Opioid-free perioperative analgesia for hemicolectomy in a patient with opioid-induced delirium: a case report and review of the analgesic efficacy of the alpha-2 agonist agents

Opioid-free anesthesia for postoperative recovery after video-assisted thoracic surgery: A prospective, randomized controlled trial

Purpose

Opioid-based anesthesia is a traditional form of anesthesia that has a significant analgesic effect; however, it can cause nausea, vomiting, delirium, and other side effects. Opioid-free anesthesia with dexmedetomidine and lidocaine has attracted widespread attention. This study aimed to compare the effects of opioid-free and opioid-based anesthesia (OFA and OBA, respectively) on postoperative recovery in patients who had undergone video-assisted thoracic surgery.

Methods

Eighty patients undergoing video-assisted thoracic surgery were assigned to receive either opioid-free anesthesia (OFA group) or opioid-based anesthesia (OBA group) according to random grouping. The primary outcome of the study was the quality of recovery-40 scores (QoR-40) 24 h postoperatively. The secondary outcome measure was numerical rating scale (NRS) scores at different times 48 h postoperatively. In addition to these measurements, other related parameters were recorded.

Results

Patients who received opioid-free anesthesia had higher QoR-40 scores (169.1 ± 5.1 vs. 166.8 ± 4.4, p = 0.034), and the differences were mainly reflected in their comfort and emotional state; however, the difference between the two groups was less than the minimal clinically important difference of 6.3. We also found that the NRS scores were lower in the OFA group than in the OBA group at 0.5 h (both p < 0.05) and 1 h (both p < 0.05) postoperatively and the cumulative 0-24 h postoperative dosage of sufentanil in the OBA group was higher than that in the OFA group (p = 0.030). There were no significant differences in postoperative nausea and vomiting (PONV) (p = 0.159). No surgical or block complications were observed between the groups.

Conclusion

Opioid-free analgesia potentially increased the postoperative recovery in patients who underwent video-assisted thoracic surgery.

Trial registration

The study protocol was registered in the Chinese Clinical Trial Register under the number ChiCTR2100045344 (http://www.chictr.org.cn/showproj.aspx?proj=125033) on April 13, 2021.

Opioid-Free Epidural-Free Anesthesia for Open Hepatectomy: A Case Report

Opioid-free perioperative approaches hold promise to reduce opioid use after surgery and their associated side effects. Here, we report the perioperative analgesic plan of a patient who requested opioid-free care for an open partial hepatectomy. Opioid-free anesthesia care for abdominal surgery is usually dependent on epidural analgesia. However, as in this case, placing an epidural is not always an option due to contraindications such as infection, coagulopathy, or patient refusal. Our multimodal management plan provided an alternative opioid-free, epidural-free perioperative strategy that may prove useful for other patients undergoing similar surgeries.

American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Perioperative Opioid Minimization in Opioid-Naïve Patients

Surgical care episodes place opioid-naïve patients at risk for transitioning to new persistent postoperative opioid use. With one of the central principles being the application of multimodal pain interventions to reduce the reliance on opioid-based medications, enhanced recovery pathways provide a framework that decreases perioperative opioid use. The fourth Perioperative Quality Initiative brought together a group of international experts representing anesthesiology, surgery, and nursing with the objective of providing consensus recommendations on this important topic. Fourth Perioperative Quality Initiative was a consensus-building conference designed around a modified Delphi process in which the group alternately convened for plenary discussion sessions in between small group discussions. The process included several iterative steps including a literature review of the topics, building consensus around the important questions related to the topic, and sequential steps of content building and refinement until agreement was achieved and a consensus document was produced. During the fourth Perioperative Quality Initiative conference and thereafter as a writing group, reference applicability to the topic was discussed in any area where there was disagreement. For this manuscript, the questions answered included (1) What are the potential strategies for preventing persistent postoperative opioid use? (2) Is opioid-free anesthesia and analgesia feasible and appropriate for routine operations? and (3) Is opioid-free (intraoperative) anesthesia associated with equivalent or superior outcomes compared to an opioid minimization in the perioperative period? We will discuss the relevant literature for each questions, emphasize what we do not know, and prioritize the areas for future research.

Evolving the management of acute perioperative pain towards opioid free protocols: a narrative review

Objective: Identification of pain as the fifth vital sign has resulted in over-prescription and overuse of opioids in the US, with addiction reaching epidemic proportions. In Europe, and more recently in the US, a shift has occurred with the global adoption of multimodal analgesia (MMA), which seeks to minimize perioperative opioid use. Improved functional outcomes and reduced healthcare utilization costs have been demonstrated with MMA, but wide scale use of opioids in pain management protocols continues. As a next step in the pain management evolution, opioid-free analgesia (OFA) MMA strategies have emerged as feasible in many surgical settings.Methods: Articles were limited to clinical studies and meta-analyses focusing on comparisons between opioid-intensive and opioid-free/opioid-sparing strategies published in English.Results: In this review, elimination or substantial reduction in opioid use with OFA strategies for perioperative acute pain are discussed, with an emphasis on improved pain control and patient satisfaction. Improved functional outcomes and patient recovery, as well as reduced healthcare utilization costs, are also discussed, along with challenges facing the implementation of such strategies.Conclusions: Effective MMA strategies have paved the way for OFA approaches to postoperative pain management, with goals to reduce opioid prescriptions, improve patient recovery, and reduce overall healthcare resource utilization and costs. However, institution-wide deployment and adoption of OFA is still in early stages and will require personalization and better management of patient expectations.

Incidence and Risk Factors for Postoperative Delirium in Patients Undergoing Spine Surgery: A Systematic Review and Meta-Analysis

Background

The present study aims to investigate the incidence and risk factors associated with postoperative delirium in patients undergoing spine surgery.

Methods

PubMed, EMBASE, Cochrane Library, and Science Citation Index were searched up to August 2019 for studies examining postoperative delirium following spine surgery. Incidence and risk factors associated with delirium were extracted. Odds ratios (OR) and 95% confidence intervals (CI) were calculated for outcomes. The Newcastle-Ottawa Scale (NOS) was used for the study quality evaluation.

Results

The final analysis includes a total of 40 studies. The pooled analysis reveals that incidence of delirium is 8%, and there are significant differences for developing delirium in age (OR 1.07; 95% CI 1.04-1.09), age more than 65 (OR 4.77; 95% CI 4.37-5.16), age more than 70 (OR 15.87; 95% CI 6.03-41.73), and age more than 80 (OR 1.91; 95% CI 1.78-2.03) years, male (OR 0.81; 95% CI 0.76-0.86), a history of alcohol abuse (OR 2.11; 95% CI 1.67-2.56), anxiety (OR 1.74; 95% CI 1.04-2.44), congestive heart failure (OR 1.4; 95% CI 1.21-1.6), depression (OR 2.5; 95% CI 1.52-3.49), hypertension (OR 1.12; 95% CI 1.04-1.2), kidney disease (OR 1.41; 95% CI 1.16-1.66), neurological disorder (OR 4.66; 95% CI 4.22-5.11), opioid use (OR 1.86; 95% CI 1.18-2.54), psychoses (OR 2.77; 95% CI 2.29-3.25), pulmonary disease (OR 1.81; 95% CI 1.27-2.35), higher mini-mental state examination (OR 0.7; 95% CI 0.5-0.89), preoperative pain (OR 1.88; 95% CI 1.11-2.64), and postoperative urinary tract infection (OR 5.68; 95% CI 2.41-13.39).

Conclusions

A comprehensive understanding of incidence and risk factors of delirium can improve prevention, diagnosis, and management. Risk of postoperative delirium can be reduced based upon identifiable risk factors.

Analysis of predictors of opioid-free analgesia for management of acute post-surgical pain in the United States

OBJECTIVES

Utilization of opioid-free analgesia (OFA) for post-surgical pain is a growing trend to counter the risks of opioid abuse and opioid-related adverse drug events (ORADEs). However, utilization patterns of OFA have not been examined. In this study, we investigated the utilization patterns and predictors of OFA in a surgical population in the United States.

