RESUMEN

INTRODUCTION: This study, conducted between December 2015 and March 2018 at a single university hospital, explored the feasibility and safety of opioid-free anesthesia combined with preoperative thoracic paravertebral block (ThPVB) for patients undergoing elective video-assisted thoracoscopic surgery (VATS). The aim was to assess the impact of this approach on postoperative pain levels and opioid consumption. MATERIAL AND METHODS: Sixty-four patients scheduled for elective VATS were randomly assigned to either the intervention group, receiving opioid-free anesthesia with ThPVB, or the control group, managed with standard general anesthesia. Postoperatively, both groups received oxycodone patient-controlled analgesia along with non-opioid analgesics. Pain intensity was measured using the Numeric Pain Rating Scale (NRS) and Prince Henry Hospital Pain Score (PHHPS). The total dose of postoperative oxycodone and the occurrence of opioid-related adverse events were recorded during the 24-hour follow-up period. RESULTS: Patients in the intervention group showed significantly lower pain levels at 20 and 24 hours post-procedure ( P = 0.015, P = 0.021, respectively) compared to the control group. Notably, oxycodone consumption at 24 hours was significantly higher in the control group ( p < 0.0001). No serious adverse events were observed during the study period. CONCLUSIONS: This study demonstrates the feasibility and safety of opioid-free anesthesia combined with ThPVB for elective VATS. The approach significantly reduces postoperative pain and the need for opioids, supporting its potential as an effective and balanced perioperative anesthetic strategy.

Asunto(s)

RESUMEN

Opioids effectively manage perioperative pain but have numerous adverse effects. Opioid-free anesthesia (OFA) eliminates intraoperative opioid use; however, evidence for its use in video-assisted thoracoscopic surgery (VATS) is limited. This study assessed the effect of OFA using ketamine in VATS patients compared to opioid-sparing anesthesia (OSA). A total of 91 patients undergoing VATS lobectomy or segmentectomy were randomized to either the OFA group (ketamine) or the OSA group (remifentanil). The primary outcome was the quality of recovery (QoR) on postoperative day (POD) 1, measured with the QoR-40 questionnaire. Secondary outcomes included postoperative pain scores and adverse events. Both groups had comparable baseline and surgical characteristics. On POD 1, the QoR-40 score was higher in the OFA group than in the OSA group (164.3 ± 10.8 vs. 158.7 ± 10.6; mean difference: 5.6, 95% CI: 1.1, 10.0; p = 0.015), though this did not meet the pre-specified minimal clinically important difference of 6.3. The visual analog scale score was lower in the OFA group as compared to the OSA group at 0-1 h (4.2 ± 2.3 vs. 6.2 ± 2.1; p < 0.001) and 1-4 h after surgery (3.4 ± 1.8 vs. 4.6 ± 1.9; p = 0.003). The OFA group had a lower incidence of PONV (2 [4.4%] vs. 9 [19.6%]; p = 0.049) and postoperative shivering (4 [8.9%] vs. 13 [28.3%]; p = 0.030) than the OSA group at 0-1 h after surgery. Using OFA with ketamine proved feasible, as indicated by the stable intraoperative hemodynamics and absence of intraoperative awareness. Patients undergoing VATS with OFA using ketamine showed a statistically significant, but clinically insignificant, QoR improvement compared to those receiving OSA with remifentanil.

RESUMEN

Objective: Opioid-sparing anesthesia reduces intraoperative use of opioids and postoperative adverse reactions. The current study investigated the effect of esketamine-based opioid-sparing anesthesia on total laparoscopic hysterectomy patients' recovery. Methods: Ninety patients undergoing total laparoscopic hysterectomy were randomly assigned to esketamine-based group (group K) or opioid-based group (group C). The allocation to groups was unknown to patients, surgeons, and postoperative medical staff. The inability to implement blinding for anesthesiologists was due to the distinct procedures followed by the various groups while administering drugs. The QoR-40 and VAS were used to measure recovery quality. Postoperative adverse events, perioperative opioid consumption, and intraoperative hemodynamics were secondary endpoints. Results: There was an absence of notable discrepancy in the baseline data observed between the two groups. The QoR-40 scores exhibited greater values in group K when compared to group C on the first day following the surgical procedure (160.91 ± 9.11 vs 151.47 ± 8.35, respectively; mean difference 9.44 [95 %CI: 5.78-13.11]; P < 0.01). Within 24 h of surgery, the VAS score of group K was lower at rest and during movement. (P < 0.05 for each). Group K had much lower rates of nausea and vomiting within 24 h of surgery. (P < 0.05 for each). Group K received significantly lower total doses of sufentanil and remifentanil than group C. (17.28 ± 2.59 vs 43.43 ± 3.52; 0.51 ± 0.15 vs 1.24 ± 0.24). The proportion of patients who used ephedrine in surgery was higher in group C than in group K (P < 0.05). Conclusions: Esketamine-based opioid-sparing anesthesia strategy is feasible and enhanced recuperation following surgery by decreasing adverse effects associated with opioids and pain scores compared to an opioid-based anesthetic regimen.

