Ewa Komorowska-Wojtunik1, *Anna M. Lotowska-Cwiklewska1, 2, Urszula Kosciuczuk2, Andrzej Siemiatkowski2
Low opioid anesthesia and opioid free anesthesia use in pain control treatment in postoperative period
Zastosowanie protokołu niskoopioidowego lub bezopioidowego w kontroli bólu w okresie okołooperacyjnym
1Department of Anaesthesiology and Intensive Care, Hospital of The Ministry of Internal Affairs and Administration, Bialystok, Poland
2Department of Anaesthesiology and Intensive Care, Medical University of Bialystok, Poland
Streszczenie
Ból pooperacyjny jest złożonym i wieloczynnikowym objawem, który wymaga przemyślanego podejścia przy użyciu różnych metod leczenia w celu uzyskania optymalnego wyniku po operacji. Współczesna anestezjologia szukając alternatywy dla postępowania przeciwbólowego z użyciem opioidów, coraz częściej zwraca się w stronę protokołów niskoopioidowego i bezopioidowego leczenia i kontroli bólu. Dzięki zastąpieniu opioidów analgetykami nieopioidowymi, koanalgetykami, a także zastosowaniu technik znieczulenia regionalnego i miejscowego ograniczamy lub unikamy działań niepożądanych opioidów przy zachowaniu satysfakcjonującego poziomu analgezji dla pacjenta. Metody przeprowadzania znieczulenia ogólnego bez użycia lub z minimalną ilością leków opioidowych zyskują szczególne znaczenie w chirurgii bariatrycznej, dzięki zmniejszeniu częstości występowania depresji oddechowej w okresie pooperacyjnym oraz nadmiernej sedacji. Pozwalają także na osiągnięcie i utrzymanie stabilności układu krążenia w okresie śród- i pooperacyjnym, zapobiegają występowaniu hiperalgezji indukowanej przez opioidy (tzw. paradoks opioidowy), a także poprawiają komfort pacjentów w okresie pooperacyjnym, dzięki mniejszej częstości występowania pooperacyjnych nudności, wymiotów i zaparć. Podkreśla się szczególne znaczenie technik analgezji regionalnej i miejscowej, które uzupełniają znieczulenie ogólne oraz zmniejszają zapotrzebowanie na leki przeciwbólowe w okresie okołooperacyjnym. W niniejszej analizie przestawiono teoretyczne podstawy multimodalnej analgezji i istniejące dowody naukowe potwierdzające jej korzyści w zakresie poprawy kontroli bólu po zabiegu chirurgicznym.
Summary
Postoperative pain is a complex and multifactorial symptom that requires a well thought approach using different treatments to achieve the optimal outcome after surgery. Contemporary anaesthesiology, looking for an alternative to analgesia with the use of opioids, more often turns to the protocols of low-opioid and opioid free treatment and pain control. By replacing opioids with non-opioid analgesics, koanalgetics, as well as using local and regional anesthetic techniques, we limit or avoid adverse effects of opioids while maintaining a satisfactory level of analgesia for the patient. Methods of general anesthesia without or with the minimum amount of opioid drugs are of particular importance in bariatric surgery due to a reduction in the incidence of post-operative respiratory depression and excessive sedation. They also allow to achieve and maintain cardiovascular stability in the intraoperative and postoperative period, prevent the occurrence of opioid-induced hyperalgesia (the so-called opioid paradox), and improve the comfort of patients in the post-operative period due to the lower incidence of post-operative nausea and vomiting and constipation. The particular significance of regional and local analgesia techniques, which supplement general anesthesia and reduce the need for analgesics in the perioperative period, is emphasized. This analysis presents the theoretical foundations of multimodal analgesia and existing scientific evidence confirming its benefits in improving pain control after surgery.
INTRODUCTION
Opioids are the main group of pharmacological substances used to perform general anaesthesia, they also have stable and established role in analgesic treatment in a direct perioperative period. Multi-faceted influence of opioid drugs understood as modulation of pain impulse on the central and peripheral nervous system level, as well as effects of interaction with opioid receptors directly in a place of mechanical damage makes them a highly effective group of drugs in terms of relieving moderate and severe pain. Unfortunately, despite the high analgetic effectiveness, the usage of opioids is connected with the risk of adverse reactions in the shape of oversedation, respiratory depression (1, 2), postoperative nausea and vomiting (PONV) (3) as well as opioid hyperalgesia (4).
Methods of conducting general anaesthesia with restriction or elimination of the opioid drugs usage are known as low opioid or opioid free anaesthesia that are widely used. In the presented methods the analgetic effect during perioperative period is caused by the usage of opioid free analgesics, co-analgesics as well as the usage of the regional or local anaesthesia techniques. It was pointed out in many publications that such methods of anaesthesiological proceeding were effective for patients with intercurrent obesity as well as for those suffering from obstructive sleep apnea (5). This kind of strategy minimalises the risk of oversedation and respiratory depression while maintaining a satisfactory level of analgesia for the patient and in case of patients with higher tolerance for opioids it effectively controls postoperative pain.
OPIOID FREE ANESTHESIA
Opioid Free Anaesthesia protocol (OFA) establishes the withdrawal of using opioids during anaesthesia as well as postoperative period (5). Opioid free anaesthesia is a component of a multimodal, balanced general anaesthesia strategy aiming at maximisation of desired analgetic effects while minimising adverse reactions and side effects of drugs through the use of synergistic influence of different pharmacological drugs combined with the regional or local anaesthesia techniques (6).
As for the pharmacological aspect, OFA includes opioid free anaesthesia with the use of non-opioid analgesics – nonsteroidal anti-inflammatory drugs, paracetamol, metamizole and co-analgesics (lidocaine, magnesium, ketamine, dexmedetomidine, gabapentinoids, corticosteroids) and local anaesthetic drugs for regional anaesthesia.
Mulier et al. presented a scheme of OFA consisting of dexmedetomidine (0.5 mcg/kg), ketamine (0.25 mg/kg) and lidocaine (1.5 mg/kg) supply during the phase of general anesthesia indution, which provided satisfactory effects of sedation, analgesia and hemodynamic (sympathomamimetic effect), and then a filler sustanting together lidocaine (1.5-3 ml/kg/h) and ketamine (0.25-1 mg/kg/h). All drugs were dosed according ideal body weight (IBW) using the Brocka equation (7). Benefits resulting from the use of ketamine are mostly improvement of analgesia combined with opioids or with the entire lack of them, minimalisation of the frequency of chronic postoperative pain and postoperative nausea and vomiting (5). Additional use of lidocaine minimises pain intensity in the early stages of postoperative pain as well as minimises high percentage of intestinal atony, nausea and vomiting after abdominal surgeries, stops inflammatory reaction induced by the surgery and minimises the need for opioids (3). It was pointed out in a lot of publications that the use of dexmedetomidine or anaesthetic induction during preoperative period minimises the need for inhaled anaesthetics in 90% and minimises also the need for propofol (a popular intravenous anaesthetic drug) in 30% (8). Numerous authors proved that the analgesic magnesium compounds’ mechanism is caused by minimising the concentration of inflammatory cytokines – interleukin 6 and TNFα in the plasma, and its perioperative use prolongs the neuromuscular blockade because of the dosage of neuromuscular non-depolarizing agents which in turn requires monitoring the extent of perioperative muscle relaxation and reduction of the dosage (5).
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Piśmiennictwo
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