Comparation Among Opioid-Based, Low Opioid and Opioid Free Anesthesia in Colorectal Oncologic Surgery.

Introduction: Opioids are the "gold standard" for pain treatment during and after colorectal surgery. They can inhibit cellular and humoral immunity and it is assumed that can promote cancer cell proliferation and metastatic spread. Adequate pain management can be achieved not only with opioids, but also with non-opioid drugs, which can be used together in small doses, i.e., multimodal analgesia, and can lower the need for opioids during and after surgery. Opioid free anesthesia (OFA) is part of multimodal analgesia, where opioids are not used in the intraoperative period. Materials and methods: In this prospective and randomized clinical study 60 patients scheduled for open colorectal surgery were enrolled. They were between the ages of 45 and 70 with the American Association of Anesthesiologists (ASA) classifications 1, 2 and 3, divided in three groups. The first group of patients, or Opioid-based anesthesia group (OBAG), received the following for induction to anesthesia: lidocaine at 1 mg/kg, fentanyl 100 at µgr, propofol at 2mg/kg and rocuronium bromide at 0.6 mg/kg. They intermittently received 50-100 µgr fentanyl intravenously and 0.25 % bupivacaine 2-3 ml every 30-45 minutes, given in the epidural catheter during surgery. The second group of patients, or Low opioid anesthesia group (LOAG), received the following for induction to anesthesia: lidocaine at 1 mg/kg, fentanyl at 100 µgr, propofol at 2mg/kg and rocuronium bromide at 0.6 mg/kg. Prior to surgery, 50 µgr of fentanyl with 5 ml 0.25% bupivacaine was given into the epidural catheter, and the same dose was received at the end of surgery. The third group, or Opioid free anesthesia group (OFAG), received the following before the induction to general anesthesia: dexamethasone at 0.1 mg/kg and 1 gr of paracetamol. Induction to general anesthesia was with lidocaine at 1 mg/kg, propofol at 2mg/kg, ketamine at 0.5 mg/kg and rocuronium bromide at 0.6 mg/kg. After intubation, intravenous continuous infusion with lidocaine was at 2 mg/kg/h, ketamine 0.2 mg/kg/h and magnesium 15 mg/kg/h loaded on and intermittently 0.25 % bupivacaine 2-3 ml every 30-45 minutes given in the epidural catheter during surgery. The primary goal was to measure the patients' pain after the first 72 postoperative hours in all three groups (2, 6, 12, 24, 36, 48 and 72 hours after surgery). The secondary goal was to measure the total amount of morphine given in the epidural catheter in the postoperative period in all three groups. Other secondary goals were: to compare the total amount of fentanyl given intravenously during surgery in the first and second groups, determine if there was a need to use rescue analgesia in the postoperative period, measure the occurrence of PONV, and to measure the total amount of bupivacaine given in the epidural catheter during operation in all three groups. Results: Visual Analogue Scale (VAS) score comparisons between groups showed patients from the OBA and LOA groups had significantly higher VAS scores, compared to the patients from the OFA group 2, 12, 24 and 48 hours after operation. After 6 hours postoperatively, patients from the LOA group had significantly higher VAS scores, compared to patients from the OBA and OFA groups. After 36 hours postoperatively, patients from the OBA group had significantly higher VAS scores compared to patients from the LOA and OFA groups. At the last follow-up point, 72 hours after the intervention, the patients from the OBA and LOA groups had significantly higher VAS scores compared to the patients from the OFA group. All patients from the OBA and LOA groups, and only 9 from the OFA group received morphine in the postoperative period via epidural catheter. Patients from the Opioid group received significantly higher amounts of fentanyl during surgery. Additional administration of another analgesic drug in the postoperative period was prescribed in 55% of patients in the OBAG, in 50% in the LOAG and in 35% of the OFA group. PONV was registered in 60% of patients from the OBAG and in 40% of patients from the LOAG. In the OFA group did not register PONV in any of the patients. The biggest amount of bupivacaine given during surgery was in the OBAG (26.37 ± 2.6 mg), in LOAG was 25.0 ± 0 and the less in OFAG group (24.50 ± 4.3). Conclusion: Patients from OFA group, compared with patients from OBAG and LOAG, have the lowest pain score in first 72 hours after open colorectal surgery, received fewer opioids via an epidural catheter in the postoperative period, had less need for rescue analgesia, no occurrence of PONV, and less need for bupivacaine via an epidural catheter in the intraoperative period.

Postoperative Nausea and Vomiting in Opioid-Free Anesthesia Versus Opioid Based Anesthesia in Laparoscopic Cholecystectomy.

Background: Postoperative nausea and vomiting (PONV) is a usual complication in patients undergoing laparoscopic cholecystectomy. Minimized opioid use due to surgery has been shown to have a better effect on patient recovery after surgery. In this study we evaluate the effect of opioid free anesthesia for postoperative nausea and vomiting in laparoscopic cholecystectomy. Materials and methods: 80 patients aged 20-65 years old were included in this randomized, clinical and prospective trial. The patients belonged to the ASA classifications 1 and 2 and were scheduled for laparoscopic cholecystectomy. Patients were classified into two groups: group 1 (fentanyl group- FG), which included 40 patients who received opioid anesthesia, and group 2 (opioid free anesthesia group-OFAG) which included 40 patients who received opioid free anesthesia. In patients from group 1 (fentanyl group -FG) introduction to general anesthesia consisted of giving midazolam at 0.04 mg/kg, fentanyl at 0.002 mg/kg, 2 mg/kg of propofol and 0.6 mg/kg of rocuronium bromide. These patients received fractionated bolus doses of fentanyl during surgery. Prior to general anesthesia these patients did not receive dexamethasone. The patients from group 2 (opioid free anesthesia group - OFAG) received dexamethasone at 0.1 mg/kg and 1 g of paracetamol before introduction to anesthesia as a pre-emptive analgesia. Introduction to anesthesia consisted of giving midazolam at 0.04 mg/kg, lidocaine at 1 mg/kg, propofol at 2 mg/kg, ketamine at 0.5 mg/kg, and 0.6 mg/kg of rocuronium bromide. Immediately after intubation, continuous intravenous infusion with lidocaine at 2 mg/kg/h and magnesium sulfate at 1.5 g/h was given. In this group, fentanyl was not given either during the introduction of anesthesia or during the intraoperative period. Immediately after extraction of the gallbladder patients from group 2 (OFAG) received 2.5 g of metamizole intravenously. PONV were recorded in the postoperative period of 24 hours after surgery. Results: There was no significant difference with respect to age, weight, sex, duration of surgery, and anesthesia time. PONV at different time intervals were statistically not significant at all postoperative time points - 1 hr, 4 hr, 8 hr, 12 hr and 24 hr after surgery in fentanyl group compared to opioid free anesthesia group. Even not statistically significant, PONV have occurred more often in patients who received opioid anesthesia. Conclusion: Postoperative nausea and vomiting occurs more often in patients who received opioids during laparoscopic cholecystectomy compared to patients who received opioid free anesthesia, but without statistical significance.

Pain and Multimodal Analgesia in Laparoscopic Cholecystectomy.

Background: The administration of high doses of opioids during surgery can lead to higher postoperative pain scores at rest and when coughing. Multimodal analgesia may lower the need for opioids during surgery and the suffering of postoperative pain. Multimodal analgesia can be achieved by providing non-opioid drugs (lidocaine, ketamine, and magnesium sulfate), three different types of drugs. Each of these drugs as different analgesic effects and they belong to three different pharmacological groups. The aim of this study is to develop a better understanding of the effects of each drug (lidocaine, ketamine, and magnesium sulfate) on postoperative analgesia, the needs for rescue analgesics, and analyze the total amount of fentanyl during the intraoperative period in patients undergoing laparoscopic cholecystectomy. Methods: 120 patients were enrolled in this randomized controlled study. They were classified as ASA 1 and 2 and were scheduled for laparoscopic cholecystectomy. They were further divided into 3 groups. Group 1, or the lidocaine group, had received lidocaine at 1 mg/kg and a continuous intravenous infusion with lidocaine at 2 mg/kg/h. Group 2, or the ketamine group, received ketamine at 0.5 mg/kg. Group 3, or the magnesium sulfate group, received a continuous intravenous infusion of magnesium sulfate at 1.5 gr/kg. The intensity of postoperative pain was assessed using a VAS score at rest and when coughing, with evaluation at 1, 4, 8, 12, and 24 hours, postoperatively. Also, the needs for rescue analgesics and the total amount of fentanyl during the intraoperative period in all groups was also followed. Results: The patients from the lidocaine group had the highest scores of pain in the postoperative period at rest and when coughing, and the ketamine group had the lowest pain scores. Rescue analgesia was given the most to lidocaine group, and less so in the magnesium group. The magnesium group received the highest dose of fentanyl during surgery and the lowest dose was received by patients from the lidocaine group. Conclusion: Multimodal analgesia can lower the need for opioids in the intra- and postoperative period after laparoscopic cholecystectomy.

