From the Guidelines
The latest management for acute pain in anesthesia involves a multimodal approach combining different medications and techniques to maximize pain relief while minimizing side effects, with a focus on pre-emptive analgesia and multimodal systemic analgesia, as recommended by the most recent guidelines 1. The cornerstone of this approach is pre-emptive analgesia, starting with acetaminophen up to 15 mg/kg every 6 hours (with a maximum of 4 g per 24 hours) as a good analgesic base in all patients except those with liver dysfunction, as suggested by the World Journal of Emergency Surgery 1.
- NSAIDs such as ketorolac or celecoxib can be used with caution due to the risk of platelet dysfunction and bleeding, as well as their effect on renal blood flow, especially in patients with a high risk of acute kidney injury (AKI) 1.
- Regional anesthesia techniques like peripheral nerve blocks or neuraxial anesthesia can significantly reduce opioid requirements, and are recommended for certain types of surgery, such as open rectal surgery, where they provide superior pain relief compared to systemic opioids 1.
- For moderate to severe pain, opioids remain important, with fentanyl, hydromorphone, or morphine titrated to effect, and patient-controlled analgesia (PCA) providing effective postoperative pain control 1.
- Adjuvants like ketamine, dexmedetomidine, and dexamethasone can enhance analgesia and reduce opioid consumption, although the use of gabapentinoids is not recommended in older patients for major surgery due to potential harm 1. This multimodal approach works by targeting different pain pathways simultaneously, reducing central sensitization, and minimizing the side effects associated with high-dose single-agent therapy, ultimately improving patient outcomes and reducing morbidity and mortality. Key considerations include the type of surgery, patient comorbidities, and the availability of an acute pain team to optimize analgesia and minimize side effects, as emphasized by the guidelines from the World Society of Emergency Surgery (WSES), Global Alliance for Infection in Surgery (GAIS), Italian Society of Anesthesia, Analgesia Intensive Care (SIAARTI), and American Association for the Surgery of Trauma (AAST) 1.
From the FDA Drug Label
Ketorolac tromethamine is indicated for the short-term (≤5 days) management of moderately severe acute pain that requires analgesia at the opioid level, usually in a postoperative setting The total combined duration of use of ketorolac tromethamine injection and oral ketorolac tromethamine is not to exceed 5 days of use because of the potential of increasing the frequency and severity of adverse reactions associated with the recommended doses Therapy should always be initiated with intravenous or intramuscular dosing of ketorolac tromethamine, and oral ketorolac tromethamine is to be used only as continuation treatment, if necessary Patients should be switched to alternative analgesics as soon as possible, but ketorolac tromethamine therapy is not to exceed 5 days.
The latest management strategies for acute pain in the field of Anesthesia include using ketorolac tromethamine for the short-term management of moderately severe acute pain, with a maximum duration of use of 5 days. Key points to consider are:
- Initiate therapy with intravenous or intramuscular dosing
- Use oral ketorolac tromethamine only as continuation treatment, if necessary
- Switch to alternative analgesics as soon as possible
- Do not exceed 5 days of ketorolac tromethamine therapy 2
From the Research
Management Strategies for Acute Pain
The latest management strategies for acute pain in the field of anesthesia involve a multimodal approach, combining different classes of analgesic drugs and techniques to maximize pain relief while minimizing adverse effects 3, 4, 5, 6. This approach is recommended by the American Society of Anesthesiologists and has been shown to be effective in reducing postoperative pain and opioid use.
Multimodal Analgesia
Multimodal analgesia involves the use of multiple agents with different mechanisms of action, including:
- Alpha 2 agonists, which have opioid-sparing effects but can cause hypotension and bradycardia 3
- NMDA receptor antagonists, such as ketamine, which has powerful analgesic effects and can be combined with other agents for synergistic effects 3
- Gabapentinoids, which have shown mixed results in studies but may be beneficial in certain cases 3, 6
- NSAIDs, which are effective analgesics for mild to moderate acute pain 4
- Acetaminophen, which is commonly used in multimodal approaches but has limited evidence for IV over oral formulations in patients who can take medications by mouth 3
- Dexamethasone, which reduces postoperative nausea and vomiting and is an effective adjunct in multimodal analgesia 3
- Duloxetine, a serotonin-norepinephrine reuptake inhibitor, which is a novel agent but requires further study 3
Regional Anesthesia
Regional anesthesia and analgesia have become increasingly utilized in the perioperative setting, including in critically ill patients 7. Various regional blocks, such as neuraxial and novel truncal blocks, can be employed to reduce acute perioperative pain, stress response, opioid use, and related side effects, and to expedite recovery and improve clinical outcomes.
Benefits of Multimodal Analgesia
The benefits of multimodal analgesia include: