Feasibility and postoperative opioid sparing effect of an opioid-free anaesthesia in adult cardiac surgery: a retrospective study

Opioid-free anaesthesia with dexmedetomidine and lidocaine versus remifentanil-based anaesthesia in cardiac surgery: study protocol of a French randomised, multicentre and single-blinded OFACS trial

INTRODUCTION

Intraoperative opioids have been used for decades to reduce negative responses to nociception. However, opioids may have several, and sometimes serious, adverse effects. Cardiac surgery exposes patients to a high risk of postoperative complications, some of which are common to those caused by opioids: acute respiratory failure, postoperative cognitive dysfunction, postoperative ileus (POI) or death. An opioid-free anaesthesia (OFA) strategy, based on the use of dexmedetomidine and lidocaine, may limit these adverse effects, but no randomised trials on this issue have been published in cardiac surgery.We hypothesised that OFA versus opioid-based anaesthesia (OBA) may reduce the incidence of major opioid-related complications after cardiac surgery.

METHODS AND ANALYSIS

Multicentre, randomised, parallel and single-blinded clinical trial in four cardiac surgical centres in France, including 268 patients scheduled for coronary artery bypass grafting under cardiac bypass, with or without aortic valve replacement. Patients will be randomised to either a control OBA protocol using remifentanil or an OFA protocol using dexmedetomidine/lidocaine. The primary composite endpoint is the occurrence of at least one of the following: (1) postoperative cognitive disorder evaluated by the Confusion Assessment Method for the Intensive Care Unit test, (2) POI, (3) acute respiratory distress or (4) death within the first 48 postoperative hours. Secondary endpoints are postoperative pain, morphine consumption, nausea-vomiting, shock, acute kidney injury, atrioventricular block, pneumonia and length of hospital stay.

ETHICS AND DISSEMINATION

This trial has been approved by an independent ethics committee (Comité de Protection des Personnes Ouest III-Angers on 23 February 2021). Results will be submitted in international journals for peer reviewing.

TRIAL REGISTRATION NUMBER

NCT04940689, EudraCT 2020-002126-90.

Opioid-free versus opioid-based anesthesia in major spine surgery: a prospective, randomized, controlled clinical trial

BACKGROUND

Major spine surgery is associated with severe postoperative pain and increased opioid consumption. Opioid-free anesthesia (OFA) is thought to provide adequate intraoperative analgesia with reduced postoperative opioid consumption. The aim of this study is to compare the impact of intraoperative OFA approach to the conventional opioid-based anesthesia (OBA) on postoperative pain, opioid consumption, and related side effects in patients undergoing multilevel spinal fusion surgery.

METHODS

Forty-eight patients undergoing elective major spine surgery were randomly allocated to either receive intraoperative dexmedetomidine and lidocaine (OFA group) or fentanyl during induction and intraoperative remifentanil (OBA group). All patients received intraoperative sevoflurane, propofol, rocuronium, ketamine, dexamethasone, ondansetron and postoperative paracetamol and patient-controlled analgesia device set to deliver intravenous morphine for 48 hours after surgery. Postoperative pain was measured using numerical rating scale. Opioid side effects were documented, when present.

RESULTS

OFA group required less morphine in the first 24 hours post-surgery (17.28±12.25 mg versus 27.96±19.75 mg, P<0.05). The incidence of postoperative nausea and vomiting (PONV) was significantly lower in the OFA group. More patients in the OFA group required antihypertensive medications compared to patients in the OBA group (P<0.05). In the post anesthesia care unit, OFA patients had a significantly longer stay than OBA patients (114.1±49.33 min versus 89.96±30.71 min, P<0.05).

CONCLUSIONS

OFA can be an alternative to OBA in patients undergoing multilevel spine fusion surgery. OFA reduces opioids consumption in the first 24 hours and PONV.