Is Multimodal Anesthesia Effecting Postoperative Nausea and Vomiting in Laparoscopic Cholecystectomy?

Background: Multimodal anesthesia represents a technique that can improve analgesia and lower the occurrence of opioid side effects in the postoperative period, such as postoperative nausea and vomiting (PONV). It can be achieved by providing different types of medication during the intraoperative period which can decrease the need for opioids. PONV happens more often in patients who have received large amounts of opioids during laparoscopic cholecystectomy. In this study, our aim was to observe the occurrence of PONV between three different groups of patients who received lidocaine, ketamine and magnesium sulfate in combination with fentanyl in the intraoperative period. We also observed any additional nausea and vomiting in the three groups as well as the amount of fentanyl given to these groups during operation. Materials and methods: 120 patients aged 20-65 years old were included in this randomized and prospective study, ASA classification 1 and 2, scheduled for laparoscopic cholecystectomy. Patients were classified into three groups randomly: Group 1 (lidocaine group-LG), these patients received lidocaine at 1 mg/kg during induction to general anesthesia and 2 mg/kg/h after intubation in continuous intravenous infusion; Group 2 (ketamine group-KG) these patients received ketamine at 0.5 mg/kg during induction to general anesthesia; and Group 3 (magnesium group-MG) these patients received magnesium sulfate at 1.5 gr/hr as a continuous intravenous infusion after intubation. In all three groups, patients additionally received bolus doses of fentanyl. Postoperative nausea and vomiting were monitored in all three groups at 1, 4, 8, 12, and 24 hours after surgery as a primary objective, and if patients had complainant of vomiting, they were treated with 10 mg of metoclopramid. Between the five control time points, additional nausea and vomiting was recorded as well, as a secondary objective. The third objective was to measure of the total amount of fentanyl given in the intraoperative period. Results: Patients from the lidocaine group experienced less PONV and they received less fentanyl compared to patients of ketamine and magnesium groups. Patients from the ketamine group had more nausea than other groups. In the magnesium group, the rate of vomiting was higher, and they received higher amounts of fentanyl during surgery. Additional nausea and vomiting occurred in 3 patients in the LG, 2 in the KG, and 3 in the MG between the five control time points. The patients from the magnesium group received the highest dose of fentanyl during surgery (307.50 ± 130.4), followed by the patients from the ketamine group (292.50 ± 60.5), and then patients from the lidocaine group (258.75 ± 60.9). The doses of fentanyl that patients received during surgery in all three groups were not statistically significant. Conclusion: Multimodal anesthesia has been shown to lower PONV 24 hours after laparoscopic cholecystectomy and can lower need for opioids during laparoscopic cholecystectomy.

Epinephrine and Dexamethasone as Adjuvants in Upper Extremity Peripheral Nerve Blocks in Pediatric Patients.

