Opioid-Free Anaesthesia Improves Anaesthesia Recovery when Compared with that of Opioid-Based Anaesthesia. Systematic Review and Meta-Analysis of Clinical Trials.

INTRODUCTION: Opioid Free Anesthesia (OFA) is a relatively new technique that has been questioned due to the lack of evidence regarding its benefit-risk balance. METHODS: Four international databases were searched for clinical trials comparing OFA with opioid based anesthesia. The primary outcome was pain control and the secondary included postoperative nausea and vomiting (PONV), gastrointestinal recovery, respiratory depression, urinary retention, length of hospital stay, surgical complications, number of patients with cessation of the intervention and other side effects. RESULTS: Pain was better controlled in the OFA group in all the measurements made (VAS 1h: Md = -0.81, CI95% = -0.48- -1.14, VAS 24h: Md = -1.25, CI95% =-2.41- -0.1, VAS >24h: Md = -1.36, CI95% = -1.73- -1). In the opioid group there was an increase in the risk of nausea (RR=2.69, CI95% = 2-3.61) and vomiting (RR = 3.99, CI95% = 2.06-7.74), whilst in the OFA group, there was an increased risk of bradycardia (RR= 1.62, CI95% = 1.02-2.57). The rest of the variables showed no differences between groups or could not be analyzed. CONCLUSION: There is a clear benefit of OFA in pain control and PONV, but there is also a higher risk of bradycardia. This technique should be considered in patients with a special risk of difficult postoperative pain control or PONV. However, the best drug combination to perform OFA is still unknown, as well as the type of patient that benefits more with less risk.

Comparison of the Use of Desflurane vs. Propofol in Aortic Valve Replacement Surgery: Differences in Nephroprotection: An Explorative and Hypothesis-Generating Study.

Introduction: The cardioprotective effect of halogenated drugs in cardiac surgery has been the subject of several studies. However, there is scarcity of data on their potential nephroprotective effects. Aortic valve replacement and coronary revascularization are the most frequent cardiac surgery procedures. The objective of this explorative study was to examine the effect of desflurane vs. propofol on renal function, when administered in aortic valve replacement surgery, including the extracorporeal circulation period. Method: A quasi-experimental prospective study was performed in 60 patients, who were allocated to receive either desflurane or propofol intraoperatively during aortic valve replacement surgery. As a hypnotic, group 1 received propofol, whereas group 2 received desflurane. Markers of renal function and level of cardiac preservation were determined based on biochemical parameters (troponin I, NTProBNP). Results: In the propofol group, there were significant variations between postoperative values of urinary NGAL and creatinine and baseline values. In contrast, no variations were found in the desflurane group in terms of hemodynamic parameters and myocardial damage. Conclusions: The use of propofol vs. desflurane during aortic valve replacement surgery is associated with a decrease in renal function.

Renal and Neurologic Benefit of Levosimendan vs Dobutamine in Patients With Low Cardiac Output Syndrome After Cardiac Surgery: Clinical Trial FIM-BGC-2014-01.

BACKGROUND: Low-cardiac output syndrome (LCOS) after cardiac surgery secondary to systemic hypoperfusion is associated with a higher incidence of renal and neurological damage. A range of effective therapies are available for LCOS. The beneficial systemic effects of levosimendan persist even after cardiac output is restored, which suggests an independent cardioprotective effect. METHODS: A double-blind clinical trial was conducted in patients with a confirmed diagnosis of LCOS randomized into two treatment groups (levosimendan vs. dobutamine). Monitoring of hemodynamic (cardiac index, systolic volume index, heart rate, mean arterial pressure, central venous pressure, central venous saturation); biochemical (e.g. creatinine, S100B protein, NT-proBNP, troponin I); and renal parameters was performed using acute kidney injury scale (AKI scale) and renal and brain ultrasound measurements [vascular resistance index (VRI)] at diagnosis and during the first 48 h. RESULTS: Significant differences were observed between groups in terms of cardiac index, systolic volume index, NT-proBNP, and kidney injury stage at diagnosis. In the levosimendan group, there were significant variations in AKI stage after 24 and 48 h. No significant differences were observed in the other parameters studied. CONCLUSION: Levosimendan showed a beneficial effect on renal function in LCOS patients after cardiac surgery that was independent from cardiac output and vascular tone. This effect is probably achieved by pharmacological postconditioning. CLINICAL TRIAL REGISTRATION: EUDRA CT, identifier 2014-001461-27. https://www.clinicaltrialsregister.eu/ctr-search/search?query=2014-001461-27.

