Opioid-Free Total Intravenous Anesthesia Improves Postoperative Quality of Recovery after Ambulatory Gynecologic Laparoscopy

Opioid-free anaesthesia and postoperative quality of recovery: a systematic review and meta-analysis with trial sequential analysis

BACKGROUND

There is still debate over whether opioid-free anaesthesia (OFA) can improve the patient-reported quality of recovery (QoR).

METHODS

A search was conducted across Pubmed, Cochrane Library, and EMBASE until June 2024 for randomized controlled trials comparing the impact of OFA and opioid-based anaesthesia (OBA) on QoR in adult patients undergoing general anaesthesia. The primary outcome was the quality of recovery measured with the QoR scale. The secondary outcomes were the five dimensions of the QoR scale.

RESULTS

The analysis included 15 studies, and showed that compared with OBA, OFA improved the global QoR score at postoperative 24 h (SMD 0.87; 95% CI, 0.48-1.27; I2: 92%; low-level evidence). Among them, 10 studies revealed a greater QoR-40 score at postoperative 24 h in the OFA than in the OBA (MD 6.59; 95% CI, 2.84-10.34; I2: 93%; moderate-level evidence), which exceeded the minimal clinically important difference of 6.3. Conversely, the synthetic data of 4 studies did not reveal an improvement in the global QoR-15 score at postoperative 24 h (MD 9.94; 95% CI, -0.15 to 12.35; I2: 97%; low-level evidence). Regarding different domains of scale, OFA had positive effects on physical comfort (SMD 0.75; 95% CI, 0.25-1.25; I2: 93%; moderate-level evidence) and pain (SMD 0.59; 95% CI, 0.15-1.03; I2: 91%; moderate-level evidence).

CONCLUSIONS

The meta-analysis indicate OFA can improve the quality of recovery at postoperative 24 h, particularly in terms of enhancing physical comfort and reducing pain. However, due to significant heterogeneity and moderate-to-low level of evidence, the external validity of OFA for improving postoperative recovery remains to be further validated.

REGISTRATION

The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database on December 07, 2023 (CRD42023486235).

Opioid-free anesthesia improves postoperative recovery quality of small and medium-sized surgery: a prospective, randomized controlled study

BACKGROUND

Opioid anesthesia (OA) is currently the predominant anesthetic method. However, its associated side effects, such as nausea and vomiting, coupled with the principle of enhanced recovery after surgery (ERAS), have spurred the adoption of opioid-free anesthesia (OFA) in select surgical procedures. For small and medium-sized operations, ERAS is particularly important. The aim of this study was to investigate the effect of OFA, utilizing esketamine in combination with dexmedetomidine and sevoflurane, on postoperative recovery quality following small and medium-sized surgical interventions.

METHODS

A total of 120 patients who underwent various small and medium-sized operations were randomly allocated to OFA and OA groups. The OA group received sufentanyl and sevoflurane, while the OFA group received esketamine, dexmedetomidine, and sevoflurane. The primary outcome measure was the postoperative quality of recovery-40 scores (QoR-40) 24 hours after surgery. Secondary outcomes included hemodynamic changes at different time intervals, the incidences of adverse events were recorded.

RESULTS

Patients in the OFA group exhibited a higher QoR-40 score of 184.0 (182.0, 186.2) compared to 182.0 (180.0, 184.0) in the OA group (P<0.001). The disparities were particularly noble in terms of Physical comfort and Emotional status. Multivariable analysis identified postoperative nausea and vomiting (PONV) as a significant independent factor impacting QoR-40 (β=-4.49 [-6.1, -2.87], P<0.001). Hemodynamic stability was more pronounced in the OFA than in the OA group. The incidence of PONV was substantially lower in the OFA group (one [1.6%] vs. 14 [25%], P<0.001), with a reduced need for vasoactive drugs (five [7.8%] vs. 15 [26.8%], P=0.005), and a lower incidence of respiratory depression (0 [0%] vs. six [10.7%], P=0.009).

CONCLUSIONS

OFA improves the postoperative recovery quality in small and medium-sized surgical procedures, potentially attributed to decreased incidence of PONV. Additionally, OFA facilitates the maintenance of more stable hemodynamics throughout the operation.

Opioid-free general anesthesia: considerations, techniques, and limitations

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.

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.

