Multimodal systemic and intra-articular analgesics.

Ambulatory surgery encompasses the majority of surgical procedures performed in the United States. The number of procedures performed on an ambulatory basis has increased owing to improvements in surgical technology, anesthetic techniques, and pharmacology—specifically analgesic agents. The latter is important as there is an increasing trend of performing more painful procedures on an outpatient basis. Inadequate management of pain or side effects from medications (such as opioids) can lead to decreased patient satisfaction and delayed discharge. Multimodal analgesia captures the effectiveness of individual agents in optimal dosages that maximize efficacy and minimize side effects. This important concept includes the theory that agents with different mechanisms of analgesia may have synergistic effects in preventing or treating pain. Joshi offered guidelines on constructing a multimodal analgesia strategy that, in addition to regional or local anesthesia, included scheduled administration of nonopioid analgesics [eg, acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), or cyclooxygenase (COX)-2 inhibitors] using oral opioids only for breakthrough pain. Successful regimens for outpatient (and inpatient) procedures have since been proposed that follow these principles. These regimens must be tailored to individual patients, keeping in mind the procedure being performed, side effects of individual medications, and patients’ preexisting medical conditions.