P034: OPIOID-FREE MULTI-MODAL ANESTHETIC PROTOCOL DURING CARDIOPULMONARY BYPASS SURGERY: FACILITATES EARLY NEUROLOGICAL EXAM AND FAST-TRACK TO EXTUBATION
Fritz-Gerald Charles, MD; Patrick Tighe, MD; Michael Franklin, DO; University of Florida
Background: Opioids remain the mainstay for providing analgesia for cardiothoracic surgery using cardiopulmonary bypass (CPB). Opioids, however, have many side effects that impairs the advancement of modern cardiothoracic anesthetic goals, which encourage early neurological exam, fast-track to extubation, early mobilization, minimal time on mechanical ventilation, and improving outcomes. Neuraxial techniques which represent a useful alternative to opioids in non-CPB thoracic cases present a feared challenge to clinicians due to the increased risks of neuraxial hematoma perpetuated by systemic heparinization which renders neuraxial techniques undesirable in this situation. Our recent clinical efforts have focused on developing a multimodal opioid-free anesthetic protocol using modern anesthetic agents, each with unique characteristics that facilitate early neurological exam and fast-track to extubation.
Method: A 74-year-old female (5’ 2”; 43.6 Kg) presented for repeat mitral valve replacement (MVR), and tricuspid ring annuloplasty due to worsening mitral stenosis (mean pressure gradient of 10 mmHg), and pulmonary hypertension (right ventricular systolic pressure of 46). The patient has multiple comorbidities, most significant for malnutrition (pre-albumin of 5mg/dL), severe mitral valve stenosis status post MVR and left atrial appendage ligation, Mitral valve balloon valvuloplasty, severe Tricuspid valve insufficiency, atrial fibrillation status post atrio-ventricular nodal ablation and pacemaker placement, coronary artery disease status post drug eluting stent to left circumflex artery, acute-on-chronic combined congestive heart failure, breast cancer treated with radiation, and status post right pleurodesis for recurrent pleural effusions. To facilitate early neurological exams, and to reduce the complications associated with opioid use in this population, an opioid-free anesthesia protocol was implemented. Preoperatively, acetaminophen was administered orally. Immediately prior to induction, infusions of lidocaine and dexmedetomidine were started. Induction of anesthesia was conducted using midazolam, followed by lidocaine, and ketamine. Propofol was then titrated to loss of consciousness, and rocuronium given for paralysis. About 1-minute prior to instrumentation of the airway, a bolus of esmolol was given to thwart the sympathetic reflex associated with intubation. The patient remains hemodynamically stable throughout induction. Maintenance of anesthesia was achieved with isoflurane and infusions of dexmedetomidine and lidocaine. Blouse doses of ketamine were used for the most stimulating parts of the procedure.
Result: Upon closure of the chest, the patient was breathing spontaneously on a pressure support ventilation setting. Tactile and voice simulations resulted in facial grimacing, with upper and lower extremity movements noted. Our ICU staff were able to obtain plausible neurological exam and reassuring Confusion Assessment Method (CAM) exam upon screening for delirium at close to 2 hours postoperatively. Effective extubation weaning parameters were obtained at around 6 hours, with eventual successful extubation soon after.
Conclusion: Our technique demonstrates that opioid-free analgesia may be feasible and expedite time to recovery in very ill patients undergoing complex cardiac surgery. This result was subsequently reproduced in five (5) other patients undergoing cardiac surgery with CPB; all of whom had complete purposeful neurological exam in the OR. A randomized control trial is necessary to compare outcome of our opioid-free protocol versus opioid analgesia technique in this population.