Opioid-free anesthesia tied to better pain control in pancreatic surgery: Study
Belgium: A recent study in the journal BMC Anesthesiology found that implementing opioid-free anesthesia (OFA) protocol during pancreatic resection is feasible and is associated with better outcomes, particularly pain outcomes.
"OFA during pancreatic resection was associated with a better pain control, a 4-day reduction in length of stay after pancreatic resection without an increase in readmissions or morbidity, and a reduced comprehensive complication index compared to opioid-based anesthesia (OBA)," Pierre Lafère, and colleagues wrote in their study. Also, no adverse hemodynamic effect was seen in the OFA group.
Pancreatic resection for pancreas cancer is the most complex abdominal operation which is associated with high morbidity. Main reasons for prolonged length id stay following the surgery are postoperative complications such as delayed gastric emptying (DGE), surgical site infection, post-pancreatectomy hemorrhage (PPH), pancreatic fistula (POPF), and poor pain control.
Previous studies have shown OFA to be associated with significantly reduced cumulative postoperative morphine consumption in comparison with OBA. There is however no clarity on whether OFA is feasible and may improve outcomes in pancreatic surgery. Considering this, Dr. Lafère and the team reviewed the outcomes in a single-center cohort of patient who underwent pancreatic resections under OBA versus OFA.
For this purpose, the researchers included and retrospectively reviewed perioperative data from 77 consecutive patients who underwent pancreatic resection. Patients received either an OBA with intraoperative remifentanil (n = 42) or an OFA (n = 35). OFA was a combination of continuous infusions of lidocaine, dexmedetomidine, and esketamine. In OBA, patients also received a single bolus of intrathecal morphine.
All patients received intraoperative propofol, diclofenac, dexamethasone, sevoflurane, neuromuscular blockade. Postoperative pain management was achieved by continuous wound infiltration and patient-controlled morphine.
Postoperative pain (Numerical Rating Scale, NRS) was the primary outcome. Opioid consumption within 48 h after extubation, length of stay, adverse events within 90 days, and 30-day mortality were included as secondary outcomes. Episodes of bradycardia and hypotension requiring rescue medication were considered as safety outcomes.
Following were the study's salient findings:
· Compared to OBA, NRS (3 vs 0) and opioid consumption (36 vs 10) were both less in the OFA group.
· Length of stay was shorter by 4 days with OFA (14 vs 10).
· OFA, with postoperative pancreatic fistula and delayed gastric emptying were identified as only independent factors for length of stay.
· The comprehensive complication index (CCI) was the lowest with OFA (24.9 ± 25.5 vs 14.1 ± 23.4).
· There were no differences in demographics, operative time, blood loss, bradycardia, vasopressors administration or time to extubation among groups.
"In this series, OFA during pancreatic resection is feasible and independently associated with a better outcome, specifically pain outcomes," wrote the authors. "The lower rate of postoperative complications may justify the need for further randomized trials to test the hypothesis that OFA may improve outcomes and shorten length of stay."
Reference:
Hublet, S., Galland, M., Navez, J. et al. Opioid-free versus opioid-based anesthesia in pancreatic surgery. BMC Anesthesiol 22, 9 (2022). https://doi.org/10.1186/s12871-021-01551-y
