Advances in our understanding of the nociceptive pathways have led to recent attempts to interrupt these pathways at several sites, rather than relying on a single modality (Fig 1). Thus peripheral sensitization is reduced by perioperative and/or postoperative use of NSAIDs, and central sensitization is reduced by intraoperative infiltration of local anesthetic by the surgeon or regional anesthesia by the anesthetist, resulting in better analgesia and fewer intravenous or epidural opioid requirements and side-effects postoperatively (Kehlet...and...iDa,hl 1993). Potential future components of the multimodal approach include the use of drugs for suppression of production of cytokines and other inflammatory mediators at the site of the stimulus, a 2-agonists for intraspinal use, and NMDA antagonists for prevention of 'wind-up'. The use of local anesthetic and opioid mixtures during epidural analgesia is another example of this approach, providing better control of pain with movement than opioids alone, and NSAIDs may also be used to augment intraspinal techniques. Multimodal analgesia may be effective both for patients undergoing major surgery and in the ambulatory care setting, proving improvement in analgesia and reduction of side-effects.
Fig. 1 Present and potential future (italics) modalities for interruption of the nociceptive pathway: TENS, transcutaneous electrical nerve stimulation.
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