Opioid-Free Anesthesia for Pain Relief After Laparoscopic Cholecystectomy: A Prospective Randomized Controlled Trial

Effect of opioid sparing strategies on postoperative pain and perioperative hemodynamics in patients undergoing laparoscopic cholecystectomy: a randomized controlled study

BACKGROUND

Opioid-sparing anesthesia(OSA) or opioid-free anesthesia(OFA) strategy can reduce postoperative pain, but the effect of different stratigies on postoperative pain for patients with high pain sensitivity remains unclear, and the effect of different stratigies on perioperative haemodynamic fluctuations remains controversial for patients undergoing laparoscopic cholecystectomy.

METHODS

A total of 173 patients scheduled for elective laparoscopic cholecystectomy were randomly assigned into three groups: opioid-free anesthesia group(Group OFA), opioid-sparing anesthesia group(Group OSA) or opioid-based anesthesia group (Group OBA). The preoperative assessment of patients' pain sensitivity was conducted using the Pain Sensitivity Questionnaire (PSQ). The visual analog scale (VAS) scores were recorded at 30 min, 1 h, 2 h, 6 h, 12 h, and 24 h postoperatively. Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP), Mean Arterial Pressure (MAP) and Heart Rate (HR) were recorded at baseline(T0), after admission (T1), after induction(T2), 1 min after tracheal intubation (T3), 1 min after pneumoperitoneum (T4), and calculated as the variability of blood pressure (BPV), coefficient of variation (CV) and average real variability (ARV). Time to awake, acute pain, rescue analgesia, postoperative nausea and vomiting (PONV), and time to first exhaust were also recorded.

RESULTS

Compared with Group OBA, VAS scores were significantly lower in Group OFA and OSA at 2 h, 6 h and 12 h postoperatively (P < 0.05). BPVSBP, BPVDBP, BPVMAP, CVSBP, CVDBP, CVMAP, ARVDBP and ARVMAP were lower in both Group OSA and OBA compared to the Group OFA (P < 0.05). Group OSA exhibited lower BPVSBP, CVDBP, and ARVDBP compared to the OBA group (P < 0.05). In the subgroup analysis of patients with high pain sensitivity, BPVSBP, BPVDBP, BPVMAP, CVDBP, CVMAP, ARVSBP, ARVDBP and ARVMAP were lower in Group OSA compared to Group OFA (P < 0.05). BPVDBP, CVDBP, ARVSBP and ARVDBP were lower in the OSA group compared to the OBA group (P < 0.05). The time to first exhaust was significantly reduced in patients in Group OFA compared with Group OSA and OBA (P < 0.05).

CONCLUSION

OSA can effectively control patients' postoperative pain with lower perioperative haemodynamic variability. It also has lower perioperative haemodynamic variability and acute pain in patients with high pain sensitivity, making it suitable for laparoscopic cholecystectomy.

TRIAL REGISTRATION

The trial is registered with the China Clinical Trials Registry Registration Number: ChiCTR2400093036. Retrospectively registered (date of registration: 27/11/2024).

A Comparative Study of Esketamine-Propofol and Sufentanil-Propofol for Analgesia and Sedation During Breast Minimally Invasive Rotary Resection with Local Anesthesia: A Randomized Double-Blind Clinical Trial

Purpose

Minimally invasive rotary resection (MIRR) is crucial for diagnosing and treating breast tumors, but the optimal intravenous anesthesia regimen is unclear. Esketamine, an NMDA receptor antagonist with anesthetic, analgesic, and sympathomimetic properties, may provide an ideal adjunct to propofol sedation. This study aims to compare the safety and efficacy of esketamine versus sufentanil as adjuncts to propofol for analgesia and sedation during breast MIRR.

Patients and Methods

A total of 90 patients undergoing elective breast MIRR were randomly assigned to receive either sufentanil-propofol or esketamine-propofol for analgesia and sedation. The primary outcome was the occurrence of hypoxia (SpO2 < 92% for >10s or exhibiting a persistent downward trajectory). Other outcomes included incidence of subclinical respiratory depression (92% ≤ SpO2 < 95% for >10s), number of airway interventions, awakening time, satisfaction scores, postoperative exhaust time, hemodynamic parameters, and side events.