Impacto de la anestesia libre de opioides en cirugía bariátrica / Impact of opioid free anaesthesia in bariatric surgery

FUNDAMENTO: Los pacientes sometidos a cirugía bariátrica presentan mayor riesgo de complicaciones debido al uso de opioides. El objetivo es valorar la seguridad e idoneidad del protocolo Anestesia libre de opioides (OFA) implantado en el Hospital Universitario Virgen de la Victoria en 2018. MATERIAL Y MÉTODOS: Estudio prospectivo llevado a cabo en 38 pacientes sometidos a cirugía bariátrica laparoscópica bajo protocolo OFA durante el año 2018 en el H.U. Virgen de la Victoria (Málaga). Se recogieron variables para establecer el control hemodinámico y del dolor perioperatorio que se analizaron mediante Stata V.16. RESULTADOS: La edad media fue 43 años, el índice de masa corporal medio 48,14 y la estancia media en quirófano 178 minutos. El control de la respuesta hipertensiva tras la laringoscopia sucedió en el 88,1% de los casos. Al ingreso en la Unidad de Recuperación Post Anestésica (URPA), la SpO2 sin aporte suplementario en el traslado presentó una mediana de 97% con p75 ≥ 95%, mientras que el p75 de la evaluación del dolor mediante escala visual analógica (EVA) fue 3, con un 68% de pacientes sin dolor. Al alta de URPA, todos presentaron EVA menor de 4 y solo fue necesario administrar una dosis baja de petidina en siete pacientes. CONCLUSIÓN: La OFA ha resultado ser segura y conseguir un control del dolor óptimo. En los casos reconvertidos, el buen control de los parámetros abre la posibilidad de su utilización en cirugías más dolorosas

BACKGROUND: Patients subjected to bariatric surgery present a greater risk of complications due to the use of opioids. The goal is to evaluate the security and suitability of the Opioid Free Anaesthesia (OFA) protocol implemented in the Hospital Universitario Virgen de la Victoria in 2018. METHOD: Prospective study carried out on 38 patients subjected to laparoscopic bariatric surgery under the OFA protocol in the year 2018 at the H.U. Virgen de la Victoria (Málaga, Spain). Variables were gathered to establish haemodynamic control and perioperative pain, which were analysed using Stata V.16. RESULTS: The average age was 43 years, the average body mass index was 48.14 and the average stay in the operating theatre was 178 minutes. Control of hypertensive response following laryngoscopy occurred in 88.1% of the cases. On entering the Post Anaesthesia Care Unit (PACU), SpO2 without a supplementary contribution in the transfer showed a median of 97% with p75 ≥ 95%, while the p75 of pain evaluation by means of Visual Analogue Scale (VAS) was 3, with 68% of patients without pain. On discharge from the PACU, all presented VAS below 4 and it was only necessary to administer a low dose of Pethidine in seven patients. CONCLUSION: The OFA has proved to be secure and achieves optimum pain control. In the reconverted cases, good control of the parameters opens up the possibility of its use in more painful surgeries

Anesthesia in Combination with Propofol Increases Disease-Free Survival in Bladder Cancer Patients Who Undergo Radical Tumor Cystectomy as Compared to Inhalational Anesthetics and Opiate-Based Analgesia.