Effect of opioid-free anesthesia on postoperative nausea and vomiting after gynecological surgery: a systematic review and meta-analysis

Background: Postoperative nausea and vomiting (PONV) is a common complication, that can reduce patient satisfaction and may lead to serious consequences, such as wound dehiscence. Many strategies have been proposed to prevent PONV; however, it remains common, especially in high-risk surgeries such as gynecological surgery. In recent years, opioid-free anesthesia has been widely studied because it minimizes adverse reactions of opioids, such as nausea, vomiting, and itching; however, conclusions have been inconsistent. Therefore, we conducted this meta-analysis to investigate the effects of opioid-free anesthesia on PONV in patients undergoing gynecological surgery. Methods: A systematic search of the PubMed, Web of Science, Cochrane Library, and Embase databases, from inception to 28 August 2023, was performed. Keywords and other free terms were used with Boolean operators (OR and, AND) to combine searches. This review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Results: Six studies involving 514 patients who underwent gynecological surgery were included. The forest plot revealed that the incidence of PONV (risk ratio = 0.52; p < 0.00001) and consumption of postoperative antiemetics use (risk ratio = 0.64; p = 0.03) were significantly lower in the opioid-free anesthesia group. In addition, opioid-free anesthesia improved the quality of recovery (mean difference = 4.69; p < 0.0001). However, there were no significant differences in postoperative pain scores (mean difference = 0.05; p = 0.85), analgesic use (risk ratio = 1.09; p = 0.65), and the time of extubation (mean difference = -0.89; p = 0.09) between the opioid-free anesthesia and control groups. Conclusion: OFA reduces PONV and the use of antiemetic drugs. In addition, it improves the quality of postoperative recovery. However, OFA can not reduce the postoperative pain scores, analgesic use and the time of extubation. Due to the strength of the evidence, we cannot support OFA as an ideal anesthesia method in gynecological surgery, and the implementation of anesthesia strategies should be case-by-case. Systematic Review Registration: [https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=462044], identifier [CRD42023462044].

The association of hemodynamic parameters and clinical demographic variables with acute postoperative pain in female oncological breast surgery patients: A retrospective cohort study

OBJECTIVES

Appropriate administration of intraoperative analgesia is an essential factor in care and reasonable recovery times. Inappropriate intraoperative analgesia puts the patient at risk of acute postoperative pain (APOP). The absence of an objective standard for intraoperative nociceptive monitoring complicates pain care. Heart rate (HR) and mean arterial blood pressure (MABP) have been suggested as useful parameters during general anesthesia for nociceptive monitoring. However, studies focusing on whether intraoperative heart rate variability (HRv) and mean arterial blood pressure variability (MABPv) during general anesthesia can accurately monitor nociception in patients have remained inconclusive. The current study aimed to (1) identify the association of intraoperative heart rate and blood pressure variability in patients undergoing low-risk surgery with the incidence of APOP in the immediate postoperative setting and (2) evaluate the associations of clinical demographic factors with the incidence of APOP.

METHODS

A retrospective observational cohort study was conducted. The outcome was moderate-to-severe APOP, defined as a numeric rating scale score of ≥ 4. HRv, MABPv, and potential confounders, such as age, body mass index, duration of surgery, smoking, depression, preoperative use of analgesics, and type of surgery, were used as independent variables.

RESULTS

Data from 764 female oncological breast surgery patients were analyzed. No statistically significant association of HRv and MABPv with APOP was found. Lower age was associated with higher odds of APOP (odds ratio [OR] 0.978, p = 0.001). Increased length of surgery (OR 1.013, p = 0.022) and a history of depression were associated with increased odds of APOP (OR 2.327, p = 0.010). The subtype of surgery was statistically significantly associated with APOP (p = 0.006).

CONCLUSIONS

Our results suggest that heart rate and blood pressure variability intraoperatively, in female patients undergoing low-risk surgery, are not associated with, and thus not predictive of, APOP in the immediate postoperative setting.

Opioid-free anesthesia: A systematic review and meta-analysis

STUDY OBJECTIVE

To evaluate all available evidence thus far on opioid based versus opioid-free anesthesia and its effect on acute and chronic postoperative pain.

DESIGN

Systematic review and meta-analysis of randomized clinical trials.

SETTING

Operating room, postoperative recovery room and ward.

PATIENTS

Patients undergoing general anesthesia.

INTERVENTIONS

After consulting MEDLINE, EMBASE and Cochrane database, studies which compared opioid free anesthesia (OFA) with opioid based anesthesia (OBA) were included (last search April 15th 2022).

MEASUREMENTS

Primary outcomes were acute and chronic pain scores in NRS or VAS. Secondary outcomes were quality of recovery and postoperative opioid consumption. Risk of bias was assessed using the RoB2 tool and a random effects model for the meta-analysis was conducted.

MAIN RESULTS

We identified 1245 citations, of which 38 studies met our inclusion criteria. There is moderate quality evidence showing no clinically relevant difference of Numeric Rating Scale (NRS) scores or opioid consumption in the postoperative period (pooled mean difference of 0.39 points with a CI of 0.19-0.59 and 4.02 MME with a CI of 1.73-6.30). We found only one small-sized study reporting no effect of opioid-free anesthesia on chronic pain. The quality of recovery was superior in patients with opioid-free anesthesia (mean difference of 8.26 points), however, this pooled analysis was comprised of only two studies. Postoperative nausea and vomiting (PONV) occurred less in opioid-free anesthesia, but bradycardia was more frequent.

