Intrathecal Dexamethasone and Dexmedetomidine as Adjuncts to Bupivacaine in Elective Cesarean Section: A Case Series.

The purpose of this study was to investigate whether the combination of intrathecal dexamethasone and dexmedetomidine in combination with bupivacaine in spinal anesthesia is effective for reducing nausea, vomiting, shivering, and pain. A retrospective review of records was used to examine the outcomes of patients undergoing cesarean delivery under spinal anesthesia with dexamethasone, dexmedetomidine, and bupivacaine. The records of 11 consecutive patients who underwent cesarean delivery under spinal anesthesia with intrathecal dexamethasone and dexmedetomidine in combination with bupivacaine were evaluated. Data collected included patient demographics, medications and fluids administered, presence of nausea, vomiting, shivering, intraoperative breakthrough pain, and postoperative pain. There were no reported complications related to the administration of intrathecal dexamethasone and dexmedetomidine in combination with bupivacaine in this case series of patients. No patients required treatment for intraoperative vomiting, shivering, or breakthrough pain. One patient required opioid pain medication postoperatively. This case series demonstrates that the administration of intrathecal dexamethasone and dexmedetomidine in combination with bupivacaine for patients undergoing elective cesarean section appears to be safe and offers some advantages as to traditional methods of intrathecal delivery for this surgical procedure.

Multimodal Analgesia and Opioid-Free Anesthesia in Spinal Surgery: A Literature Review.

PURPOSES: To determine if opioid-free anesthesia, opioid-sparing anesthesia, or multimodal analgesia improved outcomes in patients undergoing spinal fusion. DESIGN: A literature review was performed by searching PubMed, CINAHL, Embase, Web of Science, and Cochrane Library. METHODS: MeSH terms included "opioid free" AND "spine surgery," with alternative terms used including: regional anesthesia, multimodal analgesia, opioid-free anesthesia, enhanced recovery after surgery (ERAS), spinal surgery, spinal fusion, ACDF, cervical fusion, lumbar fusion, etc. Seven studies were deemed appropriate for inclusion with a combined sample size of n = 2,102. FINDINGS: All of the seven included articles evaluated total opioid administration and found a reduction in total opioid administered in the research groups versus control groups. Six of the seven included articles evaluated postoperative pain scores with mixed results. Various additional benefits of opioid-free, opioid-sparing, or multimodal analgesia included: decreased hospital length of stay (LOS), decreased post-anesthesia care unit (PACU) LOS, decreased post-operative nausea and vomiting (PONV), and decreased post-operative opioid use through 30 days. CONCLUSIONS: For patients undergoing spine surgery, opioid-free, opioid-sparing, and multimodal analgesia will be less likely to experience the adverse effects of opioid analgesics and ultimately lead to better patient outcomes and reduced hospital stays.

Spinal Anesthesia with 2-Chloroprocaine and Dexmedetomidine for Cesarean Section: A Case Report.

To our knowledge, there are currently no published articles discussing the use of 2-chloroprocaine plus dexmedetomidine in women undergoing cesarean section and only one article published on spinal anesthesia with these two medications for other types of surgery. 2-Chloroprocaine is a short-acting local anesthetic that helps patients ambulate more quickly after surgery due to its 60-minute average duration of action. Dexmedetomidine, when given in combination with local anesthetics, in spinal anesthesia, prolongs the effects of the local anesthetic. It is especially advantageous in obstetric anesthesia because of its wide safety margin, minimal ability to cross the placenta, and benefits that are unique to the parturient: dense visceral analgesia, anxiolysis without amnesia, reduced shivering, and lack of respiratory depression, nausea, and pruritis. We report a case of spinal anesthesia for cesarean section with 2-chloroprocaine plus dexmedetomidine and were able to achieve excellent surgical conditions and a more rapid recovery of motor function than with bupivacaine plus dexmedetomidine.

Short-Term Patient Outcomes After Implementation of Robotic-Assisted Radical Prostatectomy Under Opioid Free Anesthesia at an Ambulatory Surgery Center.

PURPOSE: Opioid free anesthesia (OFA) is associated with decreased risk of PONV and need for rescue analgesia, making it ideal for patients anticipating same-day discharge. The purpose of this project was to describe the perioperative care and short-term outcomes for patients undergoing robotic-assisted radical prostatectomy (RARP) under OFA at an ambulatory surgical center (ASC). DESIGN: A retrospective descriptive design was used to examine the perioperative care and short-term outcomes of patients undergoing RARP under OFA at an ASC. METHODS: The records of all sequential patients undergoing RARP over an 18-month period were reviewed. Data collected included patient comorbidities, surgical procedures, medications administered, verbal numeric rating scale (VNRS) for pain scores, times to oral intake, ambulation, and discharge, patient disposition, and unplanned return to the ER or hospital within 30 days. FINDINGS: Data were extracted from 54 sequential records. Median VNRS scores were zero throughout PACU stay. Fifty-three patients (98.1%) were successfully discharged home, with an average postoperative stay of 250.8 (SD 35.0) minutes. There were no complaints of post-discharge nausea and vomiting or intractable pain at 72 hours after surgery. One patient was transferred to the hospital and two patients returned to the emergency room within 30 days. CONCLUSIONS: Although generalizability is limited, these results suggest that carefully selected patients can be discharged home after RARP under a balanced OFA technique. Innovative practices are needed to address the current backlog of patients needing non-emergent surgery. Discharge home avoids the increase in resource consumption and infection risk associated with hospital admission.

Perioperative Pain Management for Surgical Patients with Opioid Use Disorder: A Program Development Initiative.

PURPOSE: Over the last decade an increased number of individuals have been diagnosed with Opioid Use Disorder (OUD) and state-level regulatory pressure has mounted to develop the capability to provide opioid-free anesthesia (OFA) on clinical indication or at patient request. DESIGN: A program initiative for OUD patients who require OFA was developed and implemented in two phases. METHOD: Phase I assessed the needs and knowledge of licensed nurse anesthetists in the state of Florida. Phase II recruited volunteers for a day-long event which involved both didactic and simulation training. Data collection for phase II included: demographics, knowledge, evidence-based practice belief scale (EBPBS), and evidence-based practice implementation scale (EBPIS) which measures the perceived ability to implement those beliefs. Phase II training was divided into three domains: Preoperative, Intraoperative and Postoperative with didactic and simulation experiences for each domain. FINDINGS: The phase II participants pre-simulation median total knowledge assessment score was 9 with median scores of 5 for questions 1 to 6 and 4 for questions 7 to 12. After participating in simulation, median knowledge assessment scores increased to 11, with median scores of 6 for questions 1 to 6 and 5 for questions 7 to 12. Before simulation training, median scores for the EBPBS and EBPIS were 66 (IQR 8) and 22 (IQR 24) respectively. After simulation, the median EBPBS score increased to 76 (IQR 7.5), a significant improvement from pre-simulation (P = .002). CONCLUSION: There is a lack of knowledge and training of anesthesia providers on how to manage the growing population of patients with OUD. This program initiative increased perceived ability to provide OFA care to patients with OUD presenting for surgery.