Introduction: Regional anesthesia in children in recent years has been accepted worldwide. The increased interest in it is partly due to the use of ultrasonography which provides confidence and accuracy to the anesthesiologic team. Adjuvants are used to extend the duration of the sensory and motor blocking, limiting the cumulative dose of local anesthetics. The use of adjuvants in peripheral nerve blocks in the pediatric population is still under research. Aim: To observe the effect of epinephrine and dexamethasone as adjuvants to local anesthetics in peripheral upper extremity nerve blocks in pediatric patients. Materials and methods: The study included 63 patients, aged group 4-14 years, admitted to the University Clinic of Pediatric Surgery for surgical treatment of upper limb fractures in the period of January 2020 until March 2021. Patients were randomized into three groups, and all patients in the groups received analgo-sedation prior to peripheral nerve block. Patients in group 1 (21 patients) received supraclavicular, or interscalene block with 2 ml lidocaine 2% and bupivacaine 0.25% (max 2mg/kg) with a total volume of 0.5ml/kg. In group 2, the patients (21) received 25 µg of epinephrine in 2 ml of 2% solution of lidocaine and 0.25% bupivacaine (max 2 mg/kg) with a total volume of 0.5 ml/kg, and in group 3, the patients (21) received 2% lidocaine 2ml and 0.25% bupivacaine (max 2mg/kg) in combination with 2mg dexamethasone with a total volume of 0.5ml/kg. Results: Results showed that in patients in group 1, the average duration of the sensory block was 7 hours, while the duration of the motor block was 5 hours and 30 minutes. In group 2 (epinephrine), the durations of both sensory and motor block were prolonged for about 30 minutes on average compared to the first group. In group 3 (dexamethasone) the duration of the sensory and motor block was significantly longer compared with the first two groups (p<0.0001). Conclusion: Epinephrine and dexamethasone prolong the duration of action of local anesthetics in peripheral nerve blocks of the upper extremity in pediatric patients and thus reduce the need for analgesics in the postoperative period.

Is an opioid-free anaesthesia possible without using alpha-2 agonists?

Opioid-free anaesthesia (OFA) is an anaesthetic technique where non-opioid drugs are used in the intraoperative period. It can be successful without using alpha-2 agonists, which are main drugs used in this multimodal anaesthesia. We are presenting seven different cases where OFA was used in different abdominal surgeries (laparoscopic cholecystectomy, colon cancer operation, and laparoscopic inguinal hernia repair) alone or in a combination with epidural anaesthesia and peripheral nerve block. Prior induction to general anaesthesia all patients received dexamethasone and paracetamol. Induction of general anaesthesia consisted of giving midazolam, lignocaine, propofol, ketamine, and rocuronium. After tracheal intubation anaesthesia was maintained with sevoflurane and continuous infusion with lignocaine, magnesium sulphate, and ketamine (in some patients). At the end of the surgery, all patients received metamizole. The postoperative pain scores were reduced in most of the patients without giving opioids.

Accidental injection of succinylcholine into epidural space as a test dose.

Inadvertent injection of nonepidural drugs into the epidural space is a rare situation, which is under-reported, and can lead to serious complications, such as cardiovascular and respiratory complications, paraplegia, or quadriplegia, and can worsen the patients' outcome from surgery. Succinylcholine administered epidurally leads to the appearance of fasciculation and shortness of breath and can prolong neuromuscular blockade. We report a case of accidental administration of 100 mg of succinylcholine via an epidural catheter as a test dose instead of 2 ml 0.5% bupivacaine in a patient planned for major abdominal surgery. After 2 min, the patient complained of shortness of breath; dysarthria; and fasciculation in the trunk, upper limbs, and face. This was managed with induction to general anesthesia (GA). In the postoperative period, no neurological or cardiovascular complications were observed. There is no adequate drug as an antidote of accidentally given nonepidural drugs via an epidural catheter. Succinylcholine given via epidural catheter has been shown to prolong neuromuscular blockade. Proper labeling and storage of syringes are of utmost importance for avoiding these unpleasant situations.

Hypernatremia-induced Neurologic Complications After Hepatic Hydatid Cyst Surgery: Pretreat to Prevent.

INTRODUCTION: Surgery is effective treatment for echinococcosis; however, there is a risk of hypertonic saline resorption and acute hypernatremia. AIM: We report two cases of severe hypernatremia following hydatid cyst removal. CASE REPORTS: A 17-year-old girl underwent surgical removal of hepatic hydatid cyst. Following the surgery, she developed seizures evolving to status epilepticus, and was sedated and mechanically ventilated. Blood chemistry showed hypernatremia. Fluid resuscitation with 5% dextrose infusions was started in combination with furosemide. Electrolytes were monitored frequently until plasma sodium levels normalized, 30 hours later. The patient was seizure free 48 hours later. The second patient is a 70-year-old man with hepatic hydatid cyst. After the surgery he became somnolent and confused due to severe hypernatremia. Intravenous administration of five percentage dextrose was initiated and high doses of furosemide. Sodium level normalized within 38 hours. The patient's mental status improved. CONCLUSION: A hospital protocol was established aiming to prevent hypernatremia and neurological complications.

