Opioid Free Anesthesia Its not about opioids So
Opioid. Free Anesthesia It’s not about opioids
So what is it about? 1. Patient 1. Safer anesthetic 2. Fewer side effects 3. Less pain 2. Evolution of Anesthesia 1. Increases in 1. Medications available 2. Knowledge of opioids 3. Knowledge of pain mechanisms 4. regional anesthesia options
1. Preconceptions
Pain Opioids v Analgesic v Hyperalgesic v Tolerance OFA v Analgesic v Anti- Hyperalgesic
Preconception #1 Opioids are Safe × #1 cause of emergencies in PACU are respiratory
Preconception #2 Opioids are effective for treatment of pain × >50% of patients report moderate to severe pain × Remifentanil only prevents 40% of pain transmission under general anesthesia
Preconception #3 Opioid Related Side Effects (ORADES) can be adequately managed × PONV/Pruritis most common cause of unexpected admission × Many side effects are untreatable
Preconception #4 Opioids are necessary for intra-operative hemodynamic control × Opioid-Free Anesthesia × Regional anesthesia
2. ORADES
ORADES Respiratory Pain Neurologic q Respiratory depression q Sisyphus effect (Opioid Induced Hyperalgesia & Opioid Tolerance) q Sedation q Pharyngeal muscle weakness q Pneumonia q Surgical Hyperalgesia q CPSP q Hallucination q Block REM sleep
ORADES GI/GU q PONV q Pruritis q Constipation q Ileus q Urinary Retention Immune/Endocrin e Psychologic q Inhibits immune response: Killer T Cell Inhibition & Cortisol Inhibition q Dependence q Androgen Deficiency q Bone demineralization : malunion q Addiction
3. How-to
Special populations Ø Respiratory Ø Obese, OSA, elderly, COPD Ø Complex pain management Ø Long term opioid use, treatment for opioid addiction, Acute on Chronic pain, Risk for CPSP Ø Ø Ø PONV Cancer Elderly
Toolbox Gold Standard Regional Or Neuraxial Intra-operative management Post-operative management Alpha 2 agonist Acetaminophen Ketamine Nsaids/coxibs Magnesium Dexamethasone N 2 O Gabapentinoid Lidocaine infusion SSRI Beta blockers
Postop The major complication of OFA
Alpha 2 agonist Ø Benefits Ø Analgesic/Anti-hyperalgesic Ø Anxiolysis Ø Anti-shivering Ø Reduces emergence delirium Ø No respiratory depression
Alpha 2 agonist Ø dexmedetomidine Ø Side Effects Ø Bradycardia Ø Hyper/Hypotension Ø Sedation Ø Considerations Ø 10 minute onset Ø 3 hour elimination half-life
Alpha 2 agonist Ø Dexmedetomidine Ø Induction Ø 0. 2 -1 mcg/kg/10 minutes (0. 5 mcg/kg average) Ø Maintenance Ø 0. 2 -1 mcg/kg/hr Ø 10 mcg/ml/1 minute IVP Ø PACU Ø 0. 1 -0. 5 mcg/kg/hr
Alpha 2 agonist Ø Clonidine Ø Benefits Ø Same as precedex Ø Side effects Ø Hypotension/bradycardia Ø Sedation Ø Considerations Ø 12 hour half life
Alpha 2 agonist Ø Clonidine Ø 2 -5 mcg/kg IV (personally 300 mcg max average length case) Ø Ø Ø 100 mcg on induction, 50 mcg prn after that 0. 1 -0. 3 mcg/kg/hr 3 -5 mcg/kg PO
NMDA Antagonist Ø Ketamine Benefits Ø Analgesia/Anti-hyperalgesia Ø Bronchodilation Ø Anti-depressant Ø Minimal respiratory depression
NMDA Antagonist Ø Ketamine Side Effects Ø Sedation Ø Hallucinations Ø Disassociation Ø Dysphoria
NMDA antagonist Ø Ketamine Ø Induction Ø 0. 3 -0. 5 mg/kg Ø Maintenance Ø 2 -10 mcg/kg/min = 0. 1 -0. 6 mg/kg/hr Ø PACU Ø 0. 1 -0. 3 mg/kg/5 minutes
NMDA Antagonist Ø Magnesium Benefits Ø Analgesia/Anti-hyperalgesia Ø Anti-shivering
NMDA Antagonist Ø Magnesium Side Effects Ø Prolonged non-depolarizers Ø Use caution in renal failure Ø Hypotension
NMDA Antagonist Ø Magnesium Ø 30 -50 mg/kg Ø 5 -10 mg/kg on induction Ø Rest over 1 st hour Ø 10 mg/kg/hr
NMDA Antagonist Ø N 2 O Benefits Ø Analgesia/Anti-hyperalgesia Ø Reverses chronic central sensitization
NMDA Antagonist Ø N 2 O Complication Ø Ø Ø Diffusion hypoxia Increase in nausea if no prophylaxis Pulmonary Hypertension B 12 Deficiency Genetic mutation
Na channel blocker Ø Lidocaine Ø 1. 5 mg/kg Ø 2 -3 mg/kg/hr Ø 2% lidocaine = 0. 1 ml/kg/hr (70 kg = 7 ml/hr) Ø Not typically used along with PNB
Beta blocker Ø Esmolol Ø 0. 5 -1 mg/kg Ø 5 -500 mcg/kg/min Ø Metoprolol Ø Labetolol
Mc. Lott Mix
My favorite technique Ø Short case Ø Ketamine/Precedex 10 mg/mcg/ml Ø 0. 3 -0. 5 mg/mcg/kg on induction Ø 10 mg/mcg prn Ø +/- lidocaine and Magnesium Ø Long case Ø Infusion Ø 50 mg/mcg ketamine/precedex + 50 ml 2% Ø lidocaine 0. 1 -0. 2 ml/kg/hr
4. Expectations
Need to reset our expec Initial wake up slower, but more clear-headed in PACU tations Increased respiratory rate until extubation…do not need to treat with an opioid! Less pain, more responsive to opioids
Goopioidfree. com info@goopioidfree. com
- Slides: 36