Opioid-Free Anesthesia for Laparoscopic Hysterectomy: Is it Appropriate?

Abstract

Opioids are frequently associated with adverse events such as dizziness, drowsiness [7], high incidence of PO nausea and vomiting, which varies from 20%-60% [8] or constipation which disturbs PO recovery and extends the duration of hospital stay [7].With increased awareness of both short-and longterm problems associated with liberal perioperative opioid administration, the need for routinely and clinically feasible alternatives is greater than ever [9]. Implementation of multimodal analgesic regimen achieved equivalent and effective pain control aiming to reduce the reliance on opioid-based medications [10]. The application of enhanced recovery pathways promoted opioid-free and multimodal analgesia [11] and allowedAbstract Objective: To evaluate intraoperative (IO) and postoperative (PO) outcome of women assigned to laparoscopic hysterectomy under opioidfree anesthesia (OFA) in comparison to opioid-based anesthesia (OBA).Patient and Methods: 72 women were randomly divided into OBA and OFA groups according to the provided IO analgesic regimen. OBA patients received Fentanyl (FEN) as loading and Remifentanyl (REM) infusion as maintenance analgesia. OFA patients received preoperative parecoxib sodium for preparation, dexmedetomidine (DEX) and lidocaine (LID) as loading and maintenance analgesia. Study Outcomes included the frequency of patients developed IO deviated mean arterial pressure (MAP) measures by >20% of baseline measures, duration of surgery and time till fulfilling criteria for PACU discharge, duration of PO analgesia, time till 1st ambulation, PO complications and hospital stay.Results: Demographic data and surgical characteristics were comparable in all groups. The D group showed delay in onset for first call for analgesia (900±60.9min) while M and K groups results were (600±33.4min) and (350±17.4min) respectively, all of the group's results were statistically significant than the control group result (260±14.3min).Results: MAP measures during and 30-min after abdominal insufflations were significantly higher in patients of OFA than patients of OBA. Among 216 MAP readings, increased MAP measures by >20% of baseline measure was recorded in 10 (4.6%) versus 3 (1.4%) readings in OFA and OBA groups, respectively with a non-significant difference (p=0.091) between both groups. Duration till 1st ambulation was significantly shorter with OFA compared to OBA, while duration till 1st request of rescue analgesia was significantly longer with OFA, while the frequency of patients requested more rescue analgesia was significantly higher with OBA than OFA. PONV was reported in 53 patients and 17 patients required anti-emetic therapy with significantly higher incidence with OBA compared to OFA group. Conclusion:The applied protocol for OFA provided satisfactory IO analgesia and control of surgery-induced pressor reflexes. Also, it allowed reduction of PO analgesic consumption with early ambulation and reduced PONV that were reflected as shorter PO hospital stay.

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

“…We found this adapted OFA protocol had a 100% success rate with significant lesser consumption of isoflurane, no significant intraoperative complication and better intraoperative hemodynamic stability in the OFA group. These findings re-iterate previous reports from other clinical trials on gynecological surgery [26,[28][29][30][31][35][36][37][38][39][40][41] demonstrating a 100% success rate for OFA with stable or better hemodynamics and no intra-operative complications. By contrast, a multicentre French clinical trial on 314 non-cardiac surgeries (with 5.7% gynecological surgical procedures) reported more hypertension, hypotension and severe bradycardia (less than 45 beats/min) during OFA which prompted the early termination of the clinical trial [25].…”

“…This was an expected finding that has been correlated with the pharmacodynamic properties of opioids on the intestines: a reduction of peristaltic movements [ 8 ]. Similar to other authors working on both abdominal and laparoscopic gynecological surgery [ 29 , 30 , 37 , 38 ] as well as mastectomy [ 28 , 31 ] patients in the OFA group demonstrated statistically significant quicker postoperative mobilization or recovery with better postoperative satisfaction assessed on either the QoR-40 questionnaire or verbal rating scale for satisfaction. This reinforces evidence of OFA as being safe and effective for gynecological surgery.…”

“…Moreover, this profound bradycardia occurred at a high dose of dexmedetomidine at 0.4 – 1.4 ug/kg/h which more than doubled dexmedetomidine doses of 0.2– 0. 6ug/kg/h [ 30 , 35 , 37 , 38 ] used by other clinical trials on gynecology surgery where stable hemodynamics were observed. Although dexmedetomidine is the reference OFA drug due to its α2-adrenergic analgesic-sedative-hypnotic-sympatholytic properties, its worldwide use is limited by its availability and relatively high financial cost.…”