Opioid-Free Versus Opioid-Based Anesthesia on Postoperative Pain After Thoracoscopic Surgery: The Use of Intravenous and Epidural Esketamine

Abstract

BACKGROUND: The effectiveness and safety of opioid-free anesthesia (OFA) regimens in distinct types of surgeries remain controversial. In this study, we investigated whether OFA could reduce the occurrence of chronic postoperative pain in patients receiving video-assisted thoracoscopic surgery (VATS). METHODS: We conducted a 2-center, randomized, controlled trial from September 2021 to January 2022. A total of 162 lung tumor patients scheduled to undergo VATS were randomly divided into an opioid-based anesthesia (OA) group and an OFA group. The OA group received general anesthesia combined with thoracic epidural block using morphine, while the OFA group received general anesthesia combined with thoracic epidural block using esketamine. Patient-controlled epidural analgesia (PCEA) was used after surgery (ropivacaine and morphine for the OA group versus ropivacaine and esketamine for the OFA group). The primary end point was chronic pain rates at 3 months after VATS, which were analyzed using a logistic regression model. The secondary end points were chronic pain rates at 6 months, acute pain rates at 24 hours and 48 hours postoperatively, postoperative side effects, and perioperative variables. RESULTS: The final analysis included 159 patients. Acute postoperative pain at 24 hours occurred in 0 of the 79 (0%) patients in the OA group and 10 of the 80 (17.5%) patients in the OFA group (odds ratio, 52.14; 95% confidence interval [CI], 6.47–420.10; P < .001). Acute postoperative pain at 48 hours occurred in 3 of the 79 (3.8%) patients in the OA group and 2 of the 80 (2.5%) patients in the OFA group (odds ratio, 2.07; 95% CI, 0.99–4.32; P = .053). In this study, none of the patients had moderate or severe pain in either group at 3 and 6 months postsurgically. Mild chronic postoperative pain at 3 months occurred in 27 of the 79 (34.2%) patients in the OA group and 14 of the 80 (17.5%) patients in the OFA group (odds ratio, 3.52; 95% CI, 1.49–8.31; P = .004). At 6 months, mild chronic pain still occurred in 23 of the 79 (29.1%) patients in the OA group and 9 of the 80 (11.3%) patients in the OFA group (odds ratio, 5.55; 95% CI, 2.01–15.33; P = .001). In addition, the OFA group included fewer patients with side effects, including nausea, vomiting, and pruritus, within 48 hours after surgery. CONCLUSIONS: Replacement of opioids by esketamine, intraoperatively as intravenous injection and epidural infusion and postoperatively as epidural infusion, reduces the incidence of mild chronic postoperative pain and side effects in patients after VATS.

Opioid-free anaesthesia reduces postoperative nausea and vomiting after thoracoscopic lung resection: a randomised controlled trial

“…injection and epidural infusion) reduced the incidence of chronic pain after thoracoscopic surgery. 12 However, none of the previous studies aimed PONV as the primary outcome when assessing the effects of OFA in thoracoscopic lung surgery. In a trial by An and colleagues, 11 the rate of PONV was 4.3% in the OFA group, which was significantly lower than 41.7% in the opioid-based control group.…”

“…Compared with control, OFA led to higher values of mBP from the time of intubation (mean [SD]: 115 [16] vs 106 [16] mm Hg; P¼0.002) to 1 h in surgery (88 [12] vs 83 [11] mm Hg; P¼0.021) and higher values of HR at the time of skin incision (74 [12] vs 66 [12] beats min À1 ; P¼0.001) (Table 2). The two groups had comparable SPI values throughout the anaesthesia and surgery.…”

Thrifty effect of subanesthetic‐dose S‐ketamine on postoperative opioids and its safety and analgesic effectiveness: A prospective, triple‐blind, randomized controlled, polycentric clinical trial

“…28 Continuous intravenous infusion of subanesthetic esketamine at a rate of 0.25 mg/kg/h can significantly reduce postoperative opioid consumption and improve the patient's outcomes. 29 Perioperative use of S-ketamine can indeed reduce the use of opioids, but the dosage and methods used in the previous administration were different from those in this study. And the safety analysis of its use was lacking.…”

Efficacy of epidural esketamine on postoperative sleep quality after laparoscopic and robotic lower abdominal surgeries: a study protocol for randomised, double-blind, controlled trial

“…Regarding the postoperative intervention, the analgesic regimen for the esketamine group will include: esketamine 25 mg, sufentanil 100 µg and ropivacaine 300 mg. For the control group, the analgesic regimen will comprise sufentanil 100 µg and ropivacaine 300 mg. Sufentanil is not replaced with esketamine in the formula due to concerns that opioid-free analgesia might lead to a relatively poor analgesic effect, as indicated in a previous study. 18 The total volume for the patient-controlled analgesia pump will be set at 200 mL for both groups. The background infusion rate is set at 4 mL/hour, and the bonus dose is established at 4 mL.…”