Results

Finally, 41 patients were assigned to the sufentanil group and 40 to the esketamine group. The occurrence of hypoxia was significantly lower in the esketamine group (17.5%) than in the sufentanil group (39%) (P = 0.032). Subclinical respiratory depression occurred in 32.5% of the esketamine group and 56.1% of the sufentanil group (P = 0.033). The sufentanil group required more airway interventions than the esketamine group (P = 0.032), and patients in the sufentanil group experiencing hypoxia received more mask-assisted ventilation (P = 0.029). Hemodynamic stability was better in the esketamine group. No significant differences were observed in awakening time, satisfaction score, postoperative exhaust time, or side events between groups.

Conclusion

Esketamine-propofol anesthesia significantly reduces the risk of hypoxia (SpO2 < 92%) compared to sufentanil-propofol, while maintaining similar awakening time, satisfaction, postoperative exhaust time, and side events. Its hemodynamic advantages make it valuable for clinical use, especially in procedures requiring respiratory and hemodynamic stability.

Opioid-free anesthesia for minimally invasive abdominal surgery: a systematic review, meta-analysis, and trial sequential analysis

PURPOSE

Opioid anesthesia is commonly employed in minimally invasive surgeries but is associated with adverse effects, including postoperative nausea and vomiting (PONV). Opioid-free anesthesia aims to mitigate these issues. We conducted a systematic review, meta-analysis, and trial sequential analysis (TSA) comparing opioid and opioid-free anesthesia in minimally invasive abdominal surgeries.

METHODS

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, and Embase for randomized controlled trials (RCTs) comparing these approaches. Our primary outcomes were adverse effects (PONV, bradycardia), while secondary outcomes were pain, opioid consumption, and postanesthesia care unit (PACU) length of stay (LOS). We performed a TSA to investigate the conclusiveness of the results.

RESULTS

We included 26 RCTs encompassing 2,025 patients, with 1,009 (49%) in the opioid-free anesthesia group. Opioid-free anesthesia reduced PONV significantly (risk ratio, 0.55; 95% confidence interval [CI], 0.40 to 0.74; P < 0.001), but we found no significant differences in bradycardia rates. We found nonclinically relevant higher pain scores for opioid anesthesia (mean difference [MD], -0.9; 95% CI, -1.7 to -0.2; P = 0.01) and opioid consumption at 2 hr post surgery (MD, -5.4 mg oral morphine equivalents; 95% CI, -9.1 to -1.8; P = 0.004). We also noted a reduced time to first analgesia (MD, 88 min; 95% CI, 18 to 159; P = 0.01). We found no differences in PACU LOS. The TSA confirmed the sample size's adequacy in showing PONV reduction with opioid-free anesthesia.

CONCLUSION

Opioid-free anesthesia showed a significant reduction in PONV and a decrease in opioid consumption during the first 2 hr postoperatively, suggesting it can be an alternative to opioid anesthesia in minimally invasive abdominal surgeries.

STUDY REGISTRATION

PROSPERO ( CRD42023492385 ); first submitted 18 December 2023.

Intravenous Lidocaine Compared with Quadratus Lumborum Block on Postoperative Analgesia Following Laparoscopic Renal Surgery: Protocol for a Randomized Noninferiority Trial

Background

Patients undergoing laparoscopic renal surgery often experience significant postoperative pain. Quadratus lumborum block (QLB) provides effective postoperative pain control after laparoscopic procedures, while lidocaine administered intravenously also exerts analgesic effects for surgical patients. We design this trial to compare the effects of i.v. lidocaine infusion with QLB on postoperative analgesia in patients undergoing laparoscopic renal surgery.