RESUMEN

BACKGROUND: Non-intubated video-assisted thoracoscopic surgery combines a minimally invasive technique with multimodal locoregional analgesia to enhance recovery. The mainstay sedation protocol involves propofol and fentanyl. Dexmedetomidine, given its opioid-sparing effect with minimal respiratory depression, facilitates sedation in non-intubated patients. This study aimed to evaluate the efficacy of dexmedetomidine during non-intubated video-assisted thoracoscopic surgery. METHODS: A total of 114 patients who underwent non-intubated video-assisted thoracoscopic surgery between June 2015 and September 2017 were retrospectively evaluated. Of these, 34 were maintained with dexmedetomidine, propofol, and fentanyl, and 80 were maintained with propofol and fentanyl. After a 1:1 propensity score-matched analysis incorporating sex, body mass index, American Society of Anesthesiologists classification, pulmonary disease and hypertension, the clinical outcomes of 34 pairs of patients were assessed. RESULTS: The dexmedetomidine group showed a significantly lower opioid consumption [10.3 (5.7-15.1) vs. 18.8 (10.0-31.0) mg, median (interquartile range); P = 0.001] on postoperative day 0 and a significantly shorter postoperative length of stay [3 (2-4) vs. 4 (3-5) days, median (interquartile range), P = 0.006] than the control group. During operation, the proportion of vasopressor administration was significantly higher in the dexmedetomidine group [18 (53) vs. 7 (21), patient number (%), P = 0.01]. On the other hand, the difference of the hypotension and bradycardia incidence, short-term morbidity and mortality rates between each group were nonsignificant. CONCLUSION: Adding adjuvant dexmedetomidine to propofol and fentanyl is safe and feasible for non-intubated video-assisted thoracoscopic surgery. With its opioid-sparing effect and shorter postoperative length of stay, dexmedetomidine may enhance recovery after surgery.

Asunto(s)

RESUMEN

Background: Opioids have been used as pain relievers for thousands of years. However, they may also cause undesirable side effects. We therefore performed this study to compare the effect of opioid-free anesthesia (OFA) versus opioid-sparing anesthesia (OSA) on postoperative pain and patient-controlled epidural analgesia (PCEA)-related events. Methods: This is a single center randomized clinical trial that was recruited patients aged from 18 to 70 years who received video-assisted lung surgery between October 2021 and February 2022. Participants were 1:1 randomly assigned to OFA or OSA. Patients in the OFA group received propofol, rocuronium, esmolol, lidocaine, and magnesium sulfate intravenously with epidural ropivacaine. Patients in the OSA group received propofol, rocuronium, remifentanil, and sufentanil intravenously with epidural hydromorphone and ropivacaine. Results: A total number of 124 patients were randomly allocated to the OFA or OSA group. In the OFA group, the severity of pain during coughs on the first postoperative days (PODs; VAS score 1.88 ± 0.88 vs. 2.16 ± 1.1, p = 0.044) was significantly lower than that in the OSA group. The total ratio of PCEA-related adverse events in the OFA group [11 (19.6%) vs. 26 (47.3%), p = 0.003] was significantly lower than in the OSA group. Conclusion: OFA in patients who received video-assisted lung surgery led to lower severity of acute postoperative motion-induced pain and fewer PCEA-related adverse events on the first POD than in the patients in the OSA group. Clinical trial registration: clinicaltrials.gov, identifier (NCT05063396).

