title: Multimodal analgesia: A systematic review of local NSAIDs for non-ophthalmologic postoperative pain management.
abstract: BACKGROUND
  While the analgesic benefits of systemically administered non-steroidal anti-inflammatory drugs (NSAIDs) for postoperative pain are well established, benefits of locally administered NSAIDs remain unclear outside the field of ophthalmologic surgery. Studies of local NSAID administration for postoperative analgesia vary considerably in terms of dosing and methodologic quality, making it difficult to derive clinically useful information. The primary objective of this systematic review is to summarize the currently available literature in order to assess the value of local NSAIDs as a component of the multimodal postoperative pain management regimen.
  
  
  METHODS
  A comprehensive search of PubMed and CENTRAL identified twelve randomized controlled trials comparing the use of local NSAIDs to systemic NSAIDs and/or placebo for postoperative multimodal pain management in patients undergoing non-ophthalmologic surgery. Nine trials met eligibility criteria (n = 532); each trial was classified into a subgroup based on time of NSAID administration (pre- or postoperatively) and comparison group (systemic NSAID or placebo). A frequency analysis was performed for similar outcomes reported in two or more studies. The risk of bias for each outcome and quality of evidence were assessed utilizing the Cochrane Risk of Bias instrument and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, respectively.
  
  
  RESULTS
  Low to moderate quality evidence exists indicating that pre- or postoperative administration of local NSAIDs may provide adequate postoperative analgesia within a multimodal regimen. Additional across-study analysis reveals clinically important but non-statistically significant trends towards a decreased use of additional analgesics during the postoperative period. The risk of adverse effects secondary to local NSAID administration is low.
  
  
  CONCLUSIONS
  Local NSAIDs may be effective agents in the multimodal postoperative analgesia regimen. However, small sample size and methodologic variability across trials limits power and generalizability of outcomes. Further high quality studies are required.
  CRD42016038464.
authors.affiliation: University of Central Florida College of Medicine, 6850 Lake Nona Blvd., Orlando, FL, 32827, USA. Electronic address: lisabrubaker@knights.ucf.edu.
authors.forename: Lisa
authors.initials: L
authors.lastname: Brubaker
authors.affiliation: University of Central Florida College of Medicine, 6850 Lake Nona Blvd., Orlando, FL, 32827, USA. Electronic address: lkendall@knights.ucf.edu.
authors.forename: Lauren
authors.initials: L
authors.lastname: Kendall
authors.affiliation: University of Central Florida College of Medicine, 6850 Lake Nona Blvd., Orlando, FL, 32827, USA. Electronic address: eva.reina@knights.ucf.edu.
authors.forename: Eva
authors.initials: E
authors.lastname: Reina
mesh_terms: D000700:Analgesics / Q000008:administration & dosage / Q000627:therapeutic use*; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000008:administration & dosage / Q000627:therapeutic use*; D004334:Drug Administration Schedule; D006801:Humans; D059408:Pain Management / Q000379:methods; D010147:Pain Measurement; D010149:Postoperative Pain / Q000188:drug therapy*; D016032:Randomized Controlled Trials as Topic
chemical_list: D000700:Analgesics; D000894:Anti-Inflammatory Agents, Non-Steroidal
keywords: Analgesia: local NSAIDs; Multimodal; Pain: postoperative