Methods

In this randomized noninferiority trial, a total of 120 adult patients undergoing laparoscopic renal surgery will be randomized to receive either i.v. lidocaine or unilateral QLB for postoperative pain management. Lidocaine will be i.v. administered at 1.5 mg/kg (ideal body weight) over 10 min during anesthesia induction, followed by an infusion of 1.5 mg/kg/h intraoperatively and in a post-anesthesia care unit. Ultrasound-guided anterior QLB with 0.375% ropivacaine 30 mL will be conducted before the start of surgery. Patient-controlled i.v. sufentanil will be used for pain relief during the first 48 h after surgery. The primary outcome is the cumulative sufentanil consumption during 0-24 h postoperatively, with a noninferiority margin of 5 μg. Secondary outcomes include pain intensity at rest and on coughing at 1, 6, 24, and 48 h postoperatively; sufentanil consumption within 24-48 h after surgery; rescue analgesic use within 0-48 h after surgery; nausea and vomiting within 0-48 h postoperatively; and quality of recovery at 24 and 48 h after surgery.

Discussion

The results of this trial will add to the clinical evidence for improving postoperative pain management in patients who undergo laparoscopic renal surgery.

Trial Registration

Chinese Clinical Trial Registry (ChiCTR2400082974).

The Effect of Opioid-Free Anesthesia with Transversus Abdominis Plane Block on Patients Undergoing Laparoscopic Sleeve Gastrectomy: Randomized Controlled Study

Purpose

Anesthesia for metabolic-bariatric surgery is challenging due to the increased risk of opioid-related adverse events. The purpose of the investigation was to assess the feasibility and efficacy of multimodal opioid-free general anesthesia with transversus abdominis plane (TAP) block for laparoscopic sleeve gastrectomy in contrast with conventional opioid-based general anesthesia.

Patients and Methods

Eighty patients who underwent laparoscopic sleeve gastrectomy and eventually 71 patients included in the analysis. They were randomly divided into an opioid-based anesthesia group (control group) with sufentanil or opioid-free anesthesia (OFA) group. Esketamine, dexmedetomidine, and TAP were as part of the OFA. Sevoflurane, dexamethasone, and muscle relaxants were administered intraoperatively to all patients. The primary outcome was antiemetic rescue within 24 hours after surgery. The secondary outcomes included pain scores, analgesic needs, extubation time, complications, the hemodynamic changes, and duration of hospital stay.

Results

In contrast with the control group, the need for antiemetic rescue was significantly reduced (p= 0.035). Furthermore, the visual Analog Scale (VAS) for postoperative pain was considerably lower in the OFA group (p <0.01) than it was in the control group. There was no significant difference in the need for analgesic rescue in both groups (p= 0.155). Extubation time and post-anesthesia care unit (PACU) stay duration were equal between the two groups (p =0.328 and p =0.54). At the end of the surgery and after extubation, hemodynamic changes was more pronounced in the OFA group (p =0.027) than the control group. The length of the hospital stay was significantly shorter compared with the control group (p =0.002).

Conclusion

OFA with TAP results in a significant decrease in the need for antiemetic rescue, a lower level of pain after the surgery, and a shorter hospital stay in contrast with anesthesia based on opioids.

[Opioid-free anesthesia : Wrong track or meaningful exit from the era of opioid-based analgesia?]

The limitations and disadvantages of opioids in anesthesia are very well known but the advantages combined with a lack of effective alternatives even now still prevents refraining from using opioids as part of an adequate pain therapy. For decades, pain research has had the declared goal of replacing opioids with new substances which have no serious side effects; however, currently this goal seems to be a long way off. Due to the media coverage of the "opioid crisis" in North America, the use of opioids for pain management is also increasingly being questioned by the patients. Measures to contain this crisis are only slowly taking effect in view of the increasing number of deaths, which is why the triggers are still being sought. The perioperative administration of opioids is not only a possible gateway to addiction and abuse but it can also cause outcome-relevant complications, such as respiratory depression, postoperative nausea and vomiting and an increase in postoperative pain. Therefore, these considerations gave rise to the idea of an opioid-free anesthesia (OFA), i.e., opioids are not administered as part of anesthesia to carry out surgical procedures. Although this idea may make sense at first glance, a rapid introduction of this concept appears to be risky as it entails significant changes for the entire anesthesiological management. Based on relatively robust data from clinical studies, this concept can now be evaluated and discussed not only emotionally but also objectively. This review article presents arguments for or against the complete avoidance of intraoperative or even perioperative opioids. The current conditions in Germany are primarily taken into account, so that the perioperative pain therapy is transferable to the established standards. The results from current clinical studies on the implementation of an opioid-free anesthesia are summarized and discussed.

