Hemodynamic Effects of Opioid‐Free Anesthesia Versus Opioid Anesthesia in Supratentorial Tumor Excision: A Randomized Controlled Trial

Background: General anesthesia induces frequently hyperglycemia. This is associated with an increased risk of morbidity and mortality in patients undergoing surgery. The type of anesthesia used may affect the severity of the peri-operative hyperglycemia. Methods: Patients undergoing an elective primary laparoscopic bariatric surgery at AZ Sint-Jan Brugge between February 2022 and March 2022 were randomized between opioid-free anesthesia (OFA) and opioid anesthesia (OA) after ethical approval. Any patient with diabetes type 1, diabetes type 2, having glucose intolerance at the time of surgery, or during pregnancy were excluded from the study. Dexmedetomidine, lidocaine, ketamine, and magnesium were used for the OFA, while sufentanil was given in the OA. No intravenously steroids were administered to protect the peritoneum nor as antiemetic prophylaxis. The increase in blood glucose level at 180’ was assessed as the primary outcome. A first measurement was taken just before the anesthesia induction (T0), followed by a measurement every hour (T60’, T120’, and T180’). As secondary endpoints, the total dose of opioids given in the first 24 hours and the postoperative pain using the VAS (visual analog scale) score were measured. Additionally, postoperative nausea and vomiting (PONV), duration of surgery, and surgical and/or anesthetic complications were recorded. Results: A total of 43 patients underwent an elective primary laparoscopic bariatric surgery. 22 patients received OFA and 20 patients received OA and were analyzed. One patient from the OA group withdrew written consent. 2 patients from the OFA group were lost to follow up having therefore 19 in the OA and 20 in the OFA for analysis. There were no significant differences between the two groups regarding age, BMI, gender, duration of surgery, and pre-induction glycemia. The glycemia level increased in both groups but increased significantly higher in the OA group at 180 minutes (Mann-Whitney test p = 0.027). OFA was associated with lower VAS scores postoperative (OFA: 3(2-4) vs OA: 4(4-5,5)) and a reduced need for postoperative opioids (OFA: 4.9(2,4-7,2) mg versus OA: 10,4(8,4-12,7) mg). Conclusion: This research suggest that the use of opioid-free anesthesia causes a smaller increase in glycemia during elective laparoscopic bariatric surgery compared to opioid anesthesia. Furthermore, patients undergoing OFA showed higher levels of postoperative comfort, demonstrated through the lower postoperative VAS scores and the reduced need for postoperative opioids.

Newer modalities like opioid-free analgesia overcome the opioid-related side effect profile and are equally efficacious. This study aims to compare the clinical outcomes between opioid-free anaesthesia (OFA) and opioid-based anaesthesia (OA) in elective nasal endoscopic surgeries. A randomised, open-label trial was conducted to evaluate the quality of recovery (QoR). The study included 64 patients with American Society of Anesthesiologists physical status I and II, of either gender, aged between 18 and 60 years, scheduled for elective endoscopic nasal surgery at a tertiary care centre. The patients were randomised into two groups: Group OA (patients receiving opioid anaesthesia) and Group OFA (patients receiving opioid-free anaesthesia). The primary outcome was the effects of OFA versus OA on the QoR-15 in patients undergoing endoscopic nasal surgeries under general anaesthesia. Secondary outcomes included intraoperative haemodynamics, respiratory depression, nausea/vomiting, pruritus, postoperative analgesia, and length of stay in the post-anaesthesia care unit. An independent sample t-test and Chi-squared test were employed for between-group comparisons. Patients undergoing OFA showed higher postoperative QoR-15 scores compared to the opioid group. Intraoperatively, the OFA group demonstrated a better haemodynamic profile at 15, 30, 60, 90, and 120 min, with lower mean arterial pressure values compared to the opioid group. Notably, the OFA group experienced reduced nausea/vomiting and pruritus. Postoperative analgesia requirements and length of stay in recovery were also lower in the OFA group. OFA in elective nasal endoscopic surgeries results in higher QoR-15 scores, better postoperative analgesia and fewer adverse effects associated with opioids.