Perioperative Care in Cardiac Surgery: A Joint Consensus Statement by the Enhanced Recovery After Surgery (ERAS) Cardiac Society, ERAS International Society, and The Society of Thoracic Surgeons (STS)

Enhanced Recovery After Surgery (ERAS) programs have been shown to lessen surgical insult, promote recovery, and improve postoperative clinical outcomes across a number of specialty operations. A core tenet of ERAS involves the provision of protocolized evidence-based perioperative interventions. Given both the growing enthusiasm for applying ERAS principles to cardiac surgery and the broad scope of relevant interventions, an international, multidisciplinary expert panel was assembled to derive a list of potential program elements, review the literature, and provide a statement regarding clinical practice for each topic area. This article summarizes those consensus statements and their accompanying evidence. These results provide the foundation for best practice for the management of the adult patient undergoing cardiac surgery.

Anaesthetic subspecialties and sustainable healthcare: a narrative review

The principles of environmentally sustainable healthcare as applied to anaesthesia and peri-operative care are well documented. Associated recommendations focus on generic principles that can be applied to all areas of practice. These include reducing the use of inhalational anaesthetic agents and carbon dioxide equivalent emissions of modern peri-operative care. However, four areas of practice have specific patient, surgical and anaesthetic factors that present barriers to the implementation of some of these principles, namely: neuroanaesthesia; obstetric; paediatric; and cardiac anaesthesia. This narrative review describes these factors and synthesises the available evidence to highlight areas of sustainable practice clinicians can address today, as well as posing several unanswered questions for the future. In neuroanaesthesia, improvements can be made by undertaking awake surgery, moving towards more reusables and embracing telemedicine in quaternary services. Obstetric anaesthesia continues to present questions regarding how services can move away from nitrous oxide use or limit its release to the environment. The focus for paediatric anaesthesia is addressing the barriers to total intravenous and regional anaesthesia. For cardiac anaesthesia, a significant emphasis is determining how to focus the substantial resources required on those who will benefit from cardiac interventions, rather than universal implementation. Whilst the landscape of evidence-based sustainable practice is evolving, there remains an urgent need for further original evidence in healthcare sustainability targeting these four clinical areas.

Effects of multimodal low-opioid anesthesia protocol during on-pump coronary artery bypass grafting: a prospective cohort study

BACKGROUND

The most favorable anesthesia protocol during on-pump coronary artery bypass grafting (CABG) in patients with coronary heart disease remains unclear, despite previous publications regarding the interaction between anesthesia protocol and postoperative complications. The aim of the study was to compare the effect of a multimodal low-opioid anesthesia protocol (MLOP) on early postoperative complications during on-pump CABG.

METHODS

A single-center prospective cohort study including 120 patients undergoing on-pump CABG aged 18 to 65 years, divided into two groups according to undergoing MLOP or routine-opioid anesthesia protocol (ROP). The analyzed parameters were plasma IL-6 levels, complications, duration of mechanical ventilation, length of intensive care unit stay, and hospitalization.

RESULTS

In the MLOP group, the levels of IL-6 at the end of the surgery were 25.6% significantly lower compared to the ROP group (33.4 ± 9.4 vs. 44.9 ± 15.9, p < 0.0001), the duration of mechanical ventilation was significantly shorter (2.0 (2.0; 3.0) h vs. 4.0 (3.0; 5.0) h, p < 0.001), the incidence of low cardiac output syndrome was almost two and half times lower (7 (11.7%) vs. 16 (26.7%), p = 0.037), and also the incidence of postoperative atrial fibrillation was significantly lower (9 (15.0%) vs. 19 (31.7%), p = 0.031).

CONCLUSION

Our study confirms that using MLOP was characterized by significantly lower levels of IL-6 at the end of surgery and a lower incidence of low cardiac output syndrome and postoperative atrial fibrillation than ROP.

TRIAL REGISTRATION

The study is registered in clinicaltrials.gov №NCT05514652.

Effect of opioid-free anesthesia on the incidence of postoperative nausea and vomiting: A meta-analysis of randomized controlled studies

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.