CONCLUSIONS

We concluded that we cannot recommend one strategy over the other. Future studies could focus on quality of recovery as outcome measure and adequately powered studies on the effects of opioid-free anesthesia on chronic pain are eagerly awaited.

Application of surgical pleth index in the opioid-free anesthesia: A randomized controlled trial

BACKGROUND

Currently, there is no gold standard for monitoring noxious stimulation during surgery, and the surgical pleth index (SPI) is only one of many monitoring methods. It is commonly used in the monitoring of conventional opiate anesthesia, but its effectiveness in opioid-free anesthesia (OFA) has not been evaluated. Therefore, the aim of this study was to observe the guidance value of the surgical pleth index in opioid-free anesthesia for patients undergoing lower abdominal or pelvic surgery.

METHODS

A total of 122 patients who underwent lower abdominal or pelvic surgery in our hospital between March 2021 and July 2022 were selected and equally divided into OFA (F) and control (C) groups according to the random number table method. Both groups underwent ultrasound-guided unilateral/bilateral quadratus lumborum block in the supine position according to the surgical field. In group F, 0.50% lidocaine and 0.20% ropivacaine (in 20 mL of 0.9% normal saline) were injected on each side. In group C, 20 mL 0.9% normal saline was injected on each side. Group F received general anesthesia without opioids and group C received general anesthesia with opioids. BP, pulse oxygen saturation, PETCO2, reactionentropy, stateentropy, and SPI values; Steward score; dosage of propofol, dexmedetomidine, rocuronium, and diltiazem; extubation time; and awake time were monitored in both groups.

RESULTS

There were no significant differences in the general data between the 2 groups (P > .05). There were no significant differences in SPI values at T0, T1, T2, T3, T4, and T5 or the number of cases requiring additional remifentanil, propofol, and diltiazem between the 2 groups (P > .05). The stateentropy, reactionentropy, and Steward scores were higher in group F than in group C at T4 and T5, while the extubation and awake times were lower in group F than in group C (P < .05). The heart rate and SPI of group F were lower than that of group C at T3 (P < .05).

CONCLUSION

The guiding value of SPI in OFA was similar to its use in opiated anesthesia. Its clinical efficacy is exact, vital signs are stable, enabling rapid, and complete regaining of consciousness.

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.

Opioid-free anesthesia with lidocaine for improved postoperative recovery in hysteroscopy: a randomized controlled trial

BACKGROUND

Anesthesia with opioids negatively affects patients' quality of recovery. Opioid-free anesthesia attempts to avoid these effects. This study aimed to evaluate the effect of opioid-free anesthesia on the quality of recovery, using lidocaine on patients undergoing hysteroscopy.

METHODS

A parallel-group, randomized, double-blind, controlled trial was conducted in Yichang Central Peoples' Hospital, Hubei Province, China, from January to April, 2022. We included 90 female patients (age: 18-65 years, American Society of Anesthesiologists Physical Status Class I-II) scheduled for elective hysteroscopy, 45 of whom received lidocaine (Group L), and 45 received sufentanil (Group S). Patients were randomly allocated to receive either lidocaine or sufentanil perioperatively. The primary outcome was the quality of postoperative recovery, which was assessed using the QoR-40 questionnaire (a patient-reported outcome questionnaire measuring the quality of recovery after surgery).

RESULTS

The two groups were similar in age, American Society of Anesthesiology physical status, height, weight, body mass index, and surgical duration. The QoR scores were significantly higher in Group L than Group S. The incidence of postoperative nausea and vomiting, as well as the time to extubation were significantly lower in Group L than Group S.

CONCLUSION

Opioid-free anesthesia with lidocaine achieves a better quality of recovery, faster recovery, and a shorter time to extubation than general anesthesia with sufentanil.

TRIAL REGISTRATION

The trial was registered on January 15, 2022 in the Chinese Clinical Trial Registry ( http://www.chictr.org.cn/showprojen.aspx?proj=149386 ), registration number ChiCTR2200055623.(15/01/2022).

Comparison of electronic versus phone-based administration of the Quality of Recovery-40 survey after ambulatory surgery

STUDY OBJECTIVE

Studies that track patient-centered outcomes are better suited to evaluate the relative benefits and harms of an intervention in ambulatory surgery as severe morbidity and mortality have become increasingly rare. This pilot study aimed to assess for differences in response rate and survey scores for phone-based and electronic administration of the Quality of Recovery-40 (QoR-40) survey in patients undergoing general anesthesia for ambulatory surgery.

DESIGN

A single-center prospective observational study.

SETTING

Yale New Haven Hospital (September 22-November 2, 2021).

PATIENTS

100 consecutive patients undergoing ambulatory surgery under general anesthesia.

INTERVENTIONS

Patients were randomized to receive QoR-40 surveys via email or phone.

MEASUREMENTS

The QoR-40 survey is a 40-item questionnaire that provides a global score across five dimensions: patient support, comfort, emotions, physical independence, and pain. The primary outcome was the response rate following the administration of the QoR-40 survey on postoperative days 1, 2, and 7. The secondary outcome was the mean QoR-40 score during the study period.

MAIN RESULTS

A total of 109 patients consented to participate and 100 patients were randomized in this study. A total of 76%, 72%, and 68% of patients completed the survey on POD 1, 2, and 7, respectively. There were no differences in the response rate of patients who completed the survey between phone (78%) versus electronic (74%) administration (difference 4%, 95% confidence interval (CI): -13%, 21%, respectively) on POD 1, 2 (74% vs 70%, difference 4%, 95% CI -14%, 22%, respectively) or 7 (68% vs 68%, difference 0%, 95% CI -18%, 18%, respectively). The mean (standard deviation) QoR-40 score was 176.2 (18.1), 179.8 (19.4), 187.7 (13.1) on POD 1, 2, and 7, respectively. There were no significant differences in the mean QoR-40 scores between groups at any of the time points.

CONCLUSION

The response rate following the electronic administration of the QoR-40 survey did not differ from the phone-based administration during the postoperative period following ambulatory surgery. The use of an electronic version of the survey may allow for larger sample sizes with fewer resources utilized in future interventional studies.

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.

The efficacy and safety of an adapted opioid-free anesthesia regimen versus conventional general anesthesia in gynecological surgery for low-resource settings: a randomized pilot study

INTRODUCTION

There is scarce data on the safety and efficacy of opioid-free anesthesia (OFA), in resource-limited settings due to the non-availability of dexmedetomidine, the reference OFA agent. We aimed to demonstrate the feasibility, efficacy and safety of a practical OFA protocol not containing dexmedetomidine, adapted for low-resource environments in very painful surgeries like gynecological surgery.

METHODS

We conducted a randomized pilot study on ASA I and II women undergoing elective gynecological surgery at a tertiary care hospital in Cameroon. Patients were matched in a ratio of 1:1 into an OFA and a conventional general anesthesia (CGA) group. The OFA protocol entailed the intravenous (IV) magnesium sulfate, lidocaine, ketamine, dexamethasone, propofol, and rocuronium, followed by isoflurane and a continuous infusion of a calibrated mixture of magnesium sulfate, ketamine and clonidine. The CGA protocol was IV dexamethasone, diazepam, fentanyl, propofol, and rocuronium, followed by isoflurane and reinjections of fentanyl propofol and a continuous infusion of normal saline as placebo. The primary endpoints were the success rate of OFA, isoflurane consumption and intraoperative anesthetic complications. The secondary endpoints were postoperative pain intensity, postoperative complications, patient satisfaction assessed using the QoR-40 questionnaire and the financial cost of anesthesia.

RESULTS

We enrolled a total of 36 women undergoing gynecological surgery; 18 in the OFA group and 18 in the CGA group. The success rate of OFA was 100% with significant lesser consumption of isoflurane in the OFA group, no significant intraoperative complication and better intraoperative hemodynamic stability in the OFA group. Postoperatively, compared to the CGA group, the OFA group had statistically significantly less pain during the first 24 h, no morphine consumption for pain relief, had less hypoxemia during the first six hours, less paralytic ileus, less nausea and vomiting, no pruritus and better satisfaction. The mean financial cost of this adapted OFA protocol was statistically significant lesser than that of CGA.

CONCLUSION

This OFA regimen without dexmedetomidine for a low-resource setting has a promising success rate with few perioperative complications including mild intraoperative hemodynamic changes, decrease postoperative complications, pain, and opioid consumption in patients undergoing elective gynecology surgery.

TRIAL REGISTRATION

This study was registered at clinicaltrials.gov on 03/02/2021 under the registration number NCT04737473.

Association of peripheral nerve blocks with patient-reported quality of recovery in female patients receiving breast cancer surgery: a systematic review and meta-analysis of randomized controlled studies

PURPOSE

This systematic review and meta-analysis investigated the impact of peripheral nerve blocks (PNBs) on patient-reported quality of recovery (QoR) following breast cancer surgery.

