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Shanthanna H, Joshi GP. Opioid-free general anesthesia: considerations, techniques, and limitations. Curr Opin Anaesthesiol 2024; 37:384-390. [PMID: 38841911 DOI: 10.1097/aco.0000000000001385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
PURPOSE OF REVIEW To discuss the role of opioids during general anesthesia and examine their advantages and risks in the context of clinical practice. We define opioid-free anesthesia (OFA) as the absolute avoidance of intraoperative opioids. RECENT FINDINGS In most minimally invasive and short-duration procedures, nonopioid analgesics, analgesic adjuvants, and local/regional analgesia can significantly spare the amount of intraoperative opioid needed. OFA should be considered in the context of tailoring to a specific patient and procedure, not as a universal approach. Strategies considered for OFA involve several adjuncts with low therapeutic range, requiring continuous infusions and resources, with potential for delayed recovery or other side effects, including increased short-term and long-term pain. No evidence indicates that OFA leads to decreased long-term opioid-related harms. SUMMARY Complete avoidance of intraoperative opioids remains questionable, as it does not necessarily ensure avoidance of postoperative opioids. Multimodal analgesia including local/regional anesthesia may allow OFA for selected, minimally invasive surgeries, but further research is necessary in surgeries with high postoperative opioid requirements. Until there is definitive evidence regarding procedure and patient-specific combinations as well as the dose and duration of administration of adjunct agents, it is imperative to practice opioid-sparing approach in the intraoperative period.
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MESH Headings
- Humans
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/adverse effects
- Anesthesia, General/methods
- Anesthesia, General/adverse effects
- Anesthesia, General/standards
- Pain, Postoperative/prevention & control
- Pain, Postoperative/drug therapy
- Pain, Postoperative/etiology
- Pain, Postoperative/diagnosis
- Analgesics, Non-Narcotic/administration & dosage
- Analgesics, Non-Narcotic/therapeutic use
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Affiliation(s)
- Harsha Shanthanna
- Department of Anesthesia, St. Joseph's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Girish P Joshi
- Department of Anesthesiology & Pain Management, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Pierzchajlo N, Zibitt M, Hinson C, Stokes JA, Neil ZD, Pierzchajlo G, Gendreau J, Buchanan PJ. Enhanced recovery after surgery pathways for deep inferior epigastric perforator flap breast reconstruction: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2023; 87:259-272. [PMID: 37924717 DOI: 10.1016/j.bjps.2023.10.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/29/2023] [Accepted: 10/07/2023] [Indexed: 11/06/2023]
Abstract
BACKGROUND Deep inferior epigastric perforator (DIEP) surgery is one of the most difficult breast reconstruction techniques available, both in terms of operating complexity and patient recovery. Enhanced recovery after surgery (ERAS) pathways were recently introduced in numerous subspecialties to reduce recovery time, patient pain, and cost by providing multimodal perioperative care. Plastic surgery has yet to widely integrate ERAS with DIEP reconstruction, mostly due to insufficient data on patient outcomes with this combined approach. METHODS Five major medical databases were queried using predetermined search criteria according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. Statistical analysis was performed using Cochrane's RevMan (v5.4). RESULTS A total of 466 articles were identified. A total of 14 studies were included in the review with a combined sample of 2102 patients. Eight studies were included in the meta-analysis with a combined sample of 1679 patients. On average, the included studies utilized 11.69 of 18 suggested protocols for ERAS with breast reconstruction. Our primary outcome, length of stay, was reduced by a mean of 1.12 (95% confidence interval [CI] [-1.30, -0.94], n = 1627, p < 0.001) days in the ERAS group. Postoperative oral morphine equivalents (OME) were also reduced in the ERAS group by 104.02 (95% CI [-181.43, -26.61], n = 545, p = 0.008) OME. The ERAS group saw a significant 3.54 (95% CI [-4.43, -2.65], n = 527, p < 0.001) standardized mean difference cost reduction relative to the control groups. The surgery time was reduced by 60.46 (95% CI [-125, 4.29], n = 624, p < 0.07) min, although this was not statistically significant. CONCLUSIONS The ERAS pathway in DIEP breast reconstruction is consistently associated with reduced hospital stay, opioid use, and patient cost. Moreover, there appears to be no evidence of serious adverse outcomes associated with the application of the ERAS protocol.
