Skip to main content

A multimodal approach to postoperative analgesia in ICU following major surgery

To the Editor,

Postoperative analgesia for complicated cardiovascular and oncologic surgical patients requires appropriate multimodal techniques in the intensive care unit (ICU). As the opioid epidemic continues to be problematic for physicians and patients, effective pain management techniques with an opioid-sparing effect are desired. Multimodal techniques afford significant pain relief; reduces opioid requirement, consumption, and related adverse effects; and expedites bowel recovery, earlier extubation, and overall shorter hospital stay (Mikhail and Thangathurai 1992; Aitkenhead 1989). Therefore, a combination of low-dose analgesics should be used and tailored to the patient’s clinical needs and nature of surgery.

For the past 3 years, our postoperative pain management involves ketamine (0.05–0.3 mg/kg/h) and fentanyl (1 μg/kg/h). To supplement, we add low dose dexmedetomidine (0.5 mg/kg/h), propofol (0.3 to 3 mg/kg/h), midazolam (0.05–2 mg/kg/h), acetaminophen (15 mg/kg every 4 h), or gabapentin (2 mg/kg up to do doses in 24 h). Regional techniques such as continuous lidocaine infusions (1.5–3 mg/kg/h), ON-Q pump (0.5% ropivacaine via epidural infusion 0.32 mg/kg/h), and TAP blocks (2.5–3 mg/kg ropivacaine) are considered in non-anticoagulated surgical patients. Most often, these patients may already have an existing epidural, and local anesthetic or opioids may be administered.

The benefits of an opioid-sparing approach are improved gastrointestinal function, minimal respiratory depression, mild sedation, and less opioid addiction. In turn, we observed early mobilization, fewer ventilator-dependent days (average reduction by 20%), and shorter hospital stay by 1–2 days. Of note, approximately 60% of patients suffered from chronic pain and were treated with a separate pain regimen. ICU patients were regularly monitored for signs of neurologic decline and blood pressure disturbances.

Ketamine has many therapeutic benefits such as hemodynamic stability, bronchodilation, minimal respiratory depression, analgesia, and amnesia. Ketamine also helps in acute and resistant-depressive states, which are common in the ICU. The rate of hallucinations and nightmares is < 5%, which are almost completely attenuated when ketamine is combined with midazolam or fentanyl (Hirota and Lambert 2018).

Sedative drugs such as propofol and dexmedetomidine may supplement patients who are on ventilators. Dexmedetomidine is generally reserved for hemodynamically stable patients, as bradycardia and hypotension may ensue (Shehabi et al. 2019). Intravenous acetaminophen can be used as an adjunct for pain in patients who have adequate liver function and no contraindications for hepatotoxicity. Gabapentin may be added for chronic pain. With this multimodal approach, we found a reduction in ICU and ventilator-dependent days, incidence of infections, and psychological issues such as depression and drug dependence.

In conclusion, postoperative pain control is best achieved with a combination of low-dose analgesics as opposed to any agent in isolation, as a single-medication approach is associated with more side effects, tolerance, and dependence. With multimodal techniques, specifically ketamine, fentanyl, and low-dose adjunct agents, we found that the overall opioid-sparing effect contributes to a reduction in ventilator-dependent days by up to 20%, faster bowel recovery and thus shorter hospital stay by 1–2 days, minimal vital organ dysfunction, and fewer psychological issues. Thus, patient wellness is optimized in the ICU with a multimodal approach to postoperative pain tailored to the patient’s needs.

Availability of data and materials

Not applicable



Intensive care unit


Transversus abdominis plane


  1. Aitkenhead AR (1989) Analgesia and sedation in intensive care. Br J Anaesth 63(2):196–206

    CAS  Article  Google Scholar 

  2. Hirota K, Lambert DG (2018) Ketamine and depression. Br J Anaesth 121(6):1198–1202

    CAS  Article  Google Scholar 

  3. Mikhail MS, Thangathurai D (1992) Sedating patients in intensive care units. West J Med 157(5):566

    CAS  PubMed  PubMed Central  Google Scholar 

  4. Shehabi Y, Howe BD, Bellomo R, Arabi YM, Bailey M, Bass FE et al (2019) Early sedation with dexmedetomidine in critically ill patients. N Engl J Med 380(26):2506–2517

    Article  Google Scholar 

Download references


Not applicable

Disclosure of all financial support

Not applicable

Author information




All authors were equally involved in the design, review of the literature, writing, and revision process regarding this project. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Duraiyah Thangathurai.

Ethics declarations

Ethics approval and consent to participate

Not applicable

Consent for publication

Not applicable

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Vitug, S., Hong, E., Roffey, P. et al. A multimodal approach to postoperative analgesia in ICU following major surgery. Ain-Shams J Anesthesiol 12, 3 (2020).

Download citation