The role of non-opioid analgesic techniques in the management of pain after ambulatory surgery.

I n describing how patients feel after surgery, Armitage (1) stated that “slapping the patient on the face and telling him or her that it’s all over is a complete inversion of the truth” because as far as the patient is concerned, “it is often just the beginning.” Although the current armamentarium of analgesic drugs and techniques is impressive, effective management of postoperative pain still poses some unique challenges in the ambulatory setting. The increasing number and complexity of operations being performed on an outpatient basis has presented anesthesia practitioners with new challenges with respect to acute pain management. Outpatients undergoing day-care procedures require a perioperative analgesic technique that is effective, has minimal side effects, is intrinsically safe, and can be easily managed away from the hospital or surgery center. The adequacy of postoperative pain control is one of the most important factors in determining when a patient can be safely discharged from the outpatient facility (2). Because inadequately treated pain is a major cause of prolonged stays or unanticipated hospital admissions after ambulatory surgery, the ability to provide effective pain relief by simple methods that are readily available to an outpatient in his or her home environment will be one of the major challenges for providers of ambulatory anesthesia in the future (3). Unfortunately, there are very few well controlled studies that have carefully examined the optimal approaches to managing postdischarge pain after outpatient surgery. Perioperative analgesia has traditionally been provided by opioid analgesics. However, the use of large doses of opioids during ambulatory surgery can be associated with an increased incidence of postoperative complications (e.g., ventilatory depression, sedation, postoperative nausea and vomiting, pruritus, difficulty voiding, and ileus), which in turn contribute to a delayed discharge from the day-surgery facility or to unanticipated hospital admissions. The intraoperative use of large bolus doses or continuous infusions of potent short-acting opioid analgesics (e.g., alfentanil and remifentanil) may actually increase postoperative pain as a result of their rapid elimination and the development of acute tolerance (4). Therefore, anesthesiologists practicing in the ambulatory environment are increasingly using non-opioid analgesics as adjuvants during the perioperative period (Table 1). To minimize the adverse effects of analgesic medications, “balanced” analgesic techniques involving the use of smaller doses of opioids in combination with non-opioid analgesic drugs (e.g., local anesthetics and nonsteroidal antiinflammatory drugs [NSAIDs]) are becoming increasingly popular approaches during and after ambulatory surgery (5,6). The rationale for the perioperative use of non-opioid analgesic drugs and techniques in the ambulatory setting will be reviewed in this article.