Combined opioid free and loco-regional anaesthesia enhances the quality of recovery in sleeve gastrectomy done under ERAS protocol: a randomized controlled trial

Mohamed Ibrahim, Ali M Elnabtity, Ahmed Hegab, Omar A Alnujaidi, Osama El Sanea, Mohamed Ibrahim, Ali M Elnabtity, Ahmed Hegab, Omar A Alnujaidi, Osama El Sanea

Abstract

Background: It is debatable whether opioid-free anaesthesia (OFA) is better suited than multimodal analgesia (MMA) to achieve the goals of enhanced recovery after surgery (ERAS) in patients undergoing laparoscopic sleeve gastrectomy.

Methods: In all patients, anaesthesia was conducted with an i.v. induction with propofol (2 mg. kg-1), myorelaxation with cisatracurium (0.15 mg.kg-1), in addition to an ultrasound-guided bilateral oblique subcostal transverse abdominis plane block. In addition, patients in the OFA group (n = 51) received i.v. dexmedetomidine 0.1 μg.kg-1 and ketamine (0.5 mg. kg-1) at induction, then dexmedetomidine 0.5 μg. kg-1.h-1, ketamine 0.5 mg.kg-1.h-1, and lidocaine 1 mg. kg-1.h-1 for maintenance, while patients in the MMA group (n = 52) had only i.v. fentanyl (1 μg. kg-1) at induction. The primary outcome was the quality of recovery assessed by QoR-40, at the 6th and the 24th postoperative hour. Secondary outcomes were postoperative opioid consumption, time to ambulate, time to tolerate oral fluid, and time to readiness for discharge.

Results: At the 6th hour, the QoR-40 was higher in the OFA than in the MMA group (respective median [IQR] values: 180 [173-195] vs. 185 [173-191], p < 0.0001), but no longer difference was found at the 24th hour (median values = 191 in both groups). OFA also significantly reduced postoperative pain and morphine consumption (20 mg [1-21] vs. 10 mg [1-11], p = 0.005), as well as time to oral fluid tolerance (238 [151-346] vs. 175 min [98-275], p = 0.022), and readiness for discharge (505 [439-626] vs. 444 min [356-529], p = 0.001), but did not influence time to ambulate.

Conclusion: While regional anaesthesia achieved most of the intraoperative analgesia, avoiding intraoperative opioids with the help of this OFA protocol was able to improve several sensible parameters of postoperative functional recovery, thus improving our knowledge on the OFA effects.

Clinical trial number: Registration number NCT04285255.

Keywords: Multimodal analgesia; Opioid consumption; Opioid free anaesthesia; Quality of recovery.

Conflict of interest statement

We declare that there is no conflict of interest.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
Study Flow chart showing inclusion, enrollment, randomization, allocation, and analysis
Fig. 2
Fig. 2
Numerical rating scale (NRS) at PACU and 24 h. Boxplot distribution of the NRS over time. Median is represented by a dark horizontal line, interquartile range by the upper and lower limits of the box, extreme values are represented by whiskers, outliers are represented by circles with numbers representing the case order
Fig. 3
Fig. 3
Intraoperative hemodynamics changes. *Statistically significant