SOURCE

Medline, EMBASE, Cochrane Library, and Google scholar databases were searched for randomized controlled trials (RCTs) comparing the QoR with or without PNBs in patients receiving breast cancer surgery from inception to September 2021. Using a random effects model, the primary outcome was total scores of postoperative QoR scales (i.e., QoR-15 and QoR-40).

PRINCIPAL FINDINGS

Eight RCTs (QoR-15, n = 4; QoR-40, n = 4) involving 653 patients published from 2018 to 2021 were included. For the QoR-40 scale, pooled results revealed a significantly higher total score (mean difference [MD], 12.8 [8.2%]; 95% confidence interval [CI], 10.6 to 14.9; I² = 59%; five RCTs; n = 251) and scores on all subscales, except psychological support, in the PNB group than in controls at 24 hr after surgery. For the QoR-15 scale, pooled results also showed favorable QoR (MD, 7.7 [5.2%]; 95% CI, 4.9 to 10.5; I² = 75%; four RCTs; n = 402) in the PNB group at 24 hr after surgery. Sensitivity analysis showed no effect on the QoR-40 score and the difference in total QoR-15 score was no longer significant when a single trial was omitted. The use of PNBs was associated with a significantly lower opioid consumption and risk of postoperative nausea and vomiting without significant differences in the pain score between the two groups.

CONCLUSION

Our results verified the efficacy of PNBs for enhancing postoperative QoR using two validated patient-reported tools in female patients receiving breast cancer surgery under general anesthesia.

STUDY REGISTRATION

PROSPERO (CRD42021272575); first submitted 9 August 2021.

Opioid-free anesthesia for open radical cystectomy in morbid obesity

Opioid-free anaesthesia shows evidence about its efectivity and security, even though its risks and benefits are not well defined. Neither are the patient profile or sort of surgery where it could be superior to the conventional opioid-based anaesthetic technique. Aggressive and/or long-lasting surgeries set out several queries on this technique regarding sudden hemodynamic changes, as it does not produce sympatholysis through μ receptor and there is modest experience in this technique. A morbidly obese patient received open radical cystectomy with Bricker-type urinary diversion using infraumbilical incision under OFA protocol, maintaining an adequate hemodynamic stability and excellent analgesia in postoperatory care without using any intraoperative opioids. Opioid-free anaesthesia technique is developing its evidence. However, it is necessary to keep on researching its clinical applications, different drug combinations and solutions to its expected complications.

Effect of opioid-free anesthesia on postoperative analgesia after laparoscopic gynecologic surgery

BACKGROUND

We performed this randomised controlled trial to evaluate the effect of opioid-free anesthesia (OFA) on postoperative analgesia after laparoscopic gynecologic surgery.

METHODS

78 patients undergoing laparoscopic gynecologic surgery were randomized to receive either OFA (Group OF) or opioid-inclusive anesthesia (Group C). Postoperative sufentanil consumption within the first 24 h, visual analogue scale (VAS) for pain, postoperative equivalent milligrams of morphine (EMM), severity of postoperative nausea (PN) and vomiting (PV), prevalence of PONV, use of antiemetics, time to first passage of flatus were compared by a two-tailed Student's t test, Wilcoxon rank-sum tests or Fisher's exact tests. Repeated measures ANOVA was used to assess the effect of allocation of groups over time.

RESULTS

The median [IQR] sufentanil consumption within 24 h was lower in Group OF (4[4.5]) than in Group C (6[8], mean difference [MD]=-2, 95% confidence interval [CI] [-4 to 0], P=0.029). The VAS scores at rest and during coughing at 6 h (P=0.009 at rest; P=0.002 during coughing), VAS scores during coughing at 2h (P=0.013) and 4 h (P=0.008), EMM (P=0.026), severities of PN (P=0.003) and PV (P=0.003), and the mean time to first passage of flatus (P=0.017) was significantly less in Group OF than that in Group C. The prevalence of PONV (26.3% [Group OF], 68.4% [Group C], OR=0.31, 95% CI [0.158 to 0.589], P <0.001), use of antiemetics (5.3% [Group OF], 28.9% [Group C], OR=0.136, 95% CI[0.028 to 0.667], P=0.012) was also significantly different between groups.

CONCLUSIONS

Compared to opioid-inclusive anesthesia during laparoscopic gynecologic surgery, OFA was associated with significant improvement in postoperative analgesia, reduced PONV incidenceprevalence and severity, and faster first passage of flatus.

Total opioid-free general anaesthesia can improve postoperative outcomes after surgery, without evidence of adverse effects on patient safety and pain management: A systematic review and meta-analysis

BACKGROUND

Opioid-based treatment is used to manage stress responses during surgery and postoperative pain. However, opioids have both acute and long-term side effects, calling for opioid-free anaesthetic strategies. This meta-analysis compares adverse events, postoperative recovery, discharge time from post-anaesthesia care unit, and postoperative pain, nausea, vomiting, and opioid consumption between strict opioid-free and opioid-based general anaesthesia.

METHODS

We conducted a systematic review and meta-analysis. We searched PubMed, Embase, Cinahl, Cochrane Library, selected reference lists, and Google Scholar. We included randomised controlled trials (RCTs) published between January 2000 and February 2021 with at least one opioid-free study arm, i.e. no opioids administered preoperatively, during anaesthesia induction, before skin closure, or before emergence from anaesthesia.

RESULTS

The study comprised 1934 patients from 26 RCTs. Common interventions included laparoscopic gynaecological surgery, upper gastrointestinal surgery, and breast surgery. There is firm evidence that opioid-free anaesthesia significantly reduced adverse postoperative events (OR 0.32, 95% CI 0.22 to 0.46, I²  = 56%, p < 0.00001), mainly driven by decreased nausea (OR 0.27, (0.17 to 0.42), p < 0.00001) and vomiting (OR 0.22 (0.11 to 0.41), p < 0.00001). Postoperative opioid consumption was significantly lower in the opioid-free group (-6.00 mg (-8.52 to -3.48), p < 0.00001). There was no significant difference in length of post-anaesthesia care unit stay and overall postoperative pain between groups.

CONCLUSIONS

Opioid-free anaesthesia can improve postoperative outcomes in several surgical settings without evidence of adverse effects on patient safety and pain management. There is a need for more evidence-based non-opioid anaesthetic protocols for different types of surgery as well as postoperative phases.

Opioid-free TIVA Improves Post- operative Quality of Recovery (QOR) in Patients Undergoing Oocyte Retrieval

BACKGROUND

Oocyte retrieval is a part of in vitro fertilisation (IVF) procedures performed on an ambulatory basis. Total intravenous anaesthesia (TIVA) with opioid is shown to improve quality of recovery (QOR) after ambulatory surgery. Opioid-free anaesthesia (OF) is gaining popularity in recent times as it is associated with lesser post-operative side effects related to opioids. Quality of recovery is considered as one of the principal end points in ambulatory surgery.

AIM

To compare quality of recovery using QOR-15 questionnaire between opioid-free TIVA and opioid-based TIVA at 24 h after oocyte retrieval.

SETTINGS AND DESIGN

A prospective randomised control study.

PATIENTS AND METHODS

Sixty six patients undergoing oocyte retrieval were prospectively selected. They were randomised into two equal group. OF TIVA group with dexmedetomidine (D) and propofol or opioid-based TIVA with fentanyl (F) and propofol. The primary outcome measured was quality of recovery using QOR-15 at 24 h after oocyte retrieval. Secondary outcomes measured were incidence of bradycardia, post-operative nausea and vomiting, usage of rescue analgesia and total consumption of propofol.

RESULTS

A statistically significant difference in total QOR-15 was observed between two groups (p value = 0.021) at 24 h post-operatively. Usage of rescue analgesia and incidence of post-operative nausea and vomiting was less in opioid-free TIVA.

CONCLUSION

Opioid-free TIVA improves post-operative QOR in patients undergoing oocyte retrieval.

Opioid-free anesthesia for open radical cystectomy in morbid obesity

Opioid-free anaesthesia shows evidence about its efectivity and security, even though its risks and benefits are not well defined. Neither are the patient profile or sort of surgery where it could be superior to the conventional opioid-based anaesthetic technique. Aggressive and/or long-lasting surgeries set out several queries on this technique regarding sudden hemodynamic changes, as it does not produce sympatholysis through μ receptor and there is modest experience in this technique. A morbidly obese patient received open radical cystectomy with Bricker-type urinary diversion using infraumbilical incision under OFA protocol, maintaining an adequate hemodynamic stability and excellent analgesia in postoperatory care without using any intraoperative opioids. Opioid-free anaesthesia technique is developing its evidence. However, it is necessary to keep on researching its clinical applications, different drug combinations and solutions to its expected complications.