RESUMEN

Objective: This study aims to evaluate the feasibility and safety of planned postoperative day 1 discharge (PPOD1) among patients who undergo laparotomy (XL) in the department of gynecology oncology utilizing a modified enhanced recovery after surgery (ERAS) protocol including opioid-sparing anesthesia (OSA) and defined discharge criteria. Methods: Patients undergoing XL and minimally invasive surgery (MIS) were enrolled in this prospective, observational cohort study after the departmental implementation of a modified ERAS protocol. The primary outcome was quality of life (QoL) using SF36, PROMIS GI, and ICIQ-FLUTS at baseline and 2- and 6-week postoperative visits. Statistical significance was assessed using the two-tailed Student's t-test and non-parametric Mann-Whitney two-sample test. Results: Of the 141 subjects, no significant demographic differences were observed between the XL group and the MIS group. The majority of subjects, 84.7% (61), in the XL group had gynecologic malignancy [vs. MIS group; 21 (29.2%), p < 0.001]. All patients tolerated OSA. The XL group required higher intraoperative opioids [7.1 ± 9.2 morphine milligram equivalents (MME) vs. 3.9 ± 6.9 MME, p = 0.02] and longer surgical time (114.2 ± 41 min vs. 96.8 ± 32.1 min, p = 0.006). No significant difference was noted in the opioid requirements at the immediate postoperative phase and the rest of the postoperative day (POD) 0 or POD 1. In the XL group, 69 patients (73.6%) were successfully discharged home on POD1. There was no increase in the PROMIS score at 2 and 6 weeks compared to the preoperative phase. The readmission rates within 30 days after surgery (XL 4.2% vs. MIS 1.4%, p = 0.62), rates of surgical site infection (XL 0% vs. MIS 2.8%, p = 0.24), and mean number of post-discharge phone calls (0 vs. 0, p = 0.41) were comparable between the two groups. Although QoL scores were significantly lower than baseline in four of the nine QoL domains at 2 weeks post-laparotomy, all except physical health recovered by the 6-week time point. Conclusions: PPOD1 is a safe and feasible strategy for XL performed in the gynecologic oncology department. PPOD1 did not increase opioid requirements, readmission rates compared to MIS, and patient-reported constipation and nausea/vomiting compared to the preoperative phase.

RESUMEN

PURPOSE: The purpose of this study was to examine the experiences of CRNAs using opioid sparing techniques in their perioperative anesthesia practice. DESIGN: This study used a qualitative descriptive methodology. METHODS: Semistructured individual interviews were conducted with Certified Registered Nurse Anesthetists who use opioid sparing anesthesia in their clinical practice in the United States. FINDINGS: Sixteen interviews were completed. Thematic network analysis revealed two major themes: (1) perioperative benefits of opioid sparing anesthesia and (2) prospective benefits of opioid sparing anesthesia. Perioperative benefits described include reduction or elimination of postoperative nausea and vomiting, superior pain control, and improved short-term recovery. Prospective benefits described include higher surgeon satisfaction, superior surgeon-managed pain control, increased patient satisfaction, reduction of opioids in the community, and awareness of positive prospective benefits of opioid sparing anesthesia. CONCLUSIONS: This study highlights the significance of opioid sparing anesthesia and its role in comprehensive perioperative pain control, reduction of opioids in the community, and patient recovery beyond the postanesthesia care unit.

Asunto(s)

RESUMEN

BACKGROUND: In perioperative pain control, adjuvants such as lidocaine can reduce opioid consumption in a specific type of surgery. The aim of this single-center prospective double-blinded randomized controlled trial was to determine opioid consumption in the perioperative period in patients receiving continuous lidocaine infusion. METHODS: Patients undergoing elective abdominal aorta and/or iliac arteries open surgery were randomized into two groups to receive 1% lidocaine or placebo at the same infusion rate based on ideal body weight (bolus of 0.15 mL/kg during the induction of anesthesia followed by continuous infusion of 0.2 mL/kg/h during surgery; postoperatively 0.1 mL/kg/h for 24 h) additionally to standard opioid analgesia. RESULTS: Total opioid consumption within 24 h after surgery was 89.2 mg (95%CI 80.9-97.4) in the lidocaine and 113.1 mg (95%CI 102.5-123.6) in the placebo group (p = 0.0007). Similar findings were observed in opioid consumption intraoperatively (26.7 mg (95%CI 22.2-31.3) vs. 35.1 mg (95%CI 29.1-41.2), respectively, p = 0.029) and six hours postoperatively (47.5 mg (IQR 37.5-59.5) vs. 60 mg (IQR 44-83), respectively, p = 0.01). CONCLUSIONS: In high-risk vascular surgery, lidocaine infusion as an adjunct to standard perioperative analgesia is effective. It may decrease opioid consumption by more than 20% during the first 24 h after surgery, with no serious adverse effects noted during the study period.

