Mastectomía libre de opioides bajo anestesia-analgesia epidural torácica en un paciente con estenosis traqueal crítica: caso clínico / Opioid-free mastectomy under thoracic epidural anesthesia-analgesia in a patient with critical tracheal stenosis: A case report

Mastectomy is traditionally performed under general anaesthesia and invasive ventilation, and is often complemented with regional techniques. In this setting, tracheal stenosis can pose a challenge to airway management. The aim of this report is to describe the successful management of a 68-year-old woman with severe subglottic tracheal stenosis undergoing mastectomy due to breast cancer. Surgery was performed without airway instrumentation under an opioid-free regimen consisting of thoracic epidural, propofol and dexmedetomidine perfusion, and non-opioid analgesics. Spontaneous ventilation and adequate perioperative analgesia were achieved. Opioid-free anaesthesia without airway instrumentation, consisting of thoracic epidural anaesthesia and sedation, is a good alternative in patients undergoing mastectomy in whom airway manipulation is best avoided.(AU)

La mastectomía se realiza tradicionalmente bajo anestesia general y ventilación invasiva, complementándose a menudo con técnicas regionales. En este contexto, la estenosis traqueal puede suponer un reto para el manejo de la vía aérea. El objetivo de este informe es describir el manejo exitoso de una mujer de 68 años de edad con estenosis traqueal subglótica severa, sometida a mastectomía debido a cáncer de mama. La cirugía se realizó sin instrumentación de la vía aérea bajo un régimen libre de opioides consistente en epidural torácica, propofol y perfusión de dexmedetomidina, y analgésicos no opioides, lográndose ventilación espontánea y analgesia perioperatoria adecuada. La anestesia libre de opioides sin instrumentación de la vía aérea, consistente en anestesia epidural torácica y sedación, es una buena alternativa en pacientes sometidos a mastectomía, en los que es mejor evitar la manipulación de la vía aérea.(AU)

Opioid-free mastectomy under thoracic epidural anesthesia-analgesia in a patient with critical tracheal stenosis: a case report.

Mastectomy is traditionally performed under general anaesthesia and invasive ventilation, and is often complemented with regional techniques. In this setting, tracheal stenosis can pose a challenge to airway management. The aim of this report is to describe the successful management of a 68-year-old woman with severe subglottic tracheal stenosis undergoing mastectomy due to breast cancer. Surgery was performed without airway instrumentation under an opioid-free regimen consisting of thoracic epidural, propofol and dexmedetomidine perfusion, and non-opioid analgesics. Spontaneous ventilation and adequate perioperative analgesia were achieved. Opioid-free anaesthesia without airway instrumentation, consisting of thoracic epidural anaesthesia and sedation, is a good alternative in patients undergoing mastectomy in whom airway manipulation is best avoided.

Anestesia total intravenosa libre de opioides guiada por qCON y qNOX en paciente obesa / Total Intravenous anesthesia in patients with intestinal occlusive syndrome

Introducción: En los últimos años la anestesia libre de opioides ha constituido una alternativa más a las técnicas tradicionales de anestesia general. Con la exclusión de este grupo de fármacos se evitan los múltiples efectos adversos y complicaciones asociados al mismo. A pesar de que la anestesia libre de opioides tiene sus indicaciones y que ha demostrado sus beneficios en cierto grupo de pacientes, existen aún controversias en relación con su utilidad en el paciente obeso. Características como la obesidad hacen que los modelos multimodales empleados para programar la anestesia libre de opioides sean cada vez más complejos. Objetivos: Describir un caso clínico realizado con la técnica de anestesia libre de opioides que constituye la primera experiencia en Ecuador. Presentación del caso: Se presenta el caso de una paciente obesa intervenida de colecistectomía laparoscópica mediante infusión de propofol, ketamina, lidocaína, sulfato de magnesio, y dexmedetomidina. La titulación de estos fármacos se realizó mediante cálculo de concentraciones plasmáticas a través de modelos farmacocinéticos y guiada por monitorización de profundidad anestésica y analgésica, con lo cual se logró optimizar el consumo de fármacos, disminuir las complicaciones y una evolución clínica favorable. Hasta donde se conoce a nivel local y de país (Ecuador) es la primera experiencia que se reporta con esta técnica. Conclusiones: La anestesia libre de opioides puede resultar una elección en el paciente obeso ya que asegura una adecuada recuperación sin efectos adversos asociados(AU)

