Opioid Free Anaesthesia Why, when and how to avoid opioids in obese patients

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1 Opioid Free Anaesthesia Why, when and how to avoid opioids in obese patients Daniela Godoroja Lead Anaesthetist, Ponderas Academic Hospital Assistant Professor, University Carol Davila Bucharest, Romania

2 Enhanced=Early???

3 Patterns of pain in bariatric surgery 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 Should we treat them all with opioids? Can we prevent neuropathic pain?

4 Step 4: balanced multimodal analgesia with adjuvants detect and prevent neuropathic pain Non -opioid Adjuvants Ketamine Lidocaine Dexmedetomidine/Clonidine Mg

5 What Anaesthetic Technique in Obese?

6 Anaesthesia techniques Inhalational Opioid free anaesthesia-jan Mulier TCI

7 Loco-regional Anaesthestic Techniques TAP block Epidural

8 OSA Safe Anaesthetic Management CO 2 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! opioid free /spare anaesthesia or regional no sedatives and long acting drugs

9 Rethink??? Why Opioid Free Anaesthesia in MO??? in 3 reasons

10 Dr Paul Janssen, 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?

11 Should we get rid of opioids? 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: Immuno suppression by opioids and effects on cancer recurrence Sacerdote et al.. Curr Pharm Des. 2012;18(37): Wybran J. Suggestive evidence for receptors for morphine and methionine-enkephalin on normal human blood T lymphocytes. J Immunol. 1979;123:1068

12 Why opioid free in anesthesia for the obese? Being fully awake, pain free and without respiratory depression is very important in morbidly obese patients.

13 How to avoid opioids? 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

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15 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

16 Side effects of large doses of paracetamol Augments inhibition of PLT function by diclofenac Munsterhjelm E et al., BJA 2003 Dose dependent antiplatelet effect Munsterhjelm E et al., Anesthesiology 2005 No antiplatelet effect Scharbert G et al., Blood Coagul Fibrinolysis gr paracetamol has no effect on PLT aggregation during tonsillectomy. Silvanto M et al., AAS gr paracetamol: transient increase in GSTA1-1, AST, ALT in 1 patient Silvanto M et al., AAS 2007

17 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 Sep- Oct;112(5): 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

18 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: PCA recommendations no basal infusion of morphine, bolus doses of mg with a ten minutes interval & titration to a desirable effect within the first few hours after surgery. Levin et al.anesthesiology 1992; 76: 857-8

19 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:

20 Alpha-2 agonists Indications: Premedication Opiate sparing Additives for regional anesthesia Effect on chronic (postoperative) pain Clonidine 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

21 Mechanisms of action Gilsbach J, Brit J Pharmacol 2012 Gottschalk A, Amer Fam Phys 2001

22 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

23 Ketamine reduces opioid induced hyperalgesia!! NMDA-Receptor Blocker-inhibits sensitization in response to nociceptive stimuli 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

24 Mg 2+ 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

25 Lysakowski Magnesium as an Adjuvant to Postoperative Analgesia: A Systematic Review of Randomized Trials 2007Anaesthesia &Analgesia. Manaa J.-H. Ryu Effect of Magnesium Sulfate on the Total Anesthetic and Analgesic Requirements in Neurosurgery 2012-J Neurol Neurophysiol Effects of magnesium sulphate on intraoperative anaesthetic requirements and postoperative analgesia in gynaecology patients receiving total intravenous anaesthesia 2008-BJA Dose 40mg /kg LBW- bolus before induction 2-10 mg/kg/h-intraoperative +/-5-10 mg/h postoperatively-2-6 h

26 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

27 Our anaesthetic protocol -Jan 2016 Induction MgSO4 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

28 Low Opioid Anaesthesia Protocol METHOD 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)

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30 Clinical top tips Obesity=OSAS/OHS+ Sensitivity to opioids OFA Multimodal Postoperative Analgesia ERAS 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

31 Summary Analgesia and opioid-sparing strategies in obese Opioids -rescue medication Recommendations from OSAS Avoid opioids post operative Recommendations from ERAS Avoid opioids post operative to improve bowel function

32 Děkuji Vám! You can t always get what you want, but if you try sometimes, you get what you need. daniela.godoroja@reginamaria.ro