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Affiliation(s)
| | | | - Chandler Hinson
- Frederick P. Whiddon College of Medicine, University of South Alabama, Mobile, AL, USA
| | | | | | | | - Julian Gendreau
- Department of Biomedical Engineering, Johns Hopkins, Baltimore, MD, USA
| | - Patrick J Buchanan
- Plastic, Aesthetic, & Hand/Micro Surgeon, The Georgia Institute for Plastic Surgery, Savannah, GA, USA
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Zhang Y, Ma D, Lang B, Zang C, Sun Z, Ren S, Chen H. Effect of opioid-free anesthesia on the incidence of postoperative nausea and vomiting: A meta-analysis of randomized controlled studies. Medicine (Baltimore) 2023; 102:e35126. [PMID: 37746991 PMCID: PMC10519493 DOI: 10.1097/md.0000000000035126] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/16/2023] [Accepted: 08/17/2023] [Indexed: 09/26/2023] Open
Abstract
BACKGROUND Research on opioid-free anesthesia has increased in recent years; however, it has never been determined whether it is more beneficial than opioid anesthesia. This meta-analysis was primarily used to assess the effect of opioid-free anesthesia compared with opioid anesthesia on the incidence of postoperative nausea and vomiting. METHODS We searched the electronic databases of PubMed, the Cochrane Library, Web of Science and Embase from 2014 to 2022 to identify relevant articles and extract relevant data. The incidence of postoperative nausea and vomiting, time to extubation, pain score at 24 hours postoperatively, and time to first postoperative rescue analgesia were compared between patients receiving opioid-free anesthesia and those receiving standard opioid anesthesia. Differences in the incidence of postoperative nausea and vomiting were evaluated using risk ratios (95% confidence interval [CI]). The significance of the differences was assessed using mean differences and 95% CI. The heterogeneity of the subject trials was evaluated using the I2 test. Statistical analysis was performed using the RevMan 5.4 software. RESULTS Fourteen randomized controlled trials, including 1354 participants, were evaluated in the meta-analysis. As seen in the forest plot, the OFA group had a lower risk of postoperative nausea and vomiting than the control group (risk ratios = 0.41, 95% CI: 0.33-0.51, P < .00001; n = 1354), and the meta-analysis also found that the OFA group had lower postoperative analgesia scores at 24 hours (P < .000001), but time to extubation (P = .14) and first postoperative resuscitation analgesia time (P < .54) were not significantly different. CONCLUSIONS Opioid-free anesthesia reduces the incidence of postoperative nausea and vomiting while providing adequate analgesia without interfering with postoperative awakening.
