Currently available data show that a multimodal programme of perioperative physical therapy and rehabilitation can reduce hospital stay, improve the control of dynamic pain and reduce the morbidity and mortality associated to the surgical procedure. We should begin with perioperative care that includes pain as the fifth vital sign, use of regional analgesia to decrease opioid consume, a responsible fluid therapy, maintaining intraoperative normal body temperature, early postoperative mobilisation, shortening the return to oral intake, avoiding motion-restriction factors such as drains due to less invasive surgical techiques, as well as improving postoperative sleep and stress, as they play a key role in reducing convalescence. Acute postoperative pain units are the key starting point for setting these programmes into motion, requiring the coordination between all healthcare specialists involved.

It has been recently published that the adition of IV acetaminophen (paracetamol) to a multimodal analgesia regimen can improve patient´s outcome. The authors have summarized many studies demonstrating the robust effect of IV acetaminophen on patient satisfaction. There is clear potential for IV acetaminophen to reduce the incidence of opioid-related adverse events and, in so doing, result in net hospital savings IV acetaminophen adds to drug costs. The body of evidence indicates this drug has the potential to improve outcomes and hospital efficiency.

What´s your opinion about it?

Article Intravenous Acetaminophen: A Review of Pharmacoeconomic Scie...

In this review pain relief per se did not significantly improve postoperative outcome, with the exception of patient satisfaction and pulmonary complications. Thus, postoperative morbidity and hospital stay are dependent on multiple factors, including preoperative information, quality of analgesia, and existing programs for postoperative

care and rehabilitation, including orders for mobilization, oral nutrition, and discharge criteria. Therefore, to elucidate the potential for postoperative pain relief and for an Acute Pain Service to improve postoperative morbidity and hospital stay, multimodal rehabilitation programs (fast-track surgery, clinical pathways) must be established in which postoperative pain relief is integrated into an enforced rehabilitation program with early mobilization and oral nutrition, with well defined discharge criteria.

Article Does an Acute Pain Service Improve Postoperative Outcome?

Multimodal approach seems to be the most promising therapy. Block the pain in periphery and at spinal level at a time would be the best way to alleviate the nociception.

I'm not convinced. I read the BJA paper review mentioned by Borja on the adition of IV acetaminophen (paracetamol), but still overall evidence is weak. Paracetamol use is such a knee-jerk-reflex that PACU nurse looks at me as a criminal "because I have not given anything for pain", even though the latest opioid dose has always been just 20 minutes ago.

Here's a quote from The Lancet www.thelancet.com Vol 377 June 25, 2011, page 2219

(also have a look at the latest ASA refresher course lectures). Belief is stringer than science here. But the IV paracetamol company reps are doing a great job at our place, I guess.

So, from the Lancet reference www.thelancet.com Vol 377 June 25, 2011, page 2219:

Multimodal analgesia and adjuvant agents

The use of multimodal analgesia, a strategy that concurrently uses more than one class of analgesic agent or technique (table), has been advocated as a means to improve analgesia through either additive or synergistic effects while reducing opioid-related side-effects.65 Although there are many permutations by which analgesics can be combined, multimodal analgesia realistically can be defined as a combination of an opioid and non-opioid analgesic, with or without a regional anaesthetic block, typically resulting in improved analgesia with concurrent reduction in the incidence of some opioid- related side-effects (eg, a decrease in postoperative nausea, vomiting, and sedation), presumably through an opioid- sparing effect.66,67 As a whole, research into multimodal analgesia does not reveal a consistent level of success, in part because of the large number of variables (eg,different doses or analgesic agents or techniques, type of surgery) present in available studies; however, some multimodal analgesia trials have shown improved outcomes or lowered incidence of chronic postsurgical pain.68,69