Opioid-Free Anesthesia Benefit-Risk Balance: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Opioid-free anesthesia (OFA) is used in surgery to avoid opioid-related side effects. However, uncertainty exists in the balance between OFA benefits and risks. We searched for randomized controlled trials (RCTs) comparing OFA to opioid-based anesthesia (OBA) in five international databases. The co-primary outcomes were postoperative acute pain and morphine consumption at 2, 24, and 48 h. The secondary outcomes were the incidence of postoperative chronic pain, hemodynamic tolerance, severe adverse effects, opioid-related adverse effects, and specific adverse effects related to substitution drugs. Overall, 33 RCTs including 2209 participants were assessed. At 2 h, the OFA groups had lower pain scores at rest MD (0.75 (−1.18; −0.32)), which did not definitively reach MCID. Less morphine was required in the OFA groups at 2 and 24 h, but with very small reductions: 1.61 mg (−2.69; −0.53) and −1.73 mg (p < 0.05), respectively, both not reaching MCID. The reduction in PONV in the OFA group in the PACU presented an RR of 0.46 (0.38, 0.56) and an RR of 0.34 (0.21; 0.56), respectively. Less sedation and shivering were observed in the OFA groups with an SMD of −0.81 (−1.05; −0.58) and an RR of 0.48 (0.33; 0.70), respectively. Quantitative analysis did not reveal differences between the hemodynamic outcomes, although severe side effects have been identified in the literature. No clinically significant benefits were observed with OFA in terms of pain and opioid use after surgery. A clear benefit of OFA use was observed with respect to a reduction in PONV. However, more data on the safe use of OFAs should be collected and caution should be taken in the development of OFA.

Effect of multimodal analgesia on gynecological cancer patients after radical resection

OBJECTIVE

This research was designed to probe into the effect of multimodal analgesia on gynecological cancer patients after radical resection.

METHODS

Ninety-eight cervical cancer patients undergoing laparoscopic radical resection in our hospital were included. Thereinto, 47 in the research group (RG) were given multimodal analgesia, and 51 in the control group (CG) were given conventional postoperative analgesia. The time of operation, anesthesia recovery room observation and extubation, postoperative NRS pain score, and the clinical manifestations of both groups were observed. The activity within three days after operation, the incidence of postoperative complications, hospitalization time and quality of life of both groups were compared.

RESULTS

The operation time of the RG was higher than that of the CG (P < 0.05), and the time of observation and extubation in the anesthesia room were lower than those in the CG (P < 0.05); the NRS pain score was lower than that of the CG (P < 0.05); the first time to get out of bed, and time of exhaust and diet were shorter than those of the CG (P < 0.05); the activity was better than that of the CG within three days after operation (P < 0.05); the incidence of complications was markedly lower than that in the CG (P < 0.05); the hospitalization time was shorter than that of the CG (P < 0.05); the postoperative quality of life was shorter than that in the CG (P < 0.05).

CONCLUSION

Multimodal analgesia is safe and effective for patients after laparoscopic radical resection of gynecological malignancies, which can speed up the recovery of diseases and improve the quality of life. Thus, it is worthy of clinical application.

INFLUENCE OF DIFFERENT TYPES OF ANESTHESIA FOR LAPAROSCOPIC HYSTERECTOMY ON THE DYNAMICS OF STRESS HORMONES

The aim of the study – to evaluate the influence of different variants of anesthesia, including low-opioid (LOA) and opioid-free anesthesia (OFA), on the dynamics of the stress response during laparoscopic hysterectomy. Materials and methods: 102 patients were randomly allocated into 3 groups: 37 women assigned to receive a standard opioid-based anesthesia (OBA group), 33 women – LOA group and 32 patients OFA group. Results: The patients of OFA group after induction and intubation of the trachea showed a significant (p<0.05) increase in cortisol level by 155.4 % and 160.9 % compared with the OBA group and LOA group. After completion of the hysterectomy, regardless of the variant of anesthesia, the level of cortisol exceeded the preoperative one (pOBA=0.116, pLOA=0.049, pOFA=0.043). Two hours after surgery with standard anesthesia (OBA group) there was a further increase in the concentration of cortisol in the blood, exceeding the initial values by 142.9 % (p=0.043). Patients in the LOA group and OFA group tended to decrease cortisolemia. The changes in adrenaline & glucose levels were somewhat similar. Conclusion: Use of OFA is accompanied by an aggravation of the stress response at the stage of hysterectomy, which is manifested by an increase in the level of adrenaline and cortisol. The most adequate perioperative protection is inherent in low-opioid anesthesia, which is accompanied by a lower release of stress hormones during hysterectomy and in the postoperative period. Opioid-based anesthesia provides adequate intraoperative protection, but is accompanied by insufficient postoperative analgesia.

Prevention and Treatment of Postoperative Nausea and Vomiting (PONV): A Review of Current Recommendations and Emerging Therapies

Postoperative nausea and vomiting is one of the most frequent adverse events after surgery and anesthesia. It is distressing for the patient and can lead to other postoperative complications. Management of PONV involves a framework of risk assessment, multimodal risk reduction, and prophylactic measures, as well as prompt rescue treatment. There has been a significant paradigm shift in the approach towards PONV prevention. There have also been several emerging therapeutic options for PONV prophylaxis and treatment. In this review, we will discuss the up-to-date PONV management guidelines and highlight novel therapeutic options which have emerged in the last few years.

