Pre-Operative Oral Multimodal Analgesia

More and more institutions are beginning to implement “enhanced recovery after surgery” (ERAS) protocols which include a multimodal analgesia regimen where opioids are only a part of the equation. Multimodal analgesia is just that – using various modalities to modulate pain through different mechanisms including neuraxial anesthetics (epidurals), regional anesthetics (peripheral nerve blocks), oral medications given pre-emptively in the pre-op holding area, and various non-narcotic adjuncts intra/post-operatively. Oh yeah, and narcotics are a modality too, but we are always concerned about their side effects (urinary retention, constipation, nausea/vomiting, etc.). 🙂

I’ll start many of my anesthetics in the pre-op area by giving the following (cheap) oral medications with a very small sip of water.

  • 1000 mg PO acetaminophen (Tylenol)
  • 50-100 mg PO tramadol (Ultram)
  • 300-600 mg PO gabapentin (Neurontin)


In the operating room for certain thoracic and abdominal procedures, I’ll plan for a low-mid thoracic epidural running 0.1% ropivacaine with 2 mcg/cc of fentanyl which I’ll begin running fairly early in the case (6-10 cc/hr). I’ll also drop an orogastric tube but won’t suction until at least one hour has passed since the oral medications were administered.

The surgeons will infiltrate local anesthetic with the surgical incision, and I’ll use adjuncts like ketamine (0.5 mg/kg at incision, 0.2 mg/kg every hour), dexamethasone (4-8 mg IVP), ketorolac (15 mg q4h IVP), and opioids (hydromorphone and fentanyl) to supplement the epidural analgesia. If the epidural just doesn’t seem to be doing the job, I’ll add a lidocaine drip (2 mg/kg/hr) with maybe low-dose dexmedetomidine (0.3 mcg/kg/hr) or even consider transversus abdominis plane (TAP) and PECS I/II blocks. Throughout the case, I’m also constantly repositioning the neck/shoulders/head/limbs and considering all potential areas of nerve stretching or pressure injuries.

Yes, this seems like polypharmacy, but each of these medications has a particular role in modulating the pain cascade. Obviously the regimen is tailored for a patient’s comorbidities and the nature of their surgery, but the aforementioned are just some of the modalities I routinely use.

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