Currently, enhanced recovery after surgery (ERAS) protocols are multimodal perioperative care pathways with the goal to achieve early patient recovery after surgery with minimal postoperative complications. According to studies, opioid free general anesthesia has many perioperative benefits and should be part of the ERAS protocols in specific surgical and patient indications. Opioid free general anesthesia is a multimodal balanced technique that is based on the concept that opioids are not used preoperatively or intraoperatively until the patient has aroused. The basic concept of opioid free general anesthesia is intravenous administration of several nonopioid drugs that operate at different pharmacological sites blocking surgical stress and sympathetic activation response. Moreover, current studies have shown that opioid free anesthesia is a technique which satisfactorily controls postoperative pain as the fifth vital sign, and has minimal side effects and better patient recovery with the same surgical conditions as general multimodal balanced anesthesia. However, further research is needed.

Comparison of the Effect of Opioid Anesthesia and Opioid-free Anesthesia on Postoperative Recovery: A Systematic Review and Meta-analysis.

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. 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. 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 2hr post surgery (MD, -5.4mg oral morphine equivalents; 95% CI, -9.1 to -1.8; P = 0.004). We also noted a reduced time to first analgesia (MD, 88min; 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. Opioid-free anesthesia showed a significant reduction in PONV and a decrease in opioid consumption during the first 2hr postoperatively, suggesting it can be an alternative to opioid anesthesia in minimally invasive abdominal surgeries. PROSPERO ( CRD42023492385 ); first submitted 18 December 2023.

Opioid-free anesthesia (OFA) represents an innovative approach that prioritizes patient safety, reduces the risks associated with opioid use, and seeks to enhance recovery. Few descriptions regarding the practical and implementation aspects exist. This review serves as a practical guide on OFA teaching and application. We briefly discuss the historical use of opioids in anesthesia, side effects and their consequences. We discuss pedagogical avenues and challenges, as well as implementation of OFA in less experienced settings. Opioid use in anesthesia originally coexisted with OFA. During the last decades, the advent of multimodal analgesia has resulted in decreased opioid dosages both before and after surgery. Recently, OFA increased in popularity, supported by meta-analyses, due to reduced nausea and vomiting, with a potential, even if limited, impact on pain. OFA, as part of rational prescribing, may contribute to a more patient-centered approach. Different strategies for OFA implementation coexist. Educational aspects, leadership, guidelines, local guidance, and training are all important. We propose a framework for OFA implementation with concrete options, including patient preparation, choice of OFA pharmacological agents (according to type of surgery and patient), and postoperative care. Whilst opioids still have an important place in pain management, they have brought harms that we cannot ignore. Evidence for using opioid-sparing and OFA techniques continues to emerge and there is a need to personalize more approaches. In this review, we provide evidence-based, relatively simple methods that can be used in implementing and delivering OFA.

Introduction:General anesthesia aims to induce a controlled state of unconsciousness, amnesia, and immobility while maintaining physiological balance.Optimizing hypnosis levels and administering appropriate analgesics are crucial for minimizing complications and ensuring adequate pain management during surgery.This study focuses on the Analgesia Nociception Index (ANI) as a measure of heart rate variability (HRV) to compare two general anesthesia techniques: opioid-free anesthesia and opioid induction. Methods:A retrospective comparative analytic study was conducted on patients undergoing laparoscopic procedures under general anesthesia at Hospital ngeles Metropolitano in Mexico City from January 2020 to December 2022.Patient records meeting specific criteria were classified into two groups: opioid-free anesthesia (OFA) and opioid anesthesia (OA).ANI measurements were collected at different time periods, including 5 minutes before surgical stimuli (ANI-5), at the stimulus (ANI-0), and 5 minutes after the stimulus (ANI+5). Results:The study included 32 patients, comprising 10 men (31.3%) and 22 women (68.8%) with a mean age of 52 18 years.There were no significant differences in age or surgical duration between the OFA and OA groups.The ANI measurements did not show significant differences between groups at any time point, indicating similar HRV intensity.Discussion: Although no significant differences were found between the opioid-free anesthesia and opioid induction groups, a general linear model of repeated measures was employed to assess the effect of opioids on HRV over time.However, the effect size did not reach statistical significance. Conclusion:This study comparing the intensity of heart rate variability using the ANI monitor in opioid-free anesthesia and opioid induction did not reveal significant differences between the two techniques.Further research with larger sample sizes may be necessary to elucidate the potential effects of opioids on HRV during general anesthesia.

