Current evidence of multimodal anesthesia on postoperative outcomes: A systematic review and Meta-analysis.

BACKGROUND: Multimodal anesthesia (MMA) is widely used to reduce opioid use and improve postoperative recovery. However, evidence for bundled MMA regimens-defined as opioids plus ≥2 adjunct analgesic modalities-has not been systematically synthesized across patient-centered outcomes. METHODS: We performed a systematic review and meta-analysis of randomized controlled trials comparing MMA (opioids plus ≥2 adjuncts, including regional techniques and/or systemic agents such as dexmedetomidine, ketamine, intravenous lidocaine, clonidine, or magnesium) with opioid-based general anesthesia in adults undergoing elective surgery. MEDLINE, Embase, CINAHL, Web of Science, and the Cochrane Library were searched to 28 October 2025. Primary outcomes were postoperative pain, PONV, QoR-15, and pulmonary complications. Secondary outcomes included opioid consumption in Morphine Milligram Equivalent (MME) and PACU length of stay. Risk of bias was assessed with RoB 2 and certainty with GRADE. Registered in PROSPERO (CRD42024470056). RESULTS: Twenty-one RCTs (n = 1828) were included. At 24 h, no clear effect of MMA on pain intensity was observed (10 trials, n = 785; MD -0.6, 95% CI -1.5 to 0.2; very low certainty). MMA reduced PONV incidence (4 trials, n = 352; RR 0.59, 95% CI 0.44 to 0.77; low certainty). For secondary outcomes, MMA reduced opioid consumption (10 trials, n = 915; MD -7.0 mg MME, 95% CI -12.8 to -1.3; moderate certainty), with the opioid-sparing effect persisting at 48 h (MD -14.0 mg MME) and study end (MD -16.0 mg). Data for QoR-15, PACU stay, and pulmonary complications were insufficient for pooling. CONCLUSIONS: MMA shows no clear effect on postoperative pain at 24 h but reduces PONV incidence and opioid consumption. Evidence certainty ranges from moderate to very low. Larger, standardized trials are needed to define optimal MMA regimens and patient selection.