**1.4. Preventative multimodal analgesia**

Preventative analgesia is defined as analgesia that is provided by an intervention given in the perioperative period, which may be before or after incision and surgery, that reduces analgesic requirements for post-operative pain for a period longer than the duration of action for the analgesic intervention. Consideration needs to be given, not only to efficacy of analgesia regimens, but also that the duration pain management so that it spans the whole painful experience from incision to healing [87, 88]. Preventative analgesia differs from pre-emptive analgesia, where an analgesic intervention is administered pre-operatively with the aim to provide improved analgesia post-operatively compared with the identical analgesic intervention administered after incision or in the post-operative period [89].

Multimodal analgesia utilises combinations of analgesics that act by different modes to enable a reduction in analgesic requirements of each type of medication and therefore reduce side-effect profiles. The components of multimodal analgesia are shown in **Table 1**. A multimodal approach provides significant benefits, which include reduction in; pain intensity, opioid dose requirements, and opioid-related adverse events [68, 90–93]. In the acute perioperative pain setting, preventative multimodal analgesia is required not only to provide comfort but also to minimise the potential for "wind-up" and central sensitisation. Therefore, directly impacting, the mechanisms may induce the development of CPSP or chronic pain [94].

**Table 1.** Multimodal analgesia comprises a combination of the following modalities.

Although multimodal analgesia has been shown to be effective in reducing pain in children [95, 96], it should be remembered that many drugs used worldwide for paediatric pain management do not have approved labelling for use in children [97]. Drug dosing recommendations based on clinical evidence and experience, not based on evidence may well put children/ youth at risk for medication-related adverse events [98].

A limited number of well-conducted, prospective randomized controlled trials have demonstrated improved clinical outcomes with respect to analgesia and opioid-related side effects with multimodal (vs. single) therapy [92, 93, 99]. However, there is an urgent need for research evaluating, which preventive multimodal analgesic regimens are most effective for different paediatric acute pain settings or surgical models of pain, the most appropriate timing of administration and which of these decrease or prevent long-term pain after surgery. In the meantime, paediatric acute pain teams need to develop surgery specific multimodal analgesia guidelines [100], assess effectiveness and respond quickly when the regime proves inadequate for an individual child/youth.

Good quality acute pain management enhances functional recovery, improves long-term functional outcomes [101] and improves patient and family satisfaction [93, 102].

Non-pharmacological techniques are an extremely useful component of multimodal therapy [103–105]; unfortunately, they are under-utilised in hospitalised children [106]. The mainstay of acute pain management for children and youths resides in the use of opioid analgesia, but opioid use is associated with a significant side effect profile (see **Table 2**). Adverse effects (except allergy) are dose-related and may be relieved by minimizing the opioid dose, conversion to a different opioid and/or using non-opioid adjuvants. IVLT is a useful adjuvant for specific acute pain procedures.


**Table 2.** Adverse effects of opioids.

Multimodal analgesia utilises combinations of analgesics that act by different modes to enable a reduction in analgesic requirements of each type of medication and therefore reduce side-effect profiles. The components of multimodal analgesia are shown in **Table 1**. A multimodal approach provides significant benefits, which include reduction in; pain intensity, opioid dose requirements, and opioid-related adverse events [68, 90–93]. In the acute perioperative pain setting, preventative multimodal analgesia is required not only to provide comfort but also to minimise the potential for "wind-up" and central sensitisation. Therefore, directly impacting, the mechanisms may induce the development of CPSP or

Although multimodal analgesia has been shown to be effective in reducing pain in children [95, 96], it should be remembered that many drugs used worldwide for paediatric pain management do not have approved labelling for use in children [97]. Drug dosing recommendations based on clinical evidence and experience, not based on evidence may well put children/

A limited number of well-conducted, prospective randomized controlled trials have demonstrated improved clinical outcomes with respect to analgesia and opioid-related side effects with multimodal (vs. single) therapy [92, 93, 99]. However, there is an urgent need for research evaluating, which preventive multimodal analgesic regimens are most effective for different paediatric acute pain settings or surgical models of pain, the most appropriate timing of administration and which of these decrease or prevent long-term pain after surgery. In the meantime, paediatric acute pain teams need to develop surgery specific multimodal analgesia guidelines [100], assess effectiveness and respond quickly when the regime proves

youth at risk for medication-related adverse events [98].

Adjuvant medications: ketamine, clonidine, dexmedetomidine, pregabalin/gabapentin

Cognitive behavioural therapy; relaxation/imagery/controlled breathing

Distraction techniques (games/videos/virtual reality/computer games)

**Table 1.** Multimodal analgesia comprises a combination of the following modalities.

inadequate for an individual child/youth.

chronic pain [94].

Local anaesthetic agents

Education Hypnosis

TENS Acupuncture Massage

NSAID's including COX-2 inhibitors

70 Pain Relief - From Analgesics to Alternative Therapies

Non-pharmacological techniques:

Acetaminophen

Opioids Anxiolytics
