Multimodal analgesia with evidence-based approaches serve as the bridge between patients and the Enhanced Recovery After Surgery (ERAS) pathway. Dr Michele Carella of the Department of Anaesthesia and Intensive Care Medicine, Liège University Hospital, Liège, Belgium, outlined ERAS’s core objectives, different analgesic techniques used in ERAS (eg, regional anaesthesia), and the PROSPECT (Procedure Specific Postoperative Pain Management) working group’s evidence-based recommendations.
ERAS: More than pain management
Acute postoperative pain is common and represents only the tip of an iceberg. Beneath it are risks of short- and long-term postoperative complications, chronic postsurgical pain, opioid dependence, and loss of autonomy, which are often overlooked. [Curr Opin Anaesthesiol 2009;22:738-743; Anesthesiology 2002;96:994-1003; Best Pract Res Clin Anaesthesiol 2019;96:994-1003; Zghab S, et al, CHI 2024]
ERAS is a standardized, multimodal perioperative care approach designed to reduce surgical stress and support early functional recovery. [Cureus 2023;15:e48795; https:erassociety.org] “It brings surgeons, anaesthesiologists, nurses and physiotherapists into alignment around core ERAS goals that matter to patients, including pain, function, complications, and side effects,” said Carella.
Multimodal analgesia
“Multimodal analgesia allows us to strike a fine balance between optimal analgesia and functional recovery,” said Carella. “Good analgesia should not only reduce pain, but also enable early mobilization, improve sleep and mood, hasten recovery of basic functions [eg, mobilization, eating, bowel or bladder function], and minimize harms, such as sedation, ileus, postoperative nausea and vomiting, dizziness, respiratory depression, and delirium.”
Analgesic options available for multimodal analgesia are summarized in Table 1.
“Regional anaesthesia is one of the most effective ERAS tools when integrated into a multimodal pathway and designed around function,” said Carella. In practice, regional anaesthesia aligns with ERAS objectives. (Table 2)
Rebound pain with regional anaesthesia: Myth or reality?
Rebound pain is reported in half of the patients receiving peripheral nerve block (PNB) and independently associated with younger age, female gender, bone surgery, and absence of intraoperative use of IV dexamethasone. [Br J Anaesth 2021;126:862-871]
In an observational study (n=132), patients receiving regional anaesthesia had significantly lower integrated pain scores (IPS) immediately after surgery (p<0.001) and during the post‑anaesthesia care unit stay (p<0.001) vs those receiving general anaesthesia. However, pain scores equalized between the groups after 3 hours in the ward. [Acta Anaesthesiol Scand 2023;67:1414-1422] “These results indicate that rebound pain after regional anaesthesia is a myth,” Carella highlighted. “Nevertheless, multimodal analgesia remains necessary.”
PROSPECT: Fit-for-purpose approach
“Pain research is methodologically fragile,” said Carella. “We have limited high-quality RCTs per procedure and often lack placebo or appropriate comparators. Study designs are heterogeneous — with different pain scores, time points, doses, and endpoints — which makes it very difficult to synthesize data and establish guidelines.”
PROSPECT is designed to produce evidence- based, procedure-specific, clinician-friendly recommendations on postoperative analgesia by combining expert panel discussion and a modified grading of recommendation assessment, development and evaluation (GRADE). [https://esraeurope. org/about-prospect-copy]
“The procedure-specific framework of PROSPECT changes practice by pushing clinicians to select analgesic components based on the procedure’s pain generators, the ERAS target, and feasibility and safety in the real world,” Carella pointed out.
“Instead of defaulting to the most powerful block, PROSPECT advocates a fit-for-purpose approach,” he added. “Clinicians should choose the least invasive technique that achieves the required functional outcomes, avoid methods likely to cause motor delay or other functional trade-offs, and incorporate rescue strategies and stepdown plans.”
“For many minimally invasive procedures [eg, TKA], we now adopt a balanced strategy: Baseline nonopioid analgesics plus a targeted regional or field block [ie, regional anaesthesia or LIA when appropriate], proactive prevention of analgesic gaps at block offset, and a clear analgesia plan upon discharge,” he described. (Case report)
“This multimodal approach typically yields better ERAS-aligned outcomes — earlier mobilization and fewer side effects — than relying on any single intervention,” Carella commented. “PROSPECT offers practical value, but requires critical thinking, as it is based on expert consensus, which is subjective and can vary, especially when the evidence is weak or absent,” Carella recommended.
“PROSPECT should be used as a starting point, but not a final answer. It should be combined with clinical judgement and updated literature. As described in the case report, the patient had satisfactory ERAS outcomes — not because the PROSPECT guidelines were perfect, but because they were applied wisely.”
How to overcome barriers to adoption?
“A helpful way to frame the adoption problem is to apply the ‘primary and secondary failure’ logic used in other clinical processes,” Carella said. Table 3 outlines the barriers to PROSPECT’s adoption and solutions.
“Universal adoption is not prevented by evidence alone,” he added. “Other barriers include workflow, training, and follow-through. The fix is to make recommendations easy to implement, hard to forget, and measurable beyond day 2.”
Summary
ERAS is outcome-driven and prioritizes pain control, reduced side effects, and functional recovery. PROSPECT supports a procedure‑specific approach. Multimodal analgesia improves ERAS-aligned outcomes, and regional anaesthesia is an effective ERAS tool when integrated into a multimodal procedure–tailored pathway.
