac 1 mg/kg every 8 hours 1
  • Paracetamol (oral or IV): 10-15 mg/kg every 6 hours (max daily dose: 60 mg/kg) 1
  • These should be administered pre-operatively or intra-operatively and continued throughout the postoperative period 1

Regional Anesthesia Techniques

Based on reconstruction type:

For Orthopedic Reconstruction (e.g., Total Hip Arthroplasty):

• Single-shot fascia iliaca block or local infiltration analgesia is recommended 1
• For major reconstructive procedures, consider:
  • Femoral nerve block or posterior lumbar plexus block (more effective but higher risk of complications) 1
  • Continuous infusion via catheter for extended analgesia 1

For Upper Limb/Shoulder Reconstruction:

• Continuous interscalene block is preferred over single-shot block 1
• If interscalene block is not possible, axillary nerve block with or without suprascapular nerve block 1

For Pediatric Urological Reconstruction (e.g., Hypospadias):

• Ultrasound-guided caudal block with long-acting local anesthetics 1
• For severe proximal/perineal abnormalities, consider continuous lumbar epidural block 1

Adjunct Medications

• Single intraoperative dose of IV dexamethasone 8-10 mg for analgesic and anti-emetic effects 1
• Consider methylprednisolone or dexamethasone to reduce postoperative swelling 1
• For major reconstructive procedures, consider intraoperative ketamine (0.5 mg/kg) as co-analgesic 1

Rescue Analgesia

• In PACU: IV fentanyl (1-2 μg/kg) or equivalent opioid for breakthrough pain 1
• On ward:
  • For moderate pain: Oral/IV/rectal tramadol or nalbuphine (for infants) 1
  • For severe pain in major reconstruction: IV-PCA with appropriate monitoring 1
  • Opioids should be reserved as rescue analgesics only 1

Specific Considerations by Surgery Type

Major Reconstructive Surgery

• Consider patient-controlled analgesia (IV-PCA) with appropriate monitoring 1
• With epidural catheter: patient-controlled regional anesthesia with monitoring 1
• Continue regional blocks with low concentration local anesthetic infusion 1

Thoracic Reconstruction

• Continuous thoracic epidural analgesia with long-acting local anesthetic plus adjuncts for open procedures 1
• For thoracoscopic procedures, paravertebral block with long-acting local anesthetic 1

Implementation Pearls

Key Clinical Pitfalls to Avoid

1. Inadequate baseline analgesia: Always use a combination of two non-opioid drugs (NSAID and paracetamol) to reduce opioid requirements 1
2. Delayed administration: Start analgesics pre-emptively (pre-operatively or intra-operatively) rather than waiting for pain to establish 2
3. Inappropriate route selection: Transition to oral administration as soon as possible; avoid intramuscular administration due to injection-associated pain 1
4. Inadequate monitoring: Ensure appropriate monitoring when using PCA, regional techniques, or significant opioid doses 1

Special Considerations

• Contraindications to NSAIDs: Use paracetamol as primary agent in patients with bleeding disorders, renal dysfunction, or NSAID sensitivity 2
• Regional anesthesia complications: Use ultrasound guidance when available to reduce risk of complications 1
• Pediatric dosing: Adjust all medication doses according to weight and age as specified in guidelines 1

The evidence strongly supports this multimodal approach to post-reconstruction analgesia, with the most recent guidelines emphasizing the importance of combining non-opioid analgesics as baseline treatment with appropriate regional techniques, reserving opioids for breakthrough pain only 1.