Evaluation of the Effect of New Multimodal Analgesia Regimen for Cardiac Surgery: A Prospective, Randomized Controlled, Single-Center Clinical Study

Objective

To investigate the feasibility of multimodal regimen by paracetamol, gabapentin, ketamine, lidocaine, dexmedetomidine and sufentanil among cardiac surgery patients, and compare the analgesia efficacy with conventional sufentanil-based regimen.

Design

A single-center, prospective, randomized, controlled clinical trial.

Setting

One participating center, the cardiovascular center of the major integrated teaching hospital.

Participants

A total of 115 patients were assessed for eligibility: 108 patients were randomized, 7 cases were excluded.

Interventions

The control group (group T) received conventional anesthesia management. Interventions in the multimodal group (group M) were as follows in addition to the standard of care: gabapentin and acetaminophen 1 hour before surgery; ketamine for induction and to maintain anesthesia with lidocaine and dexmedetomide. Ketamine, lidocaine, and dexmedetomidine were added to routine sedatives postoperatively in group M.

Measurements and Main Results

The incidence of moderate-to-severe pain on coughing made no significant difference (68.5% vs 64.8%, P=0.683). Group M had significantly less sufentanil use (135.72µg vs 94.85µg, P=0.000) and lower rescue analgesia rate (31.5% vs 57.4%, P=0.007). There was no significant difference in the incidence of chronic pain, PONV, dizziness, inflammation index, mechanical ventilation time, length of stay, and complications between the two groups.

Conclusion

Our multimodal regimen in cardiac surgery is feasible, but was not superior to traditional sufentanil-based regimen in the aspects of analgesia effects; however, it did reduce perioperative opioid consumption along with rescue analgesia rate. Moreover, it showed the same length of stay and the incidences of postoperative complications.

Balanced Nonopioid General Anesthesia With Lidocaine Is Associated With Lower Postoperative Complications Compared With Balanced Opioid General Anesthesia With Sufentanil for Cardiac Surgery With Cardiopulmonary Bypass: A Propensity Matched Cohort Study

BACKGROUND

There are no data on the effect of balanced nonopioid general anesthesia with lidocaine in cardiac surgery with cardiopulmonary bypass. The main study objective was to evaluate the association between nonopioid general balanced anesthesia and the postoperative complications in relation to opioid side effects.

METHODS

Patients undergoing cardiac surgery with cardiopulmonary bypass between 2019 and 2021 were identified. After exclusion of patients for heart transplantation, left ventricular assistance device, and off-pump surgery, we classified patients according to an opioid general balanced anesthesia or a nonopioid balanced anesthesia with lidocaine. The primary outcome was a collapsed composite of postoperative complications that comprise respiratory failure and confusion, whereas secondary outcomes were acute renal injury, pneumoniae, death, intensive care unit (ICU), and hospital length of stay.

RESULTS

We identified 859 patients exposed to opioid-balanced general anesthesia with lidocaine and 913 patients exposed to nonopioid-balanced general anesthesia. Propensity score matching yielded 772 individuals in each group with balanced baseline covariates. Two hundred thirty-six patients (30.5%) of the nonopioid-balanced general anesthesia versus 186 patients (24.1%) presented postoperative composite complications. The balanced lidocaine nonopioid general anesthesia group was associated with a lower proportion with the postoperative complication composite outcome OR, 0.72 (95% CI, 0.58-0.92; P = .027). The number of patients with acute renal injury, death, and hospital length of stay did not differ between the 2 groups.

CONCLUSIONS

A balanced nonopioid general anesthesia protocol with lidocaine was associated with lower odds of postoperative complication composite outcome based on respiratory failure and confusion.

The Performance of Opioid-Free Anesthesia for Bariatric Surgery in Clinical Practice

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.