References

    1. Macfater H, Xia W, Srinivasa S, et al. Evidence-based Management of postoperative pain in adults undergoing laparoscopic sleeve gastrectomy. World J Surg. 2019;43(6):1571–1580. doi: 10.1007/s00268-019-04934-y.
    1. Ruiz-Tovar J, Muñoz JL, Gonzalez J, et al. Postoperative pain after laparoscopic sleeve gastrectomy: Comparison of three analgesic schemes (isolated intravenous analgesia, epidural analgesia associated with intravenous analgesia and port-sites infiltration with bupivacaine associated with intravenous analgesia) Surg Endosc. 2017;31(1):231–236. doi: 10.1007/s00464-016-4961-3.
    1. Soffin EM, Wetmore DS, Beckman JD, et al. Opioid-free anaesthesia within an enhanced recovery after surgery pathway for minimally invasive lumbar spine surgery: A retrospective matched cohort study. Neurosurg Focus. 2019;46(4):E8. doi: 10.3171/2019.1.FOCUS18645.
    1. Brummett CM, Waljee JF, Goesling J, Moser S, Lin P, Englesbe MJ, Bohnert A, Kheterpal S, Nallamothu BK. New persistent opioid use after minor and major surgical procedures in US adults. JAMA Surgery. 2017;152(6):e170504. doi: 10.1001/jamasurg.2017.0504.
    1. Mulier JP. Perioperative opioids aggravate obstructive breathing in sleep apnea syndrome: mechanisms and alternative anaesthesia strategies. Curr Opin Anaesthesiol. 2016;29(1):129–133. doi: 10.1097/ACO.0000000000000281.
    1. Ibrahim M, El Shamaa H. Efficacy of ultrasound-guided oblique subcostal transversus abdominis plane block after laparoscopic sleeve gastrectomy: a double-blind, randomized, placebo-controlled study. Egypt J Anaesth. 2014;30:285–292. doi: 10.1016/j.egja.2014.01.003.
    1. Samuels D, Abou-Samra A, Dalvi P, Mangar D, Camporesi E. Opioid-free Anaesthesia results in reduced postoperative opioid consumption. J Clin Anesth Pain Med. 2017;2(1):1–3.
    1. Gaszynski T, Czarnik K, Lasziniski L, Gaszynski W. Dexmedetomidine for attenuating hemodynamic response to intubation stimuli in morbidly obese patients anesthetized using the low-opioid technique: comparison with fentanyl-based general anaesthesia. Anaesthesiol Intensive Ther. 2016;48(5):275–279. doi: 10.5603/AIT.a2016.0058.
    1. De Oliveira GS, Jr, Duncan K, Fitzgerald P, Nader A, Gould RW, McCarthy RJ. Systemic lidocaine to improve the quality of recovery after laparoscopic bariatric surgery: a randomized double-blinded placebo-controlled trial. Obes Surg. 2014;24(2):212–218. doi: 10.1007/s11695-013-1077-x.
    1. Ventham NT, Kennedy ED, Brady RR, et al. Efficacy of intravenous lidocaine for postoperative analgesia following laparoscopic surgery: a meta-analysis. World J Surg. 2015;39(9):2220–2234. doi: 10.1007/s00268-015-3105-6.
    1. Kumar K, Kirksey MA, Duong S, Wu CL. A review of opioid-sparing modalities in perioperative pain management: methods to decrease opioid use postoperatively. Anesth Analg. 2017;125:1749–1760. doi: 10.1213/ANE.0000000000002497.
    1. Chan JW, Shetty P. Does the use of ketamine or magnesium decrease postoperative pain scores in laparoscopic bariatric surgery for morbid obesity? Anesth Analg. 2016;123(3):814–815. doi: 10.1213/01.ane.0000493012.08816.5b.
    1. Zeltsman M., Aronsohn J, Gerasimov M, Palleschi G. Does Opioid-free anaesthesia Make a Difference in Bariatric Surgery? In: American society of anesthesiologists annual meeting on October 22, 2019. Orlando.
    1. Feld JM, Laurito CE, Beckerman M, Vincent J, Hoffman WE. Non-opioid analgesia improves pain relief and decreases sedation after gastric bypass surgery. Can J Anaesth. 2003;50(4):336–341. doi: 10.1007/BF03021029.
    1. Myles PS, Weitkamp B, Jones K, Melick J, Hensen S. Validity and reliability of a postoperative quality of recovery score: the QoR-40. Br J Anaesth. 2000;84(1):11–15. doi: 10.1093/oxfordjournals.bja.a013366.
    1. Pai MP, Paloucek FP. The origin of the “ideal” body weight equations. Ann Pharmacother. 2000;34(9):1066–1069. doi: 10.1345/aph.19381.
    1. Ramsay MA, Savage TM, Simpson BR, Goodwin R. Controlled sedation with alfaxalone-alphadolone. BMJ. 1974;2:656–659. doi: 10.1136/bmj.2.5920.656.
    1. Aldrete JA. Modifications to the post-anaesthesia score for use in ambulatory surgery. J Perianesth Nurs. 1998;13(3):148–155. doi: 10.1016/s1089-9472(98)80044-0.
    1. Terkawi AS, Myles PS, Riad W, et al. Development and validation of Arabic version of the postoperative quality of recovery-40 questionnaire. Saudi J Anaesth. 2017;11(Suppl 1):S40–S52. doi: 10.4103/sja.SJA_77_17.
    1. Palumbo P, Tellan G, Perotti B, Pacilè MA, Vietri F, Illuminati G. Modified PADSS (post Anaesthetic discharge scoring system) for monitoring outpatients discharge. Ann Ital Chir. 2013;84(6):661–665.
