Opioid Free Anaesthesia … · Daniela Godoroja Lead Anaesthetist, Ponderas Academic Hospital Assistant Professor, University ‘Carol Davila’ Bucharest, Romania Opioid Free Anaesthesia

Daniela GodorojaLead Anaesthetist, Ponderas Academic Hospital

Assistant Professor, University ‘Carol Davila’ Bucharest, Romania

Opioid Free Anaesthesia Why, when and how

to avoid opioids in obese

patients

Enhanced=Early???

Deep visceral straight after surgery

Shoulder pain, irritation of diaphragm

Peritoneum: a single layer of very active and functional cells, involved in

postoperative pain

Chronic pain component in morbidly obese patients: back pain, fibromyalgia,

Neuropathic pain patterns

Patterns of pain in bariatric surgery

Should we treat them all with opioids?

Can we prevent neuropathic pain?

Non -opioid Adjuvants

Ketamine

Lidocaine

Dexmedetomidine/Clonidine

Mg

Step 4:

balanced

multimodal

analgesia with

adjuvants

detect and prevent

neuropathic pain

What Anaesthetic Technique in Obese?

Anaesthesia techniques

Opioid free anaesthesia-Jan

Mulier

Inhalational

TCI

Anaesthestic TechniquesLoco-regional

TAP block

Epidural

OSA Safe Anaesthetic Management

opioid free /spare anaesthesia or regional

no sedatives and long acting drugs

CO2 retention over night

Peri-operative opioids

aggravate obstructive breathing

in OSA

Respiratory arrest,

postoperative respiratory

complications

Obese desaturate sooner and

faster

Panic when the oxygen

saturation starts to fall!

Rethink ???

Why Opioid Free Anaesthesia

in MO???

in…3 reasons

1960 synthetic opiates-balanced anaesthesia with opioids

-Perfect suppression of sympathetic system

-NO cardio vascular collapse or histamine release.

- High doses possible, maximum use of the interaction with other

anaesthetics resulting in hypnotic effects, relaxant effects ?

Dr Paul Janssen, 1926 - 2003

1.OSA- the hidden killer

Opioids inhibit the upper respiratory muscles, induce

upper airway collapse ,exacerbate OSAS

ASA guideline -minimise opioid in OSA

2. Opioids are naturally hyperalgesic by direct interaction with the

NMDA system.Patients receiving opioids become more sensitive

to pain. Opioids are short lasting analgesics and long-acting hyperalgesics by

upregulation of compensatory pronociceptive pathways

Angst MS.. Anesthesiology. 2006;104:570-87

3.Immuno suppression by opioids and effects on cancer recurrenceSacerdote et al.. Curr Pharm Des. 2012;18(37):6034-42

Wybran J. Suggestive evidence for receptors for morphine and methionine-enkephalin on

normal human blood T lymphocytes. J Immunol. 1979;123:1068

Should we get rid of opioids?

Why opioid free in

anesthesia for the obese?

Being fully awake, pain free and without respiratory

depression is very important in morbidly obese

patients.

Multimodal analgetics (non opoids) Paracetamol ,

Diclophenac

Sympathetic block

Clonidine, Dexmedetomidine, B blockers

Nicardipine, Lidocaine, Mg sulfate

NMDA antagonists - low dose ketamine

Epidural, plexus and local infiltration block

How to avoid opioids?

Paracetamol in adults :

personal recommendations

Use 2g paracetamol iv as loading dose

Start 30 to 60 min before end of surgery

Next dose (1g) : 4-6 hours later

Loading dose of 1g in case of:

potential or latent hepatic disease

hemostasis dysfunction

Supra-additive effect with NSAID and tramadol

Side effects of large doses of paracetamol

Augments inhibition of PLT function by diclofenacMunsterhjelm E et al., BJA 2003

Dose dependent antiplatelet effectMunsterhjelm E et al., Anesthesiology 2005

No antiplatelet effect

Scharbert G et al., Blood Coagul Fibrinolysis 2007

3 gr paracetamol has no effect on PLT aggregation during tonsillectomy.

Silvanto M et al., AAS 2007

3 gr paracetamol: transient increase in GSTA1-1, AST, ALT in 1 patient

Silvanto M et al., AAS 2007

NSAIDs doses and risks

Diclofenac 150 mg loading, 2x75 mg/day

Keterolac 40 mg loading, 3 x 10 mg/day

Ketorolac may increase the risk of postoperative haemorrhage after

laparoscopic Roux-en-Y gastric by-pass. Acta Chir Belg. 2012 Sep-

Oct;112(5):369-73.

Only increased odds for anastomotic leak in NON ELECTIVE colorectal

surgery leak. Hakkarainen et al. JAMA 2015

Cardiovascular risks?

Clinical pharmacology & Therapeutics 2009;85(2):190-7

Risk for ulcers at the gastrojejunostomy site depends on:

Type of gastric Bypass: no in RYGB

Patient compliance to avoid nicotine, alcohol and NSAIDS

Scheffel et al.Obes Facts 2011;4(suppl 1):39–41

STEP 3 Morphine intraoperative loading dose of 50 µg.kg-1 IBW morphine at the moment

of stopping the pneumoperitoneum. Ahmad et al.AA 2008; 107: 138-43

PCA recommendations

no basal infusion of morphine,

bolus doses of 0.5-1.0 mg with a ten minutes interval & titration to adesirable effect within the first few hours after surgery. Levin etal.Anesthesiology 1992; 76: 857-8

Lidocaïne

Analgesic effects well demonstrated (even in bariatric surgery)