Introduction: In recent years, opioid-free anesthesia has become another alternative in front of traditional general anesthesia techniques. The exclusion of this group of drugs avoids the numerous adverse effects and complications associated with its usage. Although opioid-free anesthesia has its indications and has showed its benefits in a certain group of patients, there is still controversy regarding its usefulness in the obese patient. Characteristics such as obesity make the multimodal models used to program opioid-free anesthesia increasingly complex. Objectives: To describe a clinical case involving the opioid-free anesthesia technique, which is the first experience in Ecuador. Case presentation: The case is presented of a female obese patient who underwent laparoscopic cholecystectomy by infusion of propofol, ketamine, lidocaine, magnesium sulfate and dexmedetomidine. Titration of these drugs was carried out by calculating plasma concentrations through pharmacokinetic models and guided by monitoring of anesthetic and analgesic depth, thus optimizing drug consumption, reducing complications and achieving a favorable clinical evolution. As far as known locally and in the country (Ecuador), this is the first reported experience with this technique. Conclusions: Opioid-free anesthesia may be a choice in the obese patient, since it ensures adequate recovery without associated adverse effects(AU)

Anestesia libre de opioides para cistectomía radical laparotómica en obesidad mórbida / Opioid-free anesthesia for open radical cystectomy in morbid obesity

El estudio de la técnica anestésica libre de opioides aporta evidencias de su efectividad y seguridad. Sin embargo, aún no están bien definidos todos sus riesgos y beneficios, ni en qué pacientes o intervenciones puede ser superior a la técnica anestésica convencional basada en opioides. Las cirugías intensivas y/o duraderas plantean dudas para la utilización de esta técnica por la respuesta a cambios hemodinámicos bruscos, al no producir la simpaticolisis a través de la actuación sobre el receptor μ y haber poca experiencia de uso. Una paciente con obesidad mórbida fue sometida a cistectomía radical con derivación urinaria tipo Bricker mediante laparotomía infraumbilical, consiguiéndose una adecuada estabilidad hemodinámica y una analgesia óptima en el postoperatorio sin emplear opioides intraoperatorios. La anestesia libre de opioides está en expansión con una evidencia creciente. No obstante, es necesario seguir investigando sobre sus posibilidades de utilización, las distintas combinaciones de fármacos que se puedan emplear y la resolución de complicaciones que puedan ocurrir.(AU)

Opioid-free anaesthesia shows evidence about its efectivity and security, even though its risks and benefits are not well defined. Neither are the patient profile or sort of surgery where it could be superior to the conventional opioid-based anaesthetic technique. Aggressive and/or long-lasting surgeries set out several queries on this technique regarding sudden hemodynamic changes, as it does not produce sympatholysis through μ receptor and there is modest experience in this technique. A morbidly obese patient received open radical cystectomy with Bricker-type urinary diversion using infraumbilical incision under OFA protocol, maintaining an adequate hemodynamic stability and excellent analgesia in postoperatory care without using any intraoperative opioids. Opioid-free anaesthesia technique is developing its evidence. However, it is necessary to keep on researching its clinical applications, different drug combinations and solutions to its expected complications.(AU)

Opioid-free anesthesia for open radical cystectomy in morbid obesity.

Opioid-free anaesthesia shows evidence about its efectivity and security, even though its risks and benefits are not well defined. Neither are the patient profile or sort of surgery where it could be superior to the conventional opioid-based anaesthetic technique. Aggressive and/or long-lasting surgeries set out several queries on this technique regarding sudden hemodynamic changes, as it does not produce sympatholysis through µ receptor and there is modest experience in this technique. A morbidly obese patient received open radical cystectomy with Bricker-type urinary diversion using infraumbilical incision under OFA protocol, maintaining an adequate hemodynamic stability and excellent analgesia in postoperatory care without using any intraoperative opioids. Opioid-free anaesthesia technique is developing its evidence. However, it is necessary to keep on researching its clinical applications, different drug combinations and solutions to its expected complications.