Introduction: Opioids have been used as a part of balanced anaesthesia and have known side effects. Opioid Free Analgesia is an emerging technique, based on avoiding intraoperative opioids.&#x0D; Aims: To compare the effectiveness of opioid-free versus opioid based anaesthesia.&#x0D; Methods: This comparative study involved 100 patients undergoing elective laparoscopic cholecystectomy under general anaesthesia with American Society of Anaesthesiologists I or II physical status. Out of 100 patients, 50 received Fentanyl (Group A) while another 50 (Group B) received Ketamine and Lignocaine. Parameters measured and compared were the gender, age, weight, ASA physical status, hemodynamic stability, postoperative pain intensity (VAS) and opioid requirements, as well as side effects.&#x0D; Results: Both groups were comparable with regards to age, gender, weight, American Society of Anaesthesiologists I or II physical status, mean duration of surgery. There was no significant difference between groups hemodynamics at all assessed times (p&gt;0.05) intraoperatively. Visual Analogue Scale pain score in the first 24 hours postoperatively showed that patients in Group A, at all analyzed time points had higher Visual Analogue Scale scores than Group B, but statistically significant difference was confirmed during the first hour (p = 0.001). Seven(14%) in Group A and 5(10%) patients in Group B got intravenous tramadol only once while 5(10%) patients in Group A required twice, which was statistically significant (p=0.05). Intraoperatively, 2 patients (4%) in group A had bradycardia while none in group B, which was statistically insignificant (p=0.153). Postoperatively, nausea was more in group A than Group B i.e. 8% vs 4% (p=0.4).&#x0D; Conclusion: Opioid Free anaesthesia has a better benefit over Opioid anaesthesia with regard to postoperative pain score, opioid consumption and its side effects.

Background: Anesthetic management practices have advanced to opioid-free anesthesia (OFA) often replacing opioids in oncologic surgeries. The study was conducted to find the quality of recovery (QoR) of patients undergoing breast cancer surgeries receiving OFA.Methods: A double-blinded, randomized controlled study was conducted with 60 patients randomized to group OFA and group OA (opioid anesthesia). Group OFA received one-time dosing of ketamine 0.3 mg/kg, lignocaine 1.5 mg/kg, and dexmedetomidine 1 mcg/kg. Group OA received fentanyl 2mcg/kg. Intraoperatively, Group OFA received dexmedetomidine 0.4 mcg/kg/h and the OA group received fentanyl 0.5 mcg/kg/h infusion. Bispectral index (BIS), hemodynamics, muscle relaxant administration, and sevoflurane concentration were noted. A modified QoR-40 score was used to assess the quality of recovery in the postoperative period.Results: A higher QoR-40 score was found in the OA group (median 182, IQR 178-186) compared to the OFA group (median 180, IQR 178-184). Out of the five components, the patient's emotional state was better in the group OA (39.9±2.77) than in the OFA group (37.9±2.77). The patient's physical comfort was found to be better in the group OFA (52.52±3.23) compared to group OA (50.93±3.23). Physical independence, psychological support, and pain were comparable between the two groups. Patients in group OFA received less sevoflurane, a muscle relaxant, and showed a mild reduction in heart rate and mean arterial pressure (MAP) when compared to group OA. The time taken to reach a Modified Aldrete score of 9 was high in OFA (11.47±2.16) and (9.17±1.09) when compared to group OA. No significant differences were noted with the visual analog score (VAS) score, Ramsay sedation score, and modified post-anesthesia discharge scoring system (PADSS) score.Conclusion: We conclude that the quality of recovery of patients receiving opioid-free methods of anesthesia was not inferior to OA in patients undergoing breast cancer surgeries.