BACKGROUND: The effect of anesthetic techniques on cancer recurrence has been the subject of intensive research in the past years, as it affects a large proportion of the population. The use of opioids and halogenated agents in cancer patients during the perioperative period may be related to higher rates of cancer recurrence and reduced disease-free survival. METHODS: This was a prospective study. The sample was composed of 100 patients who underwent a radical cystectomy for infiltrating bladder cancer in a reference center. We compared disease-free survival associated with combined anesthesia versus opiate-based analgesia. The relationship between the administered hypnotic and disease-free survival was also investigated. RESULTS: The median disease-free survival of the patients who received combined anesthesia was 585 (240-1,005) days versus 210 (90-645) days in the other group. A significant difference was observed between the two groups (p = 0.01). Combined analysis of all groups revealed significant differences in disease-free survival between patients who received combined anesthesia with propofol (510 [315-1,545] disease-free days) and those who received sevoflurane and opioids (150 [90-450] disease-free days) (p = 0.02). CONCLUSIONS: Anesthesia may play a crucial role in tumor relapse, as it is administered at the moment of the greatest risk of dissemination: surgical handling of the tumor. Opioids and volatile agents have been related to an increased risk for cancer recurrence. We compared the use of propofol + local anesthesia versus sevoflurane + opioids and also found that disease-free survival was longer among patients who received propofol + local anesthesia. Disease-free survival increases with the use of propofol in combination with epidural anesthesia in patients who undergo surgery for infiltrating bladder cancer.

Breast Cancer and Anesthesia.

Breast cancer is a complex heterogeneous disease that is categorized into several histological and genomic subtypes with relevant prognostic and therapeutical implications. Such diversity requires a multidisciplinary approach for a comprehensive treatment that will involve surgeons, radiotherapists and medical oncologists. Breast cancer is classified as either local (or locoregional), which stands for 90-95% of cases, or metastatic, representing 5% of cases. The management of breast cancer will be determined by the stage of the disease. The treatment of local breast cancer is based on surgery and/or radiotherapy. Systemic breast cancer requires chemotherapy and/or endocrine and/or biological therapy.

Opioid Free Anaesthesia and Cancer.

Opioid-free anesthesia is revolutionizing anesthetic practices for its potential benefits in selected patients. Opioid-free anesthesia represents a step forward in anesthetic practice as it has been suggested to provide potential clinical benefits for selected patients. Opioid-free anesthesia spares the use of opioids and involves the administration of multiple adjuvant anesthetics, which may have an impact on cancer progression. All this have added to the growing interest in the immune response to anesthetics, making opioid-free anesthesia a promising avenue for future research. Assessing the role of anesthetics in immunomodulation in the surgical setting is challenging, and results are often contradictory. Indeed, there is a scarcity of data of studies on humans, which hinder the interpretation of results. However, promising evidence has been published that cancer progression can be delayed by the administration of specific anesthetic agents.

Laparotomía en un paciente bajo anestesia libre de opiáceos / Laparotomy in a patient under opioid-free anaesthesia

Los pacientes obesos sometidos a cirugía bariátrica tienen una alta probabilidad de presentar complicaciones que empeoran con el uso de opiáceos y que pueden ser disminuidas gracias a técnicas anestésicas como la anestesia libre de opiáceos (OFA). El riesgo de tener que reconvertir la técnica quirúrgica laparoscópica a cirugía abierta es una de las críticas a esta modalidad anestésica, ante la posibilidad de que no exista un correcto control simpático o nociceptivo. Presentamos el caso de una paciente programada para una cirugía bariátrica laparoscópica que, manteniendo la OFA, se reconvirtió a cirugía abierta (laparotomía exploradora), logrando un correcto control tanto hemodinámico como del dolor perioperatorio

Obese patients subjected to bariatric surgery have a high probability of presenting complications that worsen with the use of opioids and can be reduced thanks to anaesthetic techniques like opioid-free anaesthetics (OFA). The risk of having to convert the laparoscopic surgical technique into open surgery is one of the criticisms aimed at this anaesthetic modality, facing the possibility of there not being a correct sympathetic or nociceptive control. We present the case of a patient scheduled for laparoscopic bariatric surgery who, while maintaining OFA, was converted to open surgery (exploratory laparoscopy), with correct control achieved of both haemodynamics and perioperative pain