    1. Myles PS, Myles DB, Galagher W, Chew C, MacDonald N, Dennis A. Minimal clinically important difference for three quality of recovery scales. Anesthesiology. 2016;125(1):39–45. doi: 10.1097/ALN.0000000000001158.
    1. Mulier JP, Wouters R, Dillemans B, De Kock M. A randomized controlled, double-blind trial evaluating the effect of opioid-free versus opioid general anaesthesia on postoperative pain and discomfort measured by the QoR-40. J Clin Anesth Pain Med. 2018;2:015.
    1. Ziemann-Gimmel P, Goldfarb AA, Koppman J, Marema RT. Opioid-free total intravenous anaesthesia reduces postoperative nausea and vomiting in bariatric surgery beyond triple prophylaxis. Br J Anaesth. 2014;112(5):906–911. doi: 10.1093/bja/aet551.
    1. Beloeil H. Opioid-free anaesthesia. Best Pract Res Clin Anaesthesiol. 2019;33(3):353–360. doi: 10.1016/j.bpa.2019.09.002.
    1. Bakan M, Umutoglu T, Topuz U, Uysal H, Bayram M, Kadioglu H, Salihoglu Z. Opioid-free total intravenous anaesthesia with propofol, dexmedetomidine and lidocaine infusions for laparoscopic cholecystectomy: a prospective, randomized, double-blinded study. Braz J Anesthesiol. 2015;65:191–199. doi: 10.1016/j.bjan.2014.05.006.
    1. Gaszynski T, Czarnik K, Lasziniski L, Gaszynski W. Dexmedetomidine for attenuating hemodynamic response to intubation stimuli in morbidly obese patients anesthetized using the low-opioid technique: comparison with fentanyl-based general anaesthesia. Anaesthesiol Intensive Ther. 2016;48(5):275–279. doi: 10.5603/AIT.a2016.0058.
    1. Lam K, Mui W. Multimodal analgesia model to achieve low postoperative opioid requirement following bariatric surgery. Hong Kong Med J. 2016;25(5):428–434.
    1. Mansour MA, Mahmoud AA, Geddawy M. Nonopioid versus opioid-based general anaesthesia technique for bariatric surgery: a randomized double-blind study. Saudi J Anaesth. 2013;7(4):387–391. doi: 10.4103/1658-354X.121045.
    1. Fletcher D, Martinez V. Opioid-induced hyperalgesia in patients after surgery: A systematic review and a meta-analysis. Br J Anaesth. 2014;112(6):991–1004. doi: 10.1093/bja/aeu137.
    1. Mulier J. Opioid free general anaesthesia : a paradigm shift? Anaesthesia libre de opioids: ¿un Cambio de paradigma? Rev Esp Anestesiol Reanim. 2017;64(8):427–430. doi: 10.1016/j.redar.2017.03.004.
    1. Rivat C, Ballantyne J. The dark side of opioids in pain management: basic science explains clinical observation. Pain Rep. 2016;1(2):e570. 10.1097/PR9.0000000000000570. Published 2016 Sep 8
    1. Forget P. Opioid-free anaesthesia. Why and how? A contextual analysis. Anaesth Crit Care Pain Med. 2019;38(2):169–172. doi: 10.1016/j.accpm.2018.05.002.
    1. Lavand'homme P, Steyaert A. Opioid-free anaesthesia opioid side effects: tolerance and hyperalgesia. Best Pract Res Clin Anaesthesiol. 2017;31(4):487–498. doi: 10.1016/j.bpa.2017.05.003.
    1. Ma P, Lloyd A, McGrath M, et al. Reduction of opioid use after implementation of enhanced recovery after bariatric surgery (ERABS) Surg Endosc. 2020;34:2184–2190. doi: 10.1007/s00464-019-07006-3.
    1. Awad S, Carter S, Purkayastha S, et al. Enhanced recovery after bariatric surgery (ERABS): clinical outcomes from a tertiary referral bariatric center. Obes Surg. 2014;24(5):753–758. doi: 10.1007/s11695-013-1151-4.
    1. Blanchet MC, Gignoux B, Matussière Y, et al. Experience with an enhanced recovery after surgery (ERAS) program for bariatric surgery: comparison of MGB and LSG in 374 patients. Obes Surg. 2017;27(7):1896–1900. doi: 10.1007/s11695-017-2694-6.
    1. Singh PM, Panwar R, Borle A, et al. Efficiency and safety effects of applying ERAS protocols to bariatric surgery: a systematic review with Meta-analysis and trial sequential analysis of evidence. Obes Surg. 2017;27(2):489–501. doi: 10.1007/s11695-016-2442-3.
    1. Sinha A, Jayaraman L, Punhani D, Chowbey P. Enhanced recovery after bariatric surgery in the severely obese, morbidly obese, super-morbidly obese and super-super morbidly obese using evidence-based clinical pathways: a comparative study. Obes Surg. 2017;27(3):560–568. doi: 10.1007/s11695-016-2366-y.
    1. Lemanu DP, Singh PP, Berridge K, et al. Randomized clinical trial of enhanced recovery versus standard care after laparoscopic sleeve gastrectomy. Br J Surg. 2013;100(4):482–489. doi: 10.1002/bjs.9026.
    1. Mannaerts GH, van Mil SR, Stepaniak PS, et al. Results of implementing an enhanced recovery after bariatric surgery (ERABS) protocol. Obes Surg. 2016;26(2):303–312. doi: 10.1007/s11695-015-1742-3.

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