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Pain Med. 2019 Sep 27. pii: pnz226. doi: 10.1093/pm/pnz226. [Epub ahead of print]

Practice Patterns in Perioperative Nonopioid Analgesic Administration by Anesthesiologists in a Veterans Affairs Hospital.

Author information

Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California.
Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California.
Departments of Medicine.
Biomedical Data Science.
Health Research and Policy (Epidemiology), Stanford University, Stanford, California, USA.



Although multimodal analgesia (MMA) is recommended for perioperative pain management, previous studies have found substantial variability in its utilization. To better understand the factors that influence anesthesiologists' choices, we assessed the associations between patient or surgical characteristics and number of nonopioid analgesic modes received intraoperatively across a variety of surgeries in a university-affiliated Veteran Affairs hospital.


We included elective inpatient surgeries (orthopedic, thoracic, spine, abdominal, and pelvic procedures) that used at least one nonopioid analgesic within a one-year period. Multivariable multinomial logistic regression models were used to estimate adjusted odds ratios and 95% confidence intervals (CIs). We also described the combinations of analgesia used in each surgical subtype and conducted exploratory analyses to test the associations between the number of modes used and postoperative outcomes.


Of the 1,087 procedures identified, 33%, 53%, and 14% were managed with one, two, and three or more modes, respectively. Older patients had lower odds of receiving three or more modes (adjusted odds ratio [aOR] = 0.28, 95% confidence interval [CI] = 0.15-0.52), as were patients with more comorbidities (two modes: aOR = 0.87, 95% CI = 0.79-0.96; three or more modes: aOR = 0.81, 95% CI = 0.71-0.94). Utilization varied across surgical subtypes Pā€‰<ā€‰0.0001). Increasing the number of modes, particularly use of regional anesthesia, was associated with shorter length of stay.


Our study suggests that age, comorbidities, and surgical type contribute to variability in MMA utilization. Risks and benefits of multiple modes should be carefully considered for older and sicker patients. Future directions include developing patient- and procedure-specific perioperative MMA recommendations.


Acute Pain; Adherence; Clinical Pathway; Implementation; Multimodal Analgesia; Postoperative Pain Management


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