Pharmacological strategies in multimodal analgesia for adults scheduled for ambulatory surgery.

The present review aims to propose pharmacological strategies to enhance current clinical practices for analgesia in ambulatory surgical settings and in the context of the opioid epidemic. Each year, a high volume of patients undergoes ambulatory surgery worldwide. The multimodal analgesia proposed to ambulatory patients must provide the best analgesic effect and patient satisfaction while respecting the rules of safety for ambulatory surgery. The role of nurses, anesthesiologists, and surgeons around said surgery is to relieve suffering, achieve early mobilization and patient satisfaction, and reduce duration of stay in hospital. Currently, and particularly in North America, overprescription of opioids has reached a critical level constituting a 'crisis'. Thus, we see the need to offer more optimal multimodal analgesia strategies to ambulatory patients. These strategies must combine three key components when not contraindicated: regional/local analgesia, acetaminophen, and nonsteroidal anti-inflammatory drugs (NSAIDs). Adjuvants such as gabapentinoids, N-methyl-D-aspartate receptor modulators, glucocorticoids, α2-adrenergic receptor agonists, intravenous lidocaine might be added to the initial multimodal strategy, however, caution must be used regarding their side effects and risks of delaying recovery after ambulatory surgery. Weaker opioids (e.g. oxycodone, hydrocodone, tramadol) could be used rather than more powerful ones (e.g. morphine, hydromorphone, inhaled fentanyl, sufentanil). This, combined with education about postoperative weaning of opioids after surgery must be done in order to avoid long-term reliance of these drugs.