Is Opioid-Free General Anesthesia More Superior for Postoperative Pain Versus Opioid General Anesthesia in Laparoscopic Cholecystectomy?

INTRODUCTION: Opioid-free anesthesia (OFA) is a new anesthesiological technique, where the giving of opioids (fentanyl) is avoided in the intra- and post-operative period. This leads to reduction in the opioid-related side effects and lower pain scores in the postoperative period. MATERIALS AND METHODS: In this randomized, single-blind clinical study, 60 patients scheduled for elective laparoscopic cholecystectomy were enrolled. Half of them (30 patients) received general balanced anesthesia with fentanyl (F group-FG), and the half received opioid-free general anesthesia (OFA group-OFAG). In the post-operative period, Visual Analogue Scale (VAS) scores were followed at rest and when coughing 1 hour, 4 hrs, 8 hrs, 12 and 24 hrs after surgery. Both groups were followed by opioid requirements in the postoperative period. RESULTS: In the postoperative period, patients in the fentanyl group (FG) have higher pain scores at rest and on coughing in all analyzed timeframes compared to patients from the OFA group, but statistically significant difference was approved 1 and 24 hours after surgery. In the OFA group 24 hours after surgery none of the patients reported pain at rest and when coughing number 7, 8, 9 and 10 according to the VAS pain score. The total opioid requirement in the postoperative period was significantly higher in the fentanyl group (FG) at rest and when coughing, compared to the OFA group. CONCLUSION: Opioid-free anesthesia as a part of multimodal analgesia and a new anesthesiology technique is a safe procedure, where opioid-related negative effects in patients undergoing elective laparoscopic cholecystectomy are avoided..

Opioid Free Anesthesia for Laparotomic Hemicolectomy: A Case Report.

Opioid free anesthesia (OFA) is deffined as anaesthesiological technique where opioids are not used in the intraoperative period (systemic, neuroaxial or intracavitary). Anaphylaxis caused by opioids (fentanyl) is very rare, and the reaction is presented with hypotension and urticaria. When we have proven allergy to fentanyl, patients' refusal of placing epidural catheter and refusal of receiving bilateral ultrasound guided transversus abdominis plane block (USG TAPB), we must think of using multimodal nonopioide analgesia. The concept of multimodal balanced analgesia is consisted of giving different analgesic drugs in purpose to change the pathophysiological process which is included in nociception, in way to receive more effective intraoperative analgesia with less adverse effects. This is a case report of a 60-year-old male patient scheduled for laparotomic hemicolectomy, who previously had proven allergy to fentanyl. We have decided to give him an opioid free anaesthesia. Before the induction to anaesthesia, the patient would receive dexamethasone (dexasone) 0.1 mg/kg and paracetamol 1 gr intravenously. The patient was induced into general endotracheal anesthesia according to a standardized protocol, with midazolam 0.04 mg/kg, lidocaine hydrochloride 1 mg/kg, propofol 2 mg/kg and rocuronium bromide 0.6 mg/kg. Anaesthesia was maintained by using sevoflurane MAC 1 in order to maintain mean arterial pressure (MAP) with a value of +/- 20% of the original value. After tracheal intubation, the patient had received ketamine hydrochloride 0.5 mg/kg (or 50 mg ketamine) in bolus intravenously and a continuous intravenous infusion with lidocaine hydrochloride (lidocaine) 2 mg/kg/hr and magnesium sulfate (MgSO4) 1,5 gr/hr. At the end of surgery the continuous intravenous infusion with lidocaine and magnesium sulfate was stopped while the abdominal wall was closed and 2.5 g of metamizole (novalgetol) was given intravenously. VAS score 2 hours after surgery was 6/10 and 1 gr of paracetamol was given and the patient was transferred to the Department. Over the next 3 days, the patient had a VAS score of 4-6/10 and only received paracetamol 3x1g and novalgetol 3x1 gr daily, every four hours.