Decreases ileus and length of stay

Co-anaesthetic: reduces consumption of volatile, BIS

Accelerates recovery after surgery

Prevention of chronic post surgery pain syndrome

Anti-tumoral effect (tumours of epithelial origine)

Prevention of postoperative cognitive dysfunction

1.5 mg/kg bolus followed by a 2 mg/kg/h infusion until the end of the surgical procedure,

continue at 1.33mg/kg/h - IBW for another 23hrs and STOP

OBES SURG (2014) 24:212–218

Alpha-2 agonistsIndications:

Premedication

Opiate sparing

Additives for regional anesthesia

Effect on chronic (postoperative) pain

Clonidine 150 - 300 ug at induction

Dexmedetomidine 0,5 to 1 ug/kg IBW

followed by 0,5 to 1 ug/kg IBW/h

Even postoperative if necessary

Dexmedetomidine 0,1 – 0,2 ug/kg/h

Gilsbach J, Brit J Pharmacol 2012

Mechanisms of action

Gottschalk A, Amer Fam Phys 2001

Side effects & complications

Bradycardia

Hypotension

Orthostatism, AV-block, arrhythmias

Constipation, dizziness, dry eye/nose

Hallucinations, confusion, decrease libido

Neurotoxicity?

Antidote: atepamizole not available for human

use

Ketamine reduces opioid induced hyperalgesia !!

Effects of intraoperative low dose ketamine on remifentanil-induced hyperalgesia

in gynecologic surgery with sevoflurane anesthesia.

Boo Hwi Hong eta l. Korean J Anesthesiol. 2011; 61: 238.

Same dose of remifentanil with ketamine 25 mg vs without ketamine

Ketamine 0,3 mg/kg followed by 3 ug/kg/min

Ketamine 0,125 to 0,25 mg/kg IBW followed by 0,125 to 0,25 mg/kg IBW/h

NMDA-Receptor Blocker-inhibits sensitization in response

to nociceptive stimuli

Mg2+

NMDA-Receptor Blocker

protection of the central nervous system from ischaemia

inhibits induction and maintenance of central sensitization

in response to nociceptive stimuli

potential antihyperalgesic agent

lowers mean arterial pressure during intubation and the

immediate postoperative period

reduces anaesthetic requirements

+ Ketamine,nitrous oxide, propofol, Sevo

Lysakowski Magnesium as an Adjuvant to Postoperative Analgesia:

A Systematic Review of Randomized Trials

2007Anaesthesia &Analgesia

J.-H. Ryu Effects of magnesium sulphate on intraoperative

anaesthetic requirements and postoperative

analgesia in gynaecology patients receiving total

intravenous anaesthesia

2008-BJA

Manaa Effect of Magnesium Sulfate on the Total Anesthetic and

Analgesic Requirements in Neurosurgery2012-J Neurol Neurophysiol

.

Dose

40mg /kg LBW- bolus before induction

2-10 mg/kg/h-intraoperative

+/-5- 10 mg/h postoperatively-2-6 h

Intraoperative glucocorticoid

Dexamethasone Analgesic (rest, mobilisation)

Antihyperalgesic

Prevention of acute pain chronicisation?

Prevention of PONV

Reduction of postoperative fatigue

Side effects? (infection, woundhealing, hyperglycemia )

Gan et al.Anesth Analg 2014;118:85–113)

Dose ? -5-10mg or 0.1mg/kg

InductionMgSO4 40mg/kg LBW(2,5 g in 15

min)

Dexamethasone-8 mg

Ketamine 20 mg

Diclofenac 150 mg

Controloc 40 mg

Ondasetron 4 mg

+

Lidocaine 1,5 mg kg/LBW(100 mg)

Sufy-10 mcg/Fy-100 mcg/Remi 3ng

/min TCI

Propofol 200 mg

Rocuronium 0,8 mg/kgLBW

Antibiotic

Maintainance

Lidocaine-1mg/kg/h

Mg SO4 5mg/kg/h

Sevo 1-1,2 MAC

Roc

Metoprolol iv boluses

Extubation

Paracetamol 2g

Nefopam 20 mg

(15 min before)

Tramadol 100 mg

Antag-Neostigmine

Our anaesthetic protocol -Jan

2016

Low Opioid

Anaesthesia

ProtocolMETHOD

1227 bariatric patients enrolled in the

study (Feb 2016-Aug 2017 in Ponderas

Academic Hospital)

We applied a protocol of low opioid

anaesthesia

Exceptions not included in the study :

* Renal impairment

* Myasthenia gravis

RESULTS

# Only 361(29,4%) of the patients

enrolled received in Morphine in

the first 24 hrs

Morphine consumption- Median

= 6.00 (mg morphine)- IQR 2.00

Sex M -Diff (p-value)

92/366 (0.25)

0.06 (0.0288)

OSA (-) Diff (p-value)

324/980 (0.33)

0.19 (<0,0001)

Clinical top tipsObesity=OSAS/OHS+ Sensitivity to opioids

Follow the WHO step ladder

Make maximum use of the drugs in step 1 and 2-First

On, Last Off

Opioids are not the answer to all pain.

Treat aggresively with appropriate Step 4 ‐adjuvamts

Multimodal analgesia offers maybe more than analgesia:

prevention of chronic pain, effect on cancer recurrence

Multimodal Postoperative

Analgesia ERASOFA

Opioids -rescue

medicationRecommendations from OSAS

Avoid opioids post operative

Recommendations from ERAS

Avoid opioids post operative to improve

bowel function

Summary

Analgesia and opioid-sparing strategies in

obese

You can’t always get what you want, but

if you try sometimes, you get what you

need.

Děkuji

Vám!

[email protected]