RESUMEN

Purpose: Ultrasound-guided interscalene nerve block (UISB) is commonly used to alleviate postoperative pain during shoulder arthroscopy. This retrospective observational study aimed to evaluate the intraoperative advantages and analgesic effects of preoperative UISB. Patients and Methods: In this retrospective observational study, a total of 170 patients underwent shoulder arthroscopy at a tertiary medical center in southern Taiwan throughout 2019. After applying the exclusion criteria, 142 of these cases were included, with 74 and 68 in the UISB group and control groups, respectively. The primary outcome was the evaluation of intraoperative morphine milligram equivalent (MME) consumption. Secondary outcomes were sevoflurane consumption, the use of intraoperative antihypertensive drugs, and postoperative visual analog scale (VAS) scores in the post-anesthesia care unit (PACU) and in the ward at 24 h after surgery. Results: Preoperative UISB effectively reduced opioids and volatile gases during surgery, supported by a 48.1% and 14.8% reduction in the median intraoperative MME and sevoflurane concentrations, respectively, and showed less need for antihypertensive drugs. The preoperative UISB group also showed significantly better performance on the VAS in both the PACU and ward. Conclusion: Taken together, the preoperative UISB reduced not only intraoperative MME and sevoflurane consumption but also had satisfactory VAS scores in both the PACU and ward without any symptomatic respiratory complications. In summary, preoperative UISB is a reliable adjuvant analgesic technique and a key factor in achieving opioid-sparing and sevoflurane-sparing anesthesia and multimodal analgesia during shoulder arthroscopy.

RESUMEN

Objective To investigate the effect of different modes of administration of dexmedeto-midine pre-nasal spray combined with pumping and conventional pumping on remifentanil and heart rate var-iability(HRV)in patients undergoing oral and maxillofacial surgery.Methods Ninety patients undergoing elective oral and maxillofacial surgery,43 males and 47 females,aged 18-64 years,BMI 18-25 kg/m2,ASA physical status Ⅰ or Ⅱ,were selected.The patients were divided into three groups by random number table method:pre-nasal spray combined with pump injection group(group PP),conventional pump injection group(group CP),and control group(group C),30 cases in each group.Patients in group PP were given a nasal spray of dexmedetomidine at a dose of 0.5 μg/kg,group CP and group C were given the same amount of normal saline by the same method 45 minutes before entering the room on the day of surgery.Dexmedetomidine was injected intravenously in group PP at doses of 0.5 μg/kg and in group CP at dose of 1 μg/kg for 10 minutes,and group C was given the same amount of normal saline 10 minutes before induc-tion of anesthesia.Ramsay sedation score on admission,duration of surgery,the dose of remifentanil during induction and maintenance of anesthesia,room admission(T1),induction intubation(T2),10 minutes after skin incision(T3),and extubation(T4),RMSSD,SDNN,LF,HF,TP,LF/HF ratio and other HRV analysis indicators,HR,MAP,and BIS values were recorded.The incidence of PONV and the use of analgesics within 24 hours after operation were recorded.Results Compared with group C,the MAP was significantly reduced,RMSSD,SDNN,and logTP were significantly increased,and LF/HF was significantly decreased in group PP at T,(P＜0.05),the LF/HF were significantly reduced in groups PP and CP at T2-T4(P＜0.05),the dosage of remifentanil during the anesthesia induction,the incidence of PONV,and the use rate of analgesic drugs in 24 hours were significantly reduced in groups PP and CP(P＜0.05).Compared with group CP,the RMSSD,SDNN,logLF,logHF,and logTP were increased sig-nificantly in group PP at T,(P＜0.05),the logHF were increased significantly in group PP at T2 and T4(P＜0.05),the Ramsay sedative evaluation was increased significantly,the dosage of remifentanil was sig-nificantly reduced during the maintenance of anesthesia in group PP(P＜0.05).Conclusion After the use of dexmedetomidine,the indicators related to stress level in HRV analysis were significantly reduced,and the dosage of opioids was significantly reduced.The use of dexmedetomidine pre-nasal spray combined with pump injection can further reduce the dosage of opioids during the anesthesia maintenance phase.