METHODS

Analysis of the Cerner Health Facts database (January 2011 to December 2015) was conducted to describe hospital and patient characteristics associated with OFA. Baseline characteristics, such as age, gender, race, discharge status, year of admission and chronic comorbidities at index admission were collected. Hospital characteristics and payer type at index admission were collected as reported in the electronic health record database. Descriptive statistics and logistic regression were used to identify statistically significant predictors of OFA on patient and institutional levels.

RESULTS

The study identified 10,219 patients, from 187 hospitals, who received post-surgical OFA and 255,196 patients who received post-surgical opioids. OFA rates varied considerably by hospital. Patients more likely to receive OFA were older (OR = 1.06, 95% CI [1.03, 1.10]; p < .001), or had neurological disorders (OR = 1.24, 95% CI [1.10, 1.39]; p < .001), diabetes (OR = 1.20, 95% CI [1.08, 1.33]; p = .001) or psychosis (OR = 1.18, 95% CI [1.01, 1.37]; p = .030). Patients with obesity and depression were less likely to receive OFA (OR = 0.80, 95% CI [0.67, 0.95]; p = .010 OR = 0.85, 95% CI [0.73, 0.98]; p = .030, respectively).

CONCLUSIONS

Use of post-surgical OFA was limited overall and was not favored in some patient groups prone to ORADEs, indicating missed opportunities to reduce opioid use and ORADE incidence. A substantial proportion of OFA patients was contributed by a few hospitals with especially high rates of OFA, suggesting that hospital policies, institutional structure and cross-functional departmental commitment to reducing opioid use may play a large role in the implementation of OFA.

Opioid Free Anesthesia for Laparotomic Hemicolectomy: A Case Report

Opioid free anesthesia (OFA) is deffined as anaesthesiological technique where opioids are not used in the intraoperative period (systemic, neuroaxial or intracavitary). Anaphylaxis caused by opioids (fentanyl) is very rare, and the reaction is presented with hypotension and urticaria. When we have proven allergy to fentanyl, patients' refusal of placing epidural catheter and refusal of receiving bilateral ultrasound guided transversus abdominis plane block (USG TAPB), we must think of using multimodal nonopioide analgesia. The concept of multimodal balanced analgesia is consisted of giving different analgesic drugs in purpose to change the pathophysiological process which is included in nociception, in way to receive more effective intraoperative analgesia with less adverse effects. This is a case report of a 60-year-old male patient scheduled for laparotomic hemicolectomy, who previously had proven allergy to fentanyl. We have decided to give him an opioid free anaesthesia. Before the induction to anaesthesia, the patient would receive dexamethasone (dexasone) 0.1 mg/kg and paracetamol 1 gr intravenously. The patient was induced into general endotracheal anesthesia according to a standardized protocol, with midazolam 0.04 mg/kg, lidocaine hydrochloride 1 mg/kg, propofol 2 mg/kg and rocuronium bromide 0.6 mg/kg. Anaesthesia was maintained by using sevoflurane MAC 1 in order to maintain mean arterial pressure (MAP) with a value of +/- 20% of the original value. After tracheal intubation, the patient had received ketamine hydrochloride 0.5 mg/kg (or 50 mg ketamine) in bolus intravenously and a continuous intravenous infusion with lidocaine hydrochloride (lidocaine) 2 mg/kg/hr and magnesium sulfate (MgSO4) 1,5 gr/hr. At the end of surgery the continuous intravenous infusion with lidocaine and magnesium sulfate was stopped while the abdominal wall was closed and 2.5 g of metamizole (novalgetol) was given intravenously. VAS score 2 hours after surgery was 6/10 and 1 gr of paracetamol was given and the patient was transferred to the Department. Over the next 3 days, the patient had a VAS score of 4-6/10 and only received paracetamol 3x1g and novalgetol 3x1 gr daily, every four hours.