Aplicación de la técnica OFA en cirugía mayor. Experiencia en un hospital secundario / OFA in major surgery. Experience at a secondary level hospital

Introducción: La técnica OFA (opioid free anaesthesia) se basa en una anestesia multimodal con menor uso de opioides, que consigue un adecuado control del dolor, con menor incidencias de náuseas y vómitos en el postoperatorio y mejora el pronóstico en los pacientes oncológicos.Pacientes y método:Estudio retrospectivo de casos de pacientes sometidos a cirugía mayor en el periodo de noviembre de 2018 a febrero de 2020. Objetivo principal: cuantificar tipo y dosis de opioide administrado en periodo intraoperatorio y en el postoperatorio inmediato. Objetivos secundarios: graduación del dolor en el postoperatorio y al alta a planta de hospitalización y presencia de náuseas/vómitos en el postoperatorio. Resultados: 157 pacientes fueron incluidos. El 29,9 % de los pacientes no precisaron ninguna dosis de opioide intraoperatorio. De los que sí la precisaron, un 72,7 % de los mismos solo necesitó morfina y a una dosis media de 3,3 mg (± 0,9); un 8,1 % solo recibieron fentanilo (dosis media de 110,1 mcg, ± 57,1), y un 19,2 % recibieron morfina y fentanilo (3,8 mg ± 1,2 y 90,4 mcg ± 62,4, respectivamente). En cuanto a la necesidad de opioide postoperatorio, solo el 31,7 % de los pacientes precisó su administración; de ellos ⅔ (33 pacientes) solo recibieron morfina (4,8 mg ± 2,6), 1/5 (10 pacientes) solo fentanilo (83,3 mcg ± 28,8) y el resto una combinación de fentanilo y morfina (140,6 mcg ± 119,4 y 8 mg ± 5,9, respectivamente).Respecto a la intensidad de dolor, el valor en la escala EVA a la llegada de los pacientes a la Reanimación tuvo un valor de 1,6 ± 1,9 y al alta de 0,3 ± 0,6. Solo dos pacientes tuvieron náuseas o vómitos.Conclusiones:El uso de una técnica OFA es factible en cirugía mayor y permite un adecuado control del dolor. La necesidad de opioides intravenosos, tanto en el intraoperatorio como en el postoperatorio, es menor cuando se realiza una técnica OFA.(AU)

Introduction: Opioid free anaesthesia is a new paradigm that focuses in multimodal analgesia with an opioid sparing approach that provides a good pain management, without nauseas nor vomiting and improves prognosis in oncological patients. Patients and method: Cases retrospective study of major surgery patients from november 2018 to february 2020. Main objective: type and dosage of opioid requeriments both in the intraoperatory and postoperative setting. Secondary objectives: pain level score cuantification at the end of the surgery and at leaving the postoperative recovery unit and incidence of nausea/vomiting. Results:157 patients were recruited. 29,9 % need no opioid intraoperatively. Those who requiered it, 72,7 % only needed morphine (3,3 mg ± 0,9), 8,1 % had to recieved fentanyl (110,1 mcg, ± 57,1) and 19,2 % need both morphine and fentanyl (3,8 mg ± 1,2 and 90,4 mcg ± 62,4). At the postoperative recovery unit, only 31,7 % precised opioids: ⅔ (33 patients) recieved morphine (4,8 mg ± 2,6), 1/5 (10 patients) only fentanyl (83,3 mcg ± 28,8) and the rest needed a combination of fentanyl and morphine (140,6 mcg ± 119,4 and 8 mg ± 5,9, respectively). Two of them have nausea or vomyting.Conclusions:An opioid free anaesthesia approach is feasible in major surgery patients and it achieves and adequate pain management. Opioid requeriments in such patients is less than in those who recieved a traditional base opioid analgesia protocol.(AU)

Opioid-free anesthesia for open radical cystectomy in morbid obesity. / Anestesia libre de opioides para cistectomía radical laparotómica en obesidad mórbida.