RESUMEN

Purpose: Opioids have several adverse effects. At present, there are no large clinical studies on the effects of opioid-sparing anesthesia on early postoperative recovery after thoracoscopic surgery. This study was to investigate the effects of opioid-sparing anesthesia on early postoperative recovery after thoracoscopic surgery. Methods: Adult patients who underwent video-assisted thoracic surgery from 1 January 2019 to 28 February 2021 were enrolled by reviewing the electronic medical records. Participants were divided into opioid-sparing anesthesia (OSA group) and opioid-containing anesthesia (STD group) based on intraoperative opioid usage. The propensity-score analysis was to compare the early postoperative recovery of two groups. The outcome measurements included the incidence of postoperative nausea and vomiting (PONV) during an entire hospital stay, need for rescue antiemetic medication, postoperative-pain episodes within 48 h after surgery, need for rescue analgesia 48 h postoperatively, duration of postoperative hospital stay, length of PACU stay, postoperative fever, postoperative shivering, postoperative atrial fibrillation, postoperative pulmonary infection, postoperative hypoalbuminemia, postoperative hypoxemia, intraoperative blood loss, and intraoperative urine output. Results: A total of 1,975 patients were identified. No significant difference was observed in patient characteristics between the OSA and STD groups after adjusting for propensity score-based inverse probability treatment weighting. The incidence of postoperative nausea and vomiting was significantly lower in the OSA group than in the STD group (14.7% vs. 18.9%, p = 0.041). The rescue antiemetic use rate was lower in the OSA group than in the STD group (7.5% vs.12.2%; p = 0.002). PACU duration was longer in the OSA group than in the STD group (70.8 ± 29.0 min vs. 67.3 ± 22.7 min; p = 0.016). The incidence of postoperative fever was higher in the STD group than that in the OSA group (11.0% vs.7.7%; p = 0.032). There were no differences between the groups in terms of other outcomes. Conclusions: Our results suggest that opioid-sparing anesthesia has a lower incidence of postoperative complications than opioid-based anesthetic techniques.

RESUMEN

Certified registered nurse anesthetists (CRNAs) provide most of the anesthesia care in the rural United States. Rural regions of the US also have the highest opioid prescribing rates and opioid-related hospital admissions and deaths. Although CRNAs are the primary anesthesia providers in these regions, little research examines the strategies CRNAs may use to mitigate the development of chronic opioid use after surgery. The purpose of this study was to assess the views of rural CRNAs regarding their role in mitigating chronic opioid use after surgery and to determine what, if any, preventative strategies they may use. A survey was developed and distributed to CRNAs practicing in rural areas of the US with the highest opioid prescribing rates. Of the 160 CRNAs who responded, 73% agreed that they could influence whether their patient developed chronic opioid use after surgery. Those who agreed were more likely to be involved in policy development to decrease opioid use. The survey also found that CRNAs with a doctoral degree, compared with those with master's level preparation, were more likely to report that they could influence whether their patient developed chronic opioid use after surgery.

Asunto(s)