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Affiliation(s)
- Yanan Zhang
- School of Anesthesiology, Weifang Medical University, Weifang, China
| | - Dandan Ma
- Department of Anesthesiology, Yidu Central Hospital Affiliated to Weifang Medical University, Weifang, China
| | - Bao Lang
- Department of Anesthesiology, Weifang People’s Hospital, Weifang, China
| | - Chuanbo Zang
- School of Anesthesiology, Weifang Medical University, Weifang, China
| | - Zenggang Sun
- School of Anesthesiology, Weifang Medical University, Weifang, China
| | - Shengjie Ren
- School of Anesthesiology, Weifang Medical University, Weifang, China
| | - Huayong Chen
- Department of Anesthesiology, Yidu Central Hospital Affiliated to Weifang Medical University, Weifang, China
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Kim PJ, Yuan M, Wu J, Gallo L, Uhlman K, Voineskos SH, O’Neill A, Hofer SO. "Spin" in Observational Studies in Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Systematic Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5095. [PMID: 37351115 PMCID: PMC10284325 DOI: 10.1097/gox.0000000000005095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 04/26/2023] [Indexed: 06/24/2023]
Abstract
The deep inferior epigastric artery perforator (DIEP) flap is widely used in autologous breast reconstruction. However, the technique relies heavily on nonrandomized observational research, which has been found to have high risk of bias. "Spin" can be used to inappropriately present study findings to exaggerate benefits or minimize harms. The primary objective was to assess the prevalence of spin in nonrandomized observational studies on DIEP reconstruction. The secondary objectives were to determine the prevalence of each spin category and strategy. Methods MEDLINE and Embase databases were searched from January 1, 2015, to November 15, 2022. Spin was assessed in abstracts and full-texts of included studies according to criteria proposed by Lazarus et al. Results There were 77 studies included for review. The overall prevalence of spin was 87.0%. Studies used a median of two spin strategies (interquartile range: 1-3). The most common strategies identified were causal language or claims (n = 41/77, 53.2%), inadequate extrapolation to larger population, intervention, or outcome (n = 27/77, 35.1%), inadequate implication for clinical practice (n = 25/77, 32.5%), use of linguistic spin (n = 22/77, 28.6%), and no consideration of the limitations (n = 21/77, 27.3%). There were no significant associations between selected study characteristics and the presence of spin. Conclusions The prevalence of spin is high in nonrandomized observational studies on DIEP reconstruction. Causal language or claims are the most common strategy. Investigators, reviewers, and readers should familiarize themselves with spin strategies to avoid misinterpretation of research in DIEP reconstruction.
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Affiliation(s)
- Patrick J. Kim
- From the Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Morgan Yuan
- Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jeremy Wu
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lucas Gallo
- Division of Plastic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Kathryn Uhlman
- Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Sophocles H. Voineskos
- Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Anne O’Neill
- Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Stefan O.P. Hofer
- Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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Ulbing S, Infanger L, Fleischmann E, Prager G, Hamp T. The Performance of Opioid-Free Anesthesia for Bariatric Surgery in Clinical Practice. Obes Surg 2023:10.1007/s11695-023-06584-5. [PMID: 37106268 DOI: 10.1007/s11695-023-06584-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 03/31/2023] [Accepted: 04/05/2023] [Indexed: 04/29/2023]
Abstract
PURPOSE Opioid-free anesthesia (OFA) is an alternative to conventional opioid-based anesthesia (OBA) in patients undergoing bariatric surgery. Several small studies and a meta-analysis have suggested advantages of OFA for bariatric surgery, but current evidence is still contradictory, and a universally accepted concept has not yet been established. The purpose of this study was to determine whether patients undergoing bariatric surgery experience less postoperative pain and better postoperative recovery when anesthetized with an OFA regimen than with an OBA regimen. MATERIALS AND METHODS This prospective observational cohort study, conducted between October 2020 and July 2021, compared patients receiving OFA with patients receiving OBA. Patients were visited 24 and 48 h after the surgical procedure and asked about their postoperative pain using the visual analogue scale (VAS). Additionally, the quality of recovery-40 questionnaire (QoR-40) and the postoperative opioid requirements were recorded. RESULTS Ninety-nine patients were included and analyzed in this study (OFA: N = 50; OBA: N = 49). The OFA cohort exhibited less postoperative pain than the OBA cohort within 24 h (VAS median [interquartile range (IQR)]: 2.2 [1-4.4] vs. 4.1 [2-6.5]; P ≤ 0.001) and 48 h (VAS median [IQR]: 1.9 [0.4-4.1] vs. 3.1 [1.4-5.8]; P ≤ 0.001) postoperatively. Additionally, the OFA cohort had higher QoR-40 scores and required less opioid therapy postoperatively. CONCLUSION Based on our results the use of OFA for bariatric surgery results in less pain, reduced opioid requirements, and improved postoperative recovery-adding additional evidence regarding the use of OFA in everyday clinical practice.
