Let's Avoid Opioids in Aesthetic Surgery.

Abstract

Opioid-free anesthesia is a new technique that enhances surgical recovery and reduces opioid consumption during the postoperative period.1 For decades, opioid use has continued to dramatically improve the development of modern anesthesia. Opioid use, however, is also often associated with adverse events such as nausea, vomiting, urinary retention, ileus, pruritus, an altered mental status, and respiratory depression. Opioid-free anesthesia avoids opioids through the use of multimodal anesthesia, including hypnotics, N-methyl-d-aspartate antagonists, alpha-2-agonists, lidocaine, magnesium sulfate, dexamethasone, and nonopioid analgesic drugs such as nonsteroidal antiinflammatory drugs and acetaminophen.1 At the end of 2016, we began the implementation of new opioid-free protocols in our seven-bed aesthetic clinic. Most of the procedures were carried out in a single operating room under monitored anesthesia care using the propofol-ketamine protocol developed by Barry Friedberg.2 The minor part of our procedure is performed under general anesthesia using the opioid-free anesthesia technique inspired by Jan Mulier.3 Consecutively, we have been reviewing the administration of perioperative sufentanil and postoperative morphine from 2016 (last non–opioid-free year) and gone completely opioid free in the latter years (reviewing stopped in October of 2019). Although the number of anesthetized patients and cosmetic procedures by type have not differed greatly over the years, less than 20 percent of the annual average of 240 patients were given general anesthesia. Eighty-four percent of our cases were female American Society of Anesthesiologists class 1 and 2 patients, with an average age of approximately 46 years, and the operations included facial aesthetics (47 percent), breast aesthetics (32 percent), body contouring (21 percent), and liposuction. We noticed that consumption of sufentanil also decreased dramatically, from 4000 μg per year in 2016 to less than 125 μg in 2019, and no patients required morphine to manage postoperative pain in the past 2 years (Fig. 1). Our nurses noticed a real change, with just a few patients having postoperative nausea and vomiting and needing antiemetic drugs, usually associated with a shorter surgical recovery time, thus allowing ambulatory management in most cases. Through this brief communication, we would like to set out that the use of opioid-free anaesthesia not only avoids the undesirable side effects of opioids but also dramatically enhances the postoperative recovery time without worsening the associated pain.Fig. 1.: Global intraoperative sufentanil (micrograms per year) and postoperative morphine (milligrams per year) consumption from January of 2016 to October of 2019. The opioid-free protocols began in 2017. The global annual opioid consumption decreased dramatically, and no postoperative rescue morphine was needed during the past 2 years.We were initially drawn toward the adoption of opioid-free anesthesia because the sedation procedure remains a primary part of our practice. We also maintain that avoiding opioid use completely during the sedation procedure is far safer, as opioid-free anesthesia can help avoid opioid-related respiratory depression. Opioid-related respiratory depression is well known to be a serious adverse event during the sedation procedure. This is because the airways are not protected by a tracheal tube or a laryngeal mask. Likewise, because the evidence-based proof in this area is still weak, the anesthetic community has been waiting and watching the results of a (400 patients) randomized study with much interest. This study observed and evaluated the effect of opioid-free anesthesia on severe postoperative opioid-related adverse events.4 We therefore collectively maintain that opioid-free anesthesia in our daily procedural experience has proven to be a safe and effective routine that adapts very well to our particular practice. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.