RESUMEN

The use of rocuronium/sugammadex in otorhinolaryngologic surgery improves intubation conditions and surgical rating scales. This study primarily aimed to evaluate the effect of the combination of rocuronium and sugammadex on intraoperative anesthetic consumption. The secondary outcomes were the intraoperative and postoperative morphine milligram equivalent (MME) consumption, duration of intraoperative hypertension, extubation time, incidence of delayed extubation and postoperative nausea and vomiting, pain score, and length of stay. A total of 2848 patients underwent otorhinolaryngologic surgery at a tertiary medical center in southern Taiwan. After applying the exclusion criteria, 2648 of these cases were included, with 167 and 2481 in the rocuronium/sugammadex and cisatracurium/neostigmine groups, respectively. To reduce potential bias, 119 patients in each group were matched by propensity scores for sex, age, body weight, and type of surgery. We found that the rocuronium/sugammadex group was associated with significant preservation of the intraoperative sevoflurane and MME consumption, with reductions of 14.2% (p = 0.009) and 11.8% (p = 0.035), respectively. The use of the combination of rocuronium and sugammadex also significantly increased the dose of intraoperative labetalol (p = 0.002), although there was no significant difference in intraoperative hypertensive events between both groups. In conclusion, our results may encourage the use of the combination of rocuronium and sugammadex as part of volatile-sparing and opioid-sparing anesthesia in otorhinolaryngologic surgery.

RESUMEN

Background and Objectives: The management of acute postoperative pain (APP) following major abdominal surgery implies various analgetic strategies. Opioids lie at the core of every analgesia protocol, despite their side effect profile. To limit patients' exposure to opioids, considerable effort has been made to define new opioid-sparing anesthesia techniques relying on multimodal analgesia. Our study aims to investigate the role of adjuvant multimodal analgesic agents, such as ketamine, lidocaine, and epidural analgesia in perioperative pain control, the incidence of postoperative cognitive dysfunction (POCD), and the incidence of postoperative nausea and vomiting (PONV) after major abdominal surgery. Materials and Methods: This is a clinical, observational, randomized, monocentric study, in which 80 patients were enrolled and divided into three groups: Standard group, C (n = 32), where patients received perioperative opioids combined with a fixed regimen of metamizole/acetaminophen for pain control; co-analgetic group, Co-A (n = 26), where, in addition to standard therapy, patients received perioperative systemic ketamine and lidocaine; and the epidural group, EA (n = 22), which included patients that received standard perioperative analgetic therapy combined with epidural analgesia. We considered the primary outcome, the postoperative pain intensity, assessed by the visual analogue scale (VAS) at 1 h, 6 h, and 12 h postoperatively. The secondary outcomes were the total intraoperative fentanyl dose, total postoperative morphine dose, maximal intraoperative sevoflurane concentration, confusion assessment method for intensive care units score (CAM-ICU) at 1 h, 6 h, and 12 h postoperatively, and the postoperative dose of ondansetron as a marker for postoperative nausea and vomiting (PONV) severity. Results: We observed a significant decrease in VAS score, as the primary outcome, for both multimodal analgesic regimens, as compared to the control. Moreover, the intraoperative fentanyl and postoperative morphine doses were, consequently, reduced. The maximal sevoflurane concentration and POCD were reduced by EA. No differences were observed between groups concerning PONV severity. Conclusions: Multimodal analgesia concepts should be individualized based on the patient's needs and consent. Efforts should be made to develop strategies that can aid in the reduction of opioid use in a perioperative setting and improve the standard of care.

Asunto(s)

RESUMEN

The epidemic of opioid crisis started getting recognised as a public health emergency in view of increasing opioid-related deaths occurring due to undetected respiratory depression. Prescribing opioids at discharge has become an independent risk factor for chronic opioid use, following which, prescription practices have undergone a radical change. A call to action has been voiced recently to end the opioid epidemic although with the pain practitioners still struggling to make opioids readily available. American Society of Anesthesiologist (ASA) has called for reducing patient exposure to opioids in the surgical setting. Opioid sparing strategies have emerged embracing loco-regional techniques and non-opioid based multimodal pain management whereas opioid free anesthesia is the combination of various opioid sparing strategies culminating in complete elimination of opioid usage. The movement away from opioid usage perioperatively is a massive but necessary shift in anesthesia which has rationalised perioperative opioid usage. Ideal way moving forward would be to adapt selective low opioid effective dosing which is both procedure and patient specific while reserving it as rescue analgesia, postoperatively. Many unknowns persist in the domain of immunologic effects of opioids, as complex interplay of factors gets associated during real time surgery towards outcome. At present it would be too premature to conclude upon opioid-induced immunosuppression from the existing evidence. Till evidence is established, there are no recommendations to change current clinical practice. At the same time, consideration for multimodal opioid sparing strategies should be initiated in each patient undergoing surgery.