Intravenous administration of dexmedetomidine and quality of recovery after elective surgery in adult patients: A meta-analysis of randomized controlled trials

STUDY OBJECTIVE

To evaluate the efficacy and safety of pre- and perioperative intravenous administration of dexmedetomidine for enhancing quality of recovery (as measured by 40-item quality of recovery questionnaire (QoR-40), ranged from 40 to 200) after surgery.

DESIGN

Meta-analysis.

SETTING

Adult patients undergoing elective surgery.

INTERVENTION

Intravenous administration of dexmedetomidine during pre- and perioperative period.

MEASUREMENTS

The primary outcome was quality of recovery after surgery. The secondary outcome was the incidence of dexmedetomidine-related adverse events.

MAIN RESULTS

Moderate to low quality evidence suggested that dexmedetomidine (DEX) increased the quality of recovery after surgery (WMD, weighted mean difference 15.71, 95% CI, confidence interval 0.43 to 31.00; 428 participants; 5 RCTs; low quality evidence), decreased the incidence of postoperative nauseas or vomiting (RR, risk ratio 0.60, 95% CI 0.44 to 0.83; 404 participants; 6 RCTs; moderate quality evidence; RR 0.32, 95% CI 0.19 to 0.55; 356 participants; 5 RCTs; moderate quality evidence) without increased risk of bradycardia (RR: 1.78, 95% CI 0.78 to 4.02; 275 participants; 4 RCTs; moderate quality evidence), dizziness (RR 0.78, 95% CI 0.31 to 2.00; 183 participants; 3 RCTs; moderate quality evidence), pruritus (RR 1.32, 95% CI 0.39 to 4.44; 186 participants; 3 RCTs; moderate quality evidence), hypotension requiring an intervention (RR: 1.48, 95% CI, 0.68 to 3.23; 254 participants; 3 RCTs; moderate quality evidence) and longer length of hospital stay (WMD: -0.75 days, 95% CI -1.95 to 0.44; 246 participants; 3 RCTs; low quality evidence) in early postoperative period.

CONCLUSIONS

Dexmedetomidine as an anesthetic adjuvant to general anesthesia was associated with an enhanced quality of recovery (15.71; far more than a clinically significant improvement of 6.3) without increased risk of adverse events in the early postoperative period (moderate to low quality evidence). Further large sample and high quality RCTs are needed to confirm the current findings.

Dexmedetomidine in Enhanced Recovery After Surgery (ERAS) Protocols for Postoperative Pain

PURPOSE OF REVIEW

Effective acute pain management has evolved considerably in recent years and is a primary area of focus in attempts to defend against the opioid epidemic. Persistent postsurgical pain (PPP) has an incidence of up to 30-50% and has negative outcome of quality of life and negative burden on individuals, family, and society. The 2016 American Society of Anesthesiologists (ASA) guidelines states that enhanced recovery after surgery (ERAS) forms an integral part of Perioperative Surgical Home (PSH) and is now recommended to use a multimodal opioid-sparing approach for management of postoperative pain. As such, dexmedetomidine is now being used as part of ERAS protocols along with regional nerve blocks and other medications, to create a satisfactory postoperative outcome with reduced opioid consumption in the Post anesthesia care unit (PACU).

RECENT FINDINGS

Dexmedetomidine, a selective alpha2 agonist, possesses analgesic effects and has a different mechanism of action when compared with opioids. When dexmedetomidine is initiated at the end of a procedure, it has a better hemodynamic stability and pain response than ropivacaine. Dexmedetomidine can be used as an adjuvant in epidurals with local anesthetic sparing effects. Its use during nerve blocks results in reduced postoperative pain. Also, local infiltration of IV dexmedetomidine is associated with earlier discharge from PACU. Perioperative use of dexmedetomidine has significantly improved postoperative outcomes when used as part of ERAS protocols. An in-depth review of the use of dexmedetomidine in ERAS protocols is presented for clinical anesthesiologists.

[Non-opioid multimodal anesthesia in the surgical treatment of colorectal cancer]

This article deal with method of multimodal, opioid-free anesthesia for colorectal surgery in the perioperative period.

AIM

To improve the quality of treatment for patients with colorectal cancer using non-opioid anesthesia and analgesia in the perioperative period.

MATERIAL AND METHODS

The study included 47 patients who underwent laparoscopic colon surgery. This anesthesia method consists of epidural anesthesia with sevoflurane during surgery end epidural analgesia after surgery. We describe the method of non-opioid anesthesia technics during colorectal surgery. The pain syndrome was evaluated at various time intervals. Harvard standard for monitoring during anesthesia is presented.

RESULTS

Opioid-free anesthesia is safety method for colorectal surgery. It was also possible to reduce the incidence of postoperative nausea and vomiting, pain, intestinal paresis, the duration of hospitalization, and rise quality of medical care for patient with colorectal cancer.