Effect of opioid-free versus opioid-based strategies during multimodal anaesthesia on postoperative morphine consumption after bariatric surgery: a randomised double-blind clinical trial

Background

The efficacy and safety of opioid-free anaesthesia during bariatric surgery remain debated, particularly when administering multimodal analgesia. As multimodal analgesia has become the standard of care in many centres, we aimed to determine if such a strategy coupled with either dexmedetomidine (opioid-free anaesthesia) or remifentanil with a morphine transition (opioid-based anaesthesia), would reduce postoperative morphine requirements and opioid-related adverse events.

Methods

In this prospective double-blind study, 172 class III obese patients having laparoscopic gastric bypass surgery were randomly allocated to receive either sevoflurane-dexmedetomidine anaesthesia with a continuous infusion of lidocaine and ketamine (opioid-free group) or sevoflurane-remifentanil anaesthesia with a morphine transition (opioid-based group). Both groups received at anaesthesia induction a bolus of magnesium, lidocaine, ketamine, paracetamol, diclofenac, and dexamethasone. The primary outcome was 24-h postoperative morphine consumption. Secondary outcomes included postoperative quality of recovery (QoR40), incidence of hypoxaemia, bradycardia, and postoperative nausea and vomiting (PONV).

Results

Eighty-six patients were recruited in each group (predominantly women, 70% had obstructive sleep apnoea). There was no significant difference in postoperative morphine consumption (median [inter-quartile range]: 16 [13-26] vs 15 [10-24] mg, P=0.183). The QoR40 up to postoperative day 30 did not differ between groups, but PONV was less frequent in the opioid-free group (37% vs 59%, P=0.005). Hypoxaemia and bradycardia were not different between groups.

Conclusions

During bariatric surgery, a multimodal opioid-free anaesthesia technique did not decrease postoperative morphine consumption when compared with a multimodal opioid-based strategy. Quality of recovery did not differ between groups although the incidence of PONV was less in the opioid-free group.

Clinical trial registration

NCT05004519.

Application of Butorphanol versus Sufentanil in Multimode Analgesia via Patient Controlled Intravenous Analgesia After Hepatobiliary Surgery: A Retrospective Cohort Study

Purpose

We investigate the efficacy and safety of butorphanol in multimodal analgesia combined with dexmedetomidine and ketorolac via patient-controlled intravenous analgesia (PCIA) after hepatobiliary surgery, as compared with sufentanil.

Patients and Methods

Postoperative follow-up data of hepatobiliary surgery patients in Henan Provincial People's Hospital from March 2018 to June 2021 were collected retrospectively and divided into butorphanol group (group B) or sufentanil group (group S) according to the postoperative intravenous controlled analgesia scheme. The baseline characteristics and surgical information of the two groups were matched through propensity score matching (PSM).

Results

A total of 3437 patients were screened, and PSM yielded 1816 patients after matching, including 908 in the butorphanol group and 908 in the sufentanil group. Compared with group S, the incidence of moderate-to-severe pain on the first postoperative day and the second postoperative day was lower in group B during rest (3.2% vs 10.9%, P<0.001; 1.2% vs 4.6%, P<0.001), and during movement (7.0% vs 18.9%, P<0.001; 2.6% vs 8.7%, P<0.001). Patients receiving butorphanol had a lower morphine consumption (50mg vs 120mg, P<0.001). The bolus attempts of an analgesic pump in group B were significantly lower than in group S (1 vs 2, P<0.001). Postoperative hospital length of stay was shortened in group B (11d vs 12d, P=0.017). The occurrence of postoperative vomiting was lower in group B (1.4% vs 3.0%, P=0.025) than in group S. However, more patients in group B experienced dizziness (0.9% vs 0.1%, P=0.019).

Conclusion

Compared with sufentanil, the application of butorphanol in multimodal analgesia combined with dexmedetomidine and ketorolac via PCIA ameliorated postoperative pain after hepatobiliary surgery, with reduced opioid consumption and shorter postoperative hospital length of stay.