BackgroundNo study has been conducted to demonstrate the feasibility of an opioid-free anesthesia (OFA) protocol in cardiac surgery to improve patient care. The aim of the present study was to evaluate the effect of OFA on post-operative morphine consumption and the post-operative course.MethodsAfter retrospectively registering to clinicaltrial.gov (NCT03816592), we performed a retrospective matched cohort study (1:1) on cardiac surgery patients with cardiopulmonary bypass between 2018 and 2019. Patients were divided into two groups: OFA (lidocaine, dexamethasone and ketamine) or opioid anaesthesia (OA) (sufentanil). The main outcome was the total postoperative morphine consumption in the 48 h after surgery. Secondary outcomes were rescue analgesic use, a major adverse event composite endpoint, and ICU and hospital length of stay (LOS).ResultsOne hundred ten patients were matched (OFA: n = 55; OA: n = 55). On inclusion, demographic and surgical data for the OFA and OA groups were comparable. The total morphine consumption was higher in the OA group than in the OFA group (15 (6–34) vs 5 mg (2–18), p = 0.001). The pain score during the first 48 post-operative hours did not differ between the two groups. Creatinine values did not differ on the first post-operative day (80 (IQR: 66–115) vs 77 mmol/l (IQR: 69–95), p = 0.284). Incidence of the composite endpoint was lower in the OFA group (25 patients (43%) vs 38 patients (68%), p = 0.021). The time to extubation and the ICU stays were shorter in the OFA group (3 (1–5) vs 5 (3–6) hours, p = 0.001 and 2 (1–3) vs 3 (2–5) days, p = 0.037).ConclusionThe use of OFA was associated with lower morphine consumption. OFA might be associated with shorter intubation time and ICU stays. Further randomized studies are needed to confirm these results.Trial registrationThis study was retrospectively registered to ct2 (identifier: NCT03816592) on January 25, 2019.

appears neither logical nor beneficial to patients.

BackgroundOpioids are commonly used in general anesthesia for pain management. However, they are linked to significant side effects. Patients undergoing laparoscopic sleeve gastrectomy, particularly those with obesity, are at higher risk of experiencing adverse effects associated with opioids. Therefore, there is a need to explore alternative anesthesia options that do not rely on opioids. This study aims to investigate the efficacy of opioid-free anesthesia (OFA) compared to traditional opioid-based anesthesia (OBA) in patients undergoing laparoscopic sleeve gastrectomy.MethodsThis single-center randomized controlled trial included eighty-three patients undergoing laparoscopic sleeve gastrectomy in a tertiary hospital. Patients were randomly assigned to dexmedetomidine and lidocaine infusion (OFA) or remifentanil (OBA). All patients received intra-operative propofol, sevoflurane, a neuromuscular blocking agent, and ketamine. The primary outcome included opioid consumption during the post-anesthesia care unit (PACU). Secondary measures included intraoperative hemodynamic stability, time to extubation, PACU stay duration, opioid consumption during the first 48 h, and anti-emetic requirements. Independent samples t-test or Mann–Whitney U test was used to assess for differences across the two groups.ResultsPACU morphine consumption, total postoperative morphine consumption, anti-emetic requirements up to 48 h after surgery, and pain levels after surgery were not statistically significantly different between OFA and OBA groups. Other variables were not statistically different between the two groups, except for intraoperative anti-hypertensives where more patients in the OFA groups required it.ConclusionsOpioid-free anesthesia hasn’t shown an opioid-sparing effect in patients with obesity undergoing laparoscopic sleeve gastrectomy. Larger multi-center studies are required to fully establish its effectiveness.Trial registrationClinicalTrials.gov (NCT03507634); first trial registration date: 12/04/2018; first posted date: 25/04/2018.

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. 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. 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). 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.

Impact of opioid-free anesthesia on complications after deep inferior epigastric perforator flap surgery: A retrospective cohort study

Impact of Opioid-free Anesthesia After Video-assisted Thoracic Surgery: A Propensity Score Study