Biological Cascade: Efficacy of Multimodal Analgesic Administration

The assignment content discusses the related events of biological cascade in patient-controlled dosages of analgesics and their adverse effects. While patient-controlled dosages involve effective control of symptoms, multimodal platforms of analgesic administration have been found to reduce hospitalization periods and alleviate adverse side effects. This is likely due to the combination of optimal dosages of individual analgesics in the multimodal approach.

Patient controlled surgical pain management 1
Patient controlled surgical pain management
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Patient controlled surgical pain management 2
Patient controlled surgical pain management
Introduction:
In a majority of patients undergoing surgical procedures, the incidence of postoperative
discomfort and acute presence of pain is a consistent occurrence [1]. The pain reported by most
patients range from being moderate, severe or even extreme in some cases [1]. Due to the
incidence of such persistent and acute pain in patients is of considerable severity [1]. The
evidence present in literature and as suggested by research, the relief of postoperative pain in
most patients is reported as being low and the postoperative pain relief is mostly inadequate [1].
The control of postoperative pain is inadequate in most cases and thus most aspects of the
patient’s life are impacted [1]. The quality of life, mobility, and activities of daily life are
affected adversely due to the persistent pain [1]. Postsurgical pain, thus affects the functioning of
the patient in everyday life and the recovery of functionality, postsurgical complications, and
inadequate response to pain stimuli [1].
The common interventions undertaken at the various stages of surgery are mostly ineffective in
pain management [1]. The common interventions are carried out firstly in the preoperative stage
wherein there is no specific requirement for pain relief or management [1]. The next stage of
medical intervention is the intraoperative stage [1]. Intraoperative pain management mainly
includes immediate symptom relief and management of discomfort affecting the surgical
protocol [1]. Further, the final stage includes the postoperative intervention that involves the
management of pain in individuals following the surgery [1]. Research indicates that most
postsurgical interventions do not adequately address the pain and the relief from pain is not
achieved in absolution [1]. The persistence of postsurgical pain is a limiting factor in the lives of

Patient controlled surgical pain management 3
the patients and thus, the degree of their functionality is greatly reduced [1]. The discomfort and
pain present in individuals at the postsurgical stage mainly leads to reduced quality of life and
decreased mobility [1]. The medical interventions and strategies of management of pain although
available in most patient care facilities, the research and evolution of more efficient pain
reduction strategies is a continuous process [1]. The American Pain Society (APS) with the
inclusion of research conducted by the American Society of Anesthesiologists (ASA) has
commissioned a guideline document for the effective management of pain in postoperative
patients [1]. The guideline emphasizes the management of postoperative pain in the patients by
way of promotion of techniques which rely on the evidence of incidence of pain [1]. The pain
management technique needs to be chosen primarily on the basis of the effectiveness and safety
of the technique [1]. Since the pain management needs to be carried out in both children and
adults, the effectiveness of the pain management technique depends on the medical intervention
and effective identification of pain [1]. The areas of pain management that need to be addressed
include raising awareness and educating the patients at the preoperative stage, the effective
planning of pain management at the perioperative intervention stage, use of variant strategies of
modalities belonging to pharmacological and non-pharmacological categories, policies and
procedures that are mainly of the organizational importance [1]. The final stage is the transition
of the intervention into the stage of caring for outpatients [1]. The pain relief in postoperative
patients is linked to mobilization and functionality in daily life [1]. Due to this, most patients
need to undergo several physiotherapy and medical interventions without achieving complete or
even satisfactory pain relief [1]. The use of analgesics in pain management is a topic of much
debate research concerning postoperative pain relief [1]. The comfort level of the patient is
mostly connected to satisfactory relief from pain and ease of mobility [1].