Opioid-free anaesthesia shows evidence about its efectivity and security, even though its risks and benefits are not well defined. Neither are the patient profile or sort of surgery where it could be superior to the conventional opioid-based anaesthetic technique. Aggressive and/or long-lasting surgeries set out several queries on this technique regarding sudden hemodynamic changes, as it does not produce sympatholysis through µ receptor and there is modest experience in this technique. A morbidly obese patient received open radical cystectomy with Bricker-type urinary diversion using infraumbilical incision under OFA protocol, maintaining an adequate hemodynamic stability and excellent analgesia in postoperatory care without using any intraoperative opioids. Opioid-free anaesthesia technique is developing its evidence. However, it is necessary to keep on researching its clinical applications, different drug combinations and solutions to its expected complications.

Anestesia libre de opioides en hemicolectomía abierta derecha extendida. Reporte de un caso y revisión / Opiod Free Anesthesia (OFA) for Open extended right colectomy. A case report and review

Opioid free anesthesia (OFA) is defined as an anesthesiologic technique where opioids are not used in the intraoperative and postoperative period. Although the mainstay of intra-operative analgesia may be opioids, current challenges are focus on reducing them and preventing the adverse effects of opioids, by rationalizing and even suspending their perioperative use, specifically at risk populations such as Obstructive Sleep Apnea Syndrome (OSAHS), obesity, Chronic Obstructive Pulmonary Disease (COPD) and cancer surgery. We present this case of OFA in a susceptible patient with complications from the use of opioids undergoing an extended right hemicolectomy. Multimodal analgesia was performed with a thoracic peridural and subanesthetic doses of intravenous agents including dexmedetomidine, ketamine and propofol, accompanied by short and long-lasting local periglotic anesthetics. The patient had given an intraand postoperative analgesia without presenting any adverse events, good recovery, early deambulation and extubation.

La anestesia libre de opioides (OFA) es una técnica anestésica donde no hay administración de opioides, tanto en el intraoperatorio como en el postoperatorio. Aunque una de las bases de la analgesia intraoperatoria podrían ser los opioides, los desafíos actuales están enfocados en reducir su uso perioperatorio, previniendo sus efectos adversos, racionalizando y limitando su empleo específicamente en poblaciones de riesgo como síndrome de apnea obstructiva del sueño (SAHOS), obesidad, enfermedad pulmonar obstructiva crónica (EPOC) y cirugía oncológica. Presentamos este caso de OFA en un paciente susceptible de complicaciones por uso de opioides sometido a una hemicolectomía derecha extendida. Se realizó analgesia multimodal con peridural torácica y dosis subanestésicas de agentes endovenosos como dexmedetomidina, ketamina y propofol, acompañado de anestésicos locales periglóticos de corta y larga duración. Se otorgó una adecuada analgesia intra y postoperatoria, el paciente no tuvo eventos adversos, presentando una buena recuperación, deambulación y extubación precoz.

Intravenous lidocaine infusion. / Perfusión de lidocaína intravenosa.

Systemic lidocaine used in continuous infusion during the peri-operative period has analgesic, anti-hyperalgesic, as well as anti-inflammatory properties. This makes it capable of reducing the use of opioids and inhalational anaesthetics, and the early return of bowel function, and patient hospital stay. The aim of this narrative review was to highlight the pharmacology and indications for clinical application, along with new and interesting research areas. The clinical applications of peri-operative lidocaine infusion have been reviewed in several recent systematic reviews and meta-analyses in patients undergoing open and laparoscopic abdominal procedures, ambulatory procedures, and other types of surgery. Peri-operative lidocaine infusion may be a useful analgesic adjunct in enhanced recovery protocols. Potential benefits of intravenous lidocaine in chronic post-surgical pain, post-operative cognitive dysfunction, and cancer recurrence are under investigation. Due to its immunomodulation properties over surgical stress, current evidence suggests that intravenous lidocaine could be used in the context of multimodal analgesia.