2019 FSA Posters
P065: FOUR OPIOID-FREE ANESTHESIA PROTOCOLS EVALUATED FOR ENT SURGERIES
Enrico M Camporesi, MD1, David J Samuels, MD2, Hesham Abowali, MD1, Matteo Paganini, MD3, Maha Balouch, BA1, Garrett Enten, BS1; 1TEAMHealth Anesthesia Research Institute, 2TEAMHealth Anesthesia, 3University of Padova; Padova, Italy
Introduction: Opioids have been used for decades in anesthesia and for post-operative pain. Often, a patient’s first exposure to opioids is during surgery, and at times patients continue to use opioids for long times after healing [1]. Therefore, surgery can be the gateway to iatrogenic opioid dependence.
Multimodal, opioid-free anesthesia (OFA) protocols have been developed for general anesthesia [2]. Often the multi-modal agents eliminate or reduce the need for any opioid medications, reducing their unwanted side effects. Here we report on the changes in post-operative outcomes during 4 OFA protocols developed over a 20 month period.
Methods: A retrospective chart review was conducted after approval from the local IRB. The study comprised 2663 adult patients who underwent scheduled nasal/sinus, or middle ear or tonsillectomy/adenoidectomy surgeries from 01/2016 through 09/2017 at a surgery center in Tampa (FL,USA) (Table 1). During this time, four different opioid-free anesthesia protocols were developed.
The first intra-operative OFA protocol (Group 1; control, 1248 patients) comprised: acetaminophen 1g PO 30 min pre-op, induction with propofol 3-5 mg/kg, 0.3mg/kg ketamine, (+ succinylcholine if endotracheal intubation), and maintenance with sevoflurane (half MAC), IV magnesium sulfate 30mg-60mg/kg, IV Lidocaine 1.5mg/kg, IV decadron 10mg, and IV ondansetron 4mg (IV ketorolac 15-30mg was added if surgeon allowed). No IV opioid was ever administered post-op but oral opioids on request were provided in PACU. Group 2 comprised 961 patients (Ibuprofen staff and patient education). A further modification applied in Group 3 (pre-operative Gabapentin and Benadryl) comprised 305 patients. Finally, Group 4 (no intra-operative Zofran) comprised 149 patients.
Results: Table 1 shows the percentage of patients requesting oral opioids and reporting nausea.
In the control group (Group 1= 1248 patients) we noticed the largest percentage of patients receiving post-operative oral opioids and reporting nausea. Group 2 showed a large decrease in post-operative opioids and nausea (13.2% and 8.4%, respectively). Group 3 resulted in a further decrease in opiate and nausea (10.5% and 3.3%). Group 4 lowered the post-operative intake of opioids to 9.4% and the incidence of nausea to 2%. In this group, it was expected that incidence of nausea would increase due to cessation of intra-operative administration of Zofran: the paradoxical decrease is an interesting topic to evaluate in further studies.
While performing sub-group analyses on the three types of surgeries (Table 2), it was noted that the highest incidence of opioid intake was in post-tonsillectomy/adenoidectomy patients, which could be attributed to the type of patients and the higher pain scores.
Discussion: There is an ongoing quest to define the most appropriate protocols to minimize the usage of opioids or even eliminate them from surgery. In our group of patients we maintained surgeon and patient satisfaction, while patient use of postoperative oral opioid medication was continually reduced. Our educational efforts, combined with the use of multimodal analgesic therapies contributed to minimizing postoperative narcotics requirements and nausea.
References:
[1] Bennett KG et al.: Plast Reconstr Surg. 2019;143(1):87-96.
[2] Samuels DJ et al.: Journal of Clinical Anesthesia and Pain Medicine. 2017;1(2):1-3.