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Affiliation(s)
- Stefan Ulbing
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Ludwig Boltzmann Institute Digital Health and Patient Safety, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
| | - Lukas Infanger
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Edith Fleischmann
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Gerhard Prager
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Thomas Hamp
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
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Tian P, Zhang S, Guo L. Reconstruction Algorithm-Based Ultrasonic and Spiral CT Images in Evaluating the Effects of Dexmedetomidine Anesthesia for Acute Abdomen. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2021; 2021:3712701. [PMID: 34992671 PMCID: PMC8727126 DOI: 10.1155/2021/3712701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 11/28/2021] [Accepted: 12/08/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The study focused on the application value of iteration reconstruction algorithm-based ultrasound and spiral computed tomography (CT) examinations, and the safety of dexmedetomidine anesthesia in acute abdominal surgery. METHODS 80 cases having the acute abdomen surgery were selected as the research subjects. They were divided into group A (40 cases) and group B (40 cases) according to the anesthetic drugs used in the later period. The experimental group was injected with propofol, remifentanil, and atracurium combined with dexmedetomidine; the control group was injected with propofol, remifentanil, and atracurium only. After the operation, the patient was for observed for the pain, agitation, adverse reactions, heart rate (HR), and blood pressure. All patients received ultrasound and spiral CT examinations, and based on the characteristics of the back-projection algorithm, an accelerated algorithm was established and used to process the image, and according to which, the patient's condition and curative effects were evaluated. RESULTS After image reconstruction, the ultrasound and spiral CT images were clearer with less noise and more prominent lesions than before reconstruction. Before image reconstruction, the accuracy rates of ultrasound and spiral CT in diagnosing acute abdomen were 92.3% and 91.1%, respectively. After reconstruction, the corresponding numbers were 96.3% and 98.1%, respectively. After reconstruction, the accuracy of the two methods in diagnosing acute abdomen was significantly improved compared with that before reconstruction, and the difference was statistically significant (P < 0.05). The Ramsay score of the experimental group was significantly higher than that of the control group at each time period, P < 0.05; the agitation score and visual analogue scale (VAS) score of the experimental group were significantly lower than the control group at each time period after waking up, P < 0.05. CONCLUSION Reconstruction algorithm-based ultrasound and spiral CT images have high application value in the diagnosis of patients with acute abdomen, and dexmedetomidine has good safety in anesthesia surgery.
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Affiliation(s)
- Pinghua Tian
- Department of Anesthesiology, Changxing People's Hospital, Huzhou 313100, China
| | - Shuhong Zhang
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, 430061 Hubei, China
| | - Linling Guo
- Department of Anesthesiology, Changxing People's Hospital, Huzhou 313100, China
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Kapritsou M, Fyrfiris N, Kotrotsiou M, Stavrianos S. Letter to the Editor regarding "Impact of opioid-free anesthesia on complications after deep inferior epigastric perforator flap surgery: A retrospective cohort study". J Plast Reconstr Aesthet Surg 2021; 74:2776-2820. [PMID: 34217648 DOI: 10.1016/j.bjps.2021.05.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 05/27/2021] [Indexed: 02/05/2023]
Affiliation(s)
- Maria Kapritsou
- Chair of the Hellenic Perianaesthesia Nursing Organization, Chief Nurse of Anesthesiology Department. Hellenic Anticancer Institute, "Saint Savvas" Hospital, Athens, Greece
| | - Nikolaos Fyrfiris
- Consultant Anesthesiologist, "Saint Savvas" Hospital, Athens, Greece, Av. Alexandras 171, Athens, 11522 Greece
| | - Maria Kotrotsiou
- Director of Plastic and Reconstructive Clinic, Evaggelismos Hospital, Athens, Greece
| | - Spyros Stavrianos
- Head Director of Plastic and Reconstructive Clinic, "Saint Savvas" Hospital, Athens, Greece.
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