Can Opioid-Free Anaesthesia Be Personalised? A Narrative Review

Background: A significant amount of evidence suggests that Opioid-Free Anaesthesia (OFA) may provide better outcomes for patients undergoing surgery, sparing patients who are particularly vulnerable to adverse side effects of opioids. However, to what extent personalizing OFA is feasible and beneficial has not been adequately described. Methods: We conducted a narrative literature review aiming to provide a comprehensive understanding of nociception and pain and its context within the field of OFA. Physiological (including monitoring), pharmacological, procedural (type of surgery), genetical and phenotypical (including patients’ conditions) were considered. Results: We did not find any monitoring robustly associated with improved outcomes. However, we found evidence supporting particular OFA indications, such as bariatric and cancer surgery. We found that vulnerable patients may benefit more from OFA, with an interesting field of research in patients suffering from vascular disease. We found a variety of techniques and medications making it impossible to consider OFA as a single technique. Our findings suggest that a vast field of research remains unexplored. In particular, a deeper understanding of nociception with an interest in its genetic and acquired contributors would be an excellent starting point paving the way for personalised OFA. Conclusion: Recent developments in OFA may present a more holistic approach, challenging the use of opioids. Understanding better nociception, given the variety of OFA techniques, may help to maximize their potential in different contexts and potential indications.

Evaluation of the Relationship between Baseline Autonomic Tone and Haemodynamic Effects of Dexmedetomidine

Dexmedetomidine, a central α-2 agonist, is used for procedural sedation and for conscious sedation influences on heart rate and blood pressure. Authors verified whether it is possible to predict bradycardia and hypotension with the use of heart rate variability (HRV) analysis for an autonomic nervous system (ANS) activity assessment. The study included adult patients of both sexes with an ASA score of I or II scheduled for ophthalmic surgery to be performed under sedation. The loading dose of dexmedetomidine was followed by a 15 min infusion of the maintenance dose. The frequency domain heart rate variability parameters from the 5-min Holter electrocardiogram recordings before dexmedetomidine administration were used for the analysis. The statistical analysis also included pre-drug heart rate and blood pressure as well as patient age and sex. The data from 62 patients were analysed. There was no relationship between the decrease in heart rate (42% of cases) and initial HRV parameters, haemodynamic parameters or sex and age of patients. In multivariate analysis, the only risk factor for a decrease in mean arterial pressure (MAP) > 15% from the pre-drug value (39% of cases) was the systolic blood pressure before dexmedetomidine administration as well as for a >15% decrease in MAP sustained at more than one consecutive time point (27% of cases). The initial condition of the ANS did not correlate with the incidence of bradycardia or hypotension; HRV analysis was not helpful in predicting the abovementioned side effects of dexmedetomidine.

The Effect of Opioid-Free Anesthesia on the Quality of Recovery After Gynecological Laparoscopy: A Prospective Randomized Controlled Trial

Purpose

Opioid-free anesthesia (OFA) is an emerging technique that eliminates intraoperative use of opioids and is associated with lower postoperative opioid consumption and reduced adverse postoperative events. The present study investigated the effect of OFA on the quality of recovery in patients undergoing gynecological laparoscopy.

Patients and Methods

Seventy-five adult patients undergoing elective gynecological laparoscopy were randomly assigned to the OFA group with dexmedetomidine and lidocaine or the remifentanil-based anesthesia (RA) group with remifentanil. Patients, surgeons, and medical staff members providing postoperative care and assessing outcomes were blinded to group allocation. The anesthesiologist performing general anesthesia could not be blinded due to the different drug administration protocols by groups. The primary outcome was the quality of recovery measured using the Quality of Recovery-40 (QoR-40) questionnaire. Secondary outcomes were postoperative pain score, intraoperative and postoperative adverse events, and stress hormones levels.

Results

The patients in both groups had comparable baseline characteristics. The QoR-40 score on postoperative day 1 was significantly higher in the OFA group than in the RA group (155.9 ± 21.2 in the RA group vs 166.9 ± 17.8 in the OFA group; mean difference: −11.0, 95% confidence interval: −20.0, −2.0; p = 0.018). The visual analog scale score at 30 min after surgery was significantly lower in the OFA group than in the RA group (6.3 ± 2.3 in the RA group vs 4.1 ± 2.1 in the OFA group; p < 0.001). The incidences of nausea and shivering in the post-anesthetic care unit were also significantly lower in the OFA group (p = 0.014 and 0.025; respectively). Epinephrine levels were significantly lower in the OFA group (p = 0.002).