Patient controlled surgical pain management 4
Poor recovery of functional aspects in postsurgical patients has been associated with inadequate
management of postsurgical pain [1]. This leads to the activation of a variety of cascade systems
of biological functions in the body following the surgical procedure [1]. This results in side
effects such as ileus, delayed or compromised mobility, limitations in feeding, nausea, delay in
discharge from hospital, and readmission into hospital care at unexpected instances [1].
Therefore, understandably, the primary concern in most patients is the incidence of pain in the
postsurgical phase [1]. The upper extremities tend to be relatively more vulnerable to the
incidence of injury due to which they have a higher predisposition to surgical interventions [1].
Additionally, since the upper extremities typically have the utility for multiple joints, they have
the requirement for fine degrees of manipulation of the joints [1]. Thus, when there is a poor
intervention setup of postoperative rehabilitation and pain management along with longer
periods of immobilization ultimately result in several complications [1]. Common complications
include stiffness of the joint and complex regional syndrome [1]. These complications have
several negative implications on the functional outcomes in most postoperative patients [1]. As
an important part of the pain management technique in postoperative patients, analgesia has been
used as a primary agent in most interventions [1].
Patient controlled epidural analgesia (PCEA):
Pain control is considered as one of the most important considerations in postsurgical
interventions [2, 3]. The primary reason for this is that pain control has been linked to
mobilization at the earlier stages, improvement in the total range of motion, and overall reduction
in the time taken for complete healing [2, 3]. The cost of medical intervention and the length of
stay that are affected by the surgical process cause a significant limitation in the quality of life of

Patient controlled surgical pain management 5
the individual involved [2, 3]. Thus, a recent and effective approach to the management of
postoperative pain is the use of patient controlled epidural analgesia (PCA/PCEA) [2, 3]. PCEA
has been utilized on several occasions [2, 3]. Additionally, PCEA has been viewed as being an
effective form of administrating postoperative analgesia [2, 3]. However, PCEA has been found
to induce urinary retention, pruritus, and hypertension amidst other symptoms [2, 3]. It is also
seen as being responsible for causing blockade in motor functions [2, 3]. PCEA is likely to lead
to considerable increase in the length of stay in the hospital [2, 3]. Most patients often experience
nausea and vomiting continuously due to which the length of hospital stay is enhanced [2, 3].
The result of such unpleasant side effects is that the pain management is carried out in various
other forms and modes of pain control [2, 3]. A few common methods of pain management
include periarticular injection (PAI) with the administration of medications including morphine,
corticosteroids, non-steroidal anti-inflammatory drugs (NSAIDS), and even local anesthetics in
most cases [2, 3]. The pain regimen is primarily of a multimodal structure [2, 3]. The primary
goal of the regimen is to target the various pathways of pain is a manner of synergy and
congruence to the human system [2, 3]. Most of the specific agents used for the pain
management technique include several analgesics and anti-inflammatory properties [2, 3]. The
most common preemptive method or intervention is mainly achieved by the administration of
medications at the preoperative stage [2, 3]. The most commonly observed levels of pain in the
postoperative patients range from being moderate to a severe amount of pain [2, 3]. This is one
of the most common complaints in most individuals [2, 3]. Pain which is not completely
managed or relieved leads to the initiation of a consequent stress response in most patients [2, 3].
This in turn leads to unpleasant delays in hospitalization, medication, and recovery [2, 3]. As
described earlier, patient controlled analgesics of PCA is regarded as an effective and well-

Patient controlled surgical pain management 6
designed technique for the management of pain in most postsurgical patients [2, 3]. PCA is
characterized by a technique of pain management in which the patients administer narcotic
medication themselves [2, 3]. This ensures that the administration occurs only in times of need
[2, 3]. However, although narcotics are considered as some of the most effective agents in
providing considerable relief from pain, they have several side effects as well [2, 3]. Narcotic
analgesics typically involve the risk of severe side effects such as nausea, vomiting, urinary
retention, sedation, dizziness, pruritus, respiratory depression, confusion, constipation, and
discomfort [2, 3]. Multimodal analgesia (MMA) is yet another critical method of pain
management in postoperative patients [2, 3]. In essence, MMA is a technique that includes
capturing the complete effectiveness of different individual doses of analgesic and in order to
achieve the maximum efficacy [2, 3]. The efficacy of the drug administered is typically enhanced
by administering optimal individual dosages of the various analgesics [2, 3]. However, by
limiting the dosages of each of the analgesics, most of the side effects are typically minimized
and the efficacy of the medicine is enhanced [2, 3]. One of the most common procedures in the
pain management of postoperative patients includes anterior cervical discectomy and fusion
(ACDF) in most cases of several common pathologies of the spinal cord [2, 3]. MMA can be
used in total joint arthroplasty, procedures of the lumbar and the spinal cord bone, and
heterogeneous combinations of several procedures on the spinal cord [2, 3].
Intravenous use of patient controlled analgesia (IV-PCA) is an important method of pain
management [4]. The procedure of IV-PCA has been used over several years and has proven
effective [4]. The patients who have undergone hospitalization typically are prescribed the IV-
PCA method [4]. The method of IV-PCA allows for the patients to calibrate and titrate the
prescribed opioids on self [4]. The IV-PCA has been found to be effective in patients who

