Multimodal analgesia or balanced analgesia: the better choice?

Abstract

The concept of balanced anesthesia was introduced by John S. Lundy in 1926 [1]. He suggested that a balanced application of different agents and techniques could produce the different components of anesthesia such as amnesia, analgesia, motor paralysis, and abolition of autonomic reflexes. Induction of anesthesia with a single agent alone can cause several complications. On the other hand, using a combination of more than one anesthetic drugs and techniques can improve patient safety, reduce the side effects of anesthesia, and increase patient satisfaction [2]. Almost everyone suffers from postoperative pain, whether mild or severe. Postoperative pain, along with nausea and vomiting, is the most common complication after surgery, but satisfactory management has not been achieved. Nearly 86% of patients undergoing surgery reported postoperative pain in USA [3], and 11% and 37% of patients reported severe and moderate pain, respectively, in the first 24 hours in UK [4]. Patients' desire for postoperative pain control has increased in recent times; hence, it has become an important issue for anesthesiologists. Therefore, methods to achieve satisfactory analgesia in patients while minimizing side effects are being devised. Poorly controlled pain is associated with several negative consequences for the patient, including delayed discharge, delayed recovery of organ function, and increased risk of persistent post-surgical pain [5,6]. The goal of well-controlled pain management is more likely to have superior functional outcomes and quicker return to daily living activities. Kehlet and Dahl [7] described multimodal analgesia (MMA) in 1993. They recommended combined analgesic regimens (balanced analgesia) or multimodal approach to treat postoperative pain. MMA uses a combination of analgesic drugs from different classes along with analgesic techniques targeting different pain mechanisms. The nerve block technique is a key element of MMA. Peripheral nerve blocks have been used in upper and lower extremity surgeries as important anesthetic techniques previously. The recent expansion of the number and types of nerve block approaches poses a great challenge for anesthesiologists. We need to know which regional anesthetic technique is the best, and what skills and anatomical knowledge will be needed to implement it. Fortunately, advances in technology and the accumulation of anatomical knowledge are solving these problems. The development in ultrasound-guided techniques and the equipment advances have opened a new horizon in regional anesthesia. A proper regional blockade helps to maintain and restore organ functions, including pulmonary function. Lim et al. [8] described respiratory and analgesic effects of interscalene block (ISB), anterior suprascapular nerve block (SSB), and posterior SSB in arthroscopic shoulder surgeries. In their study, the ISB group showed a 31.2% reduction of forced vital capacity, while the anterior and posterior SSB groups showed significantly lower reductions of 3.6% and 6.8%, respectively. The di...

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