Conclusion

OFA significantly improved the quality of recovery in patients undergoing gynecological laparoscopy.

An Opioid-Sparing Strategy for Laparoscopic Sleeve Gastrectomy: A Retrospective Matched Case-Controlled Study in China

Background: Opioid-sparing anesthesia may enhance postoperative recovery by reducing opioid-related side effects. The present study was to evaluate the effect of an opioid-sparing strategy in bariatric surgery.

Methods: This study was conducted as a retrospective matched case-controlled (1:1) study. A total of 44 patients receiving either an opioid-based approach (OBA group) or an opioid-sparing strategy (OSA group) who under laparoscopic sleeve gastrectomy were included between May 2017 and October 2020. The primary outcome was the postoperative hospital length of stay (PLOS). Secondary outcomes were the hospital costs, operative opioid consumption, time to recovery, postoperative pain score at rest and rescue antiemetic administered in the PACU.

Results: The clinical demographic and operative data in both groups were comparable. There were no significant differences between the two groups in the PLOS (OSA vs. OBA: 6.18 ± 0.23 days vs. 6.73 ± 0.39 days, p = 0.24). Compared to the OBA group, opioid consumption in the OSA group was significantly decreased (48.79 ± 4.85 OMEs vs. 10.57 ± 0.77 OMEs, p < 0.001). There were no significant differences in the hospital costs, time to recovery, and rescue antiemetic administered, the incidence of intravenous opioids and vasopressor use in the PACU.

Conclusion: The opioid-sparing anesthesia for laparoscopic sleeve gastrectomy was feasible but did not decrease the PLOS.

Opioid-Free Labor Analgesia: Dexmedetomidine as an Adjuvant Combined with Ropivacaine

Background

Side effects of the use of opioid analgesics during painless delivery are the main factors that affect rapid postpartum recovery. Opioid use can result in dangerous respiratory depression in the patient. Opioids can also disrupt the baby's breathing and heart rate. The nonopioid analgesic dexmedetomidine, a new a2-adrenergic agonist, possesses higher selectivity, greater analgesic effects, and fewer side effects. Moreover, epidural administration of dexmedetomidine also reduces local anesthetic consumption.

Objective

Our study aims to compare the analgesic effects as well as the side effects of ropivacaine with dexmedetomidine against sufentanyl as an epidural labor analgesia.

Methods

This study is a randomized, double-blinded, controlled trial (registration no. ChiCTR2200055360) involving 120 primiparous (a woman who has given birth once), singleton pregnancy women who are greater than 38 weeks into gestation and have requested epidural labor analgesia. The participants were randomized to receive 0.1% ropivacaine with sufentanyl (0.4 μg/ml) or dexmedetomidine (0.4 μg/ml). The primary outcomes included Visual Analogue Score (VAS), duration of first epidural infusions, the requirement of additional PCEA bolus, and adverse reactions during labor analgesia.

Results

Of the 120 subjects who consented, 91 parturient women (women in the condition of labor) had complete data for analysis. Demographics and VAS, as well as maternal and fetal outcomes, were similar between the groups. The duration of first epidural infusions in dexmedetomidine was significantly longer than sufentanyl (median value: 115 vs 68 min, P < 0.01); the parturient women who received dexmedetomidine and who required additional PCEA bolus were fewer in comparison to those who received sufentanyl (27.5% vs 49.0%, P < 0.05). Furthermore, the incidence of pruritus in the dexmedetomidine group was lower in comparison to the sufentanyl group (0% vs 11.8%, P < 0.05).

Conclusions

Dexmedetomidine, a nonopioid, is superior to the opioid analgesic sufentanyl in providing a prolonged analgesic effect as an epidural during labor. It also reduces local anesthetic consumption and has fewer side effects. The trial is registered with ChiCTR2200055360.