Patient controlled surgical pain management 7
experience moderate to severe levels of postsurgical pain [4]. The technique of pain management
in patients which is typically patient controlled enhances the satisfaction levels in patients [4].
However, there are several concerns regarding the effectiveness of the technique and the level of
safety [4]. The route of administration is mainly intravenous due to which the safety of the
technique since it poses a risk of infection in the patients [4]. There are several gaps in the
analgesics caused from infiltration in the catheter tubes [4]. There is a likelihood of obstructions
in the catheter pr the tubing in the intravenous administration contraption [4]. There is a
prevalent risk in the prescription and the various errors in programming that create a significant
amount of morbidity and mortality in the patients [4]. Most interventions tend to use morphine
which is an opioid for pain control in most postsurgical interventions [4]. Morphine typically
consists of slow equilibration with the central nervous system [4]. Due to this, when morphine is
the chosen IV opioid, there is an increase in the complication in the approach intended for the
management of acute pain in inpatients in surgery interventions [4]. One of the common adverse
events that occur due to the use of morphine as the primary pain management opioid includes
respiratory depression [4]. The effector sites in the central nervous system achieve the peak level
of concentration of morphine and morphine-6-gluconuride which is an active metabolite of
morphine after several hours of the event of administration of the dosing with IV PCA [4].
Melson et al (2014) utilized sufentanil sublingual tablet system (SSTS) and have found it to be a
novel technique which is a promising technique [4]. The findings from Melson et al (2014)
indicated that there are several advantages of SSTS over IV PCA and it eliminates some of the
primary concerns of IV PCA [4]. This technique has been shown to provide rapid analgesia and
has led to the achievement of high satisfaction in nurses and patients [4]. Their findings
additionally suggest that there can be a reduction in the adverse events during pain management

Patient controlled surgical pain management 8
with the use of multimodal approach alongside the SSTS strategy leads to the minimization of
adverse events and optimization of postoperative pain management [4]. Lee et al (2017) found
that the incorporation of PCA in most postoperative patients is critical in the pain management
interventions in most cases due to the incidence of severe pain in most patients [5, 6]. Most
often, the pain presents in intense spurts and the management of the disease is often difficult to
achieve [5, 6]. The study by Lee et al (2017) additionally found that there was a relatively low
rate of complication with the incorporation of multimodal analgesia that includes preemptive
analgesics for the pain management in the perioperative procedures in most surgeries of upper
extrimities [5, 6]. The pain rescue rate was also found to be low with the use of multimodal
analgesics [5, 6]. The analgesic effects and the functional outcomes of the use of multimodal
analgesics were on a similar plane as that of IV PCA [5, 6]. Thus, Lee et al (2017) conclude that
multimodal analgesics that include pre-emptive analgesics are effective alternatives for the pain
management in perioperative patients as compared with IV PCA [5, 6]. Thus Lee et al (2017)
suggest that in upper extremity surgical procedures, multimodal analgesics are acceptable
alternatives [5, 6]. Lee et al (2017) note that this replacement is possible in the upper extremity
surgical procedures as they are reported to have lower degrees of postsurgical pain [5, 6].
The American Pain Society and the American Society of Anesthesiologists have formulated the
guidelines program based on the evidenced that supports the utilization of multimodal regimens
that are spread across several situations [7]. A precise account of the components present in the
multimodal regimen of patient care is unavailable to the situation [7]. The multimodal care
primarily varies depending on the various elements of patient care [7]. The variability depends
on the individual patients, the setting of the operation, and the procedure of surgery [7]. Bohl et
al, (2016) have found that patients who underwent anterior cervical discectomy and fusion

Patient controlled surgical pain management 9
(ACDF) have reported lower level of consumption of narcotics [3, 4]. The rates of consumption
of narcotics were analyzed during the stay in the inpatient wards during the procedure of surgery
[3, 4]. In the study by Bohl et al, (2016), the assessment of narcotic consumption in the inpatients
was conducted using a protocol of multimodal analgesia [3, 4]. Bohl et al (2016) deduced that
the reduction in the consumption of narcotics has primarily been associated with the shorter
length of stay at the hospital [3, 4]. The length of the hospital stay also reduced the number of
episodes of nausea and vomiting that occur during the hospitalization [3, 4]. The pain relief
protocols are maintained as usual during the stay at the hospital [3, 4]. The reduction in the
consumption of narcotics in patients who underwent the MMA procedure and the ACDF
procedure was found to be similar to the findings that reflect the total joint arthroplasty and the
procedures of the spine [3, 4]. Research indicates that MMA also results in the reduction in
consumption of opioids [3, 4]. Thus, it leads to a considerable reduction in the rates of nausea,
vomiting instances, and an improvement in the mobilization during the postoperative stage [3, 4].
On a similar prospect, several studies have found that patients who undergo surgery for lumbar
decompression also have reported reduced consumption rates of narcotics [3, 4]. MMA has been
found to have a clear impact on the reduction of the aforementioned symptoms [3, 4].
Conclusion:
Most surgical interventions are associated with the postoperative pain. Most patients experience
postoperative pain that limits their functioning and everyday activities of life. Postoperative pain
additionally leads to extended stay in the hospitals accompanied by several complications such
as nausea, vomiting, discomfort, and acute pain. Most patients report acute postoperative pain
with intensities ranging from moderate to severe. Pain management is therefore one of the most

Patient controlled surgical pain management 10
crucial aspects of postoperative interventions. The surgery-related interventions are mostly
conducted in stages of preoperative medical care, perioperative, intraoperative, and postoperative
medical care. However, most of the times, the postoperative interventions do not ascertain
complete pain relief. The achievement of complete relief from pain is often challenged in most
cases due to the complexity of the acute incidence of pain.
Analgesics are used predominantly in pain management protocols in most cases. Patient
controlled administration of analgesics is a common technique adapted for pain relief in most of
the cases. Most often, the pain management strategy of patient controlled analgesic
administration is conducted by the route of intravenous administration via catheters. The
technique of intravenous administration of patient controlled dosages of analgesics is accepted as
one of the most efficacious means of pain management and relief in postoperative patients.
However, the patient controlled analgesic administration is associated with several adverse
events such as nausea, vomiting, and extended stay duration at the hospital to regain the ability to
function in daily life. Thus, there have been several studies that have assessed the various
efficacious methods of pain management. The most common options include multimodal
analgesic administration or MMA. The option of using multimodal analgesics as common
alternatives to patient controlled analgesic administration has been advocated in research.
Research has indicated that the use of MMA along with several perioperative measures can
greatly reduce the discomfort and postoperative pain commonly encountered in several
inpatients. Consequently, the duration of hospitalization is reduced due to the use of MMA as
there is an absence of adverse events including nausea, vomiting, acute pain, and discomfort. The
primary cause for the administration of MMA is that the use of patient controlled analgesics can
lead to recurrence of pain in the area of surgery or other related events of biological cascade.

Patient controlled surgical pain management 11
Although patient controlled dosages of analgesics involve the efficacious control of symptoms
whenever the patient undergoes the pain symptom specifically, there are several adverse effects
of analgesic administration as mentioned earlier. Several studies have suggested that the efficacy
of MMA is higher in terms of reduction of the duration of the hospitalization period apart from
the control of adverse side effects. However, in most cases, the inpatients have experienced
reduction in symptoms with the use of multimodal platform of analgesic administration. The
primary reason for this is likely to be that the multimodal dosage primarily includes an effective
combination of the optimal dosages of individual analgesics.

Patient controlled surgical pain management 12
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