• Can J Anaesth · Nov 2024

    Opioid-free anesthesia for minimally invasive abdominal surgery: a systematic review, meta-analysis, and trial sequential analysis.

    Opioid-free anesthesia for laparoscopic abdominal surgery is associated with significant PONV reduction.

    pearl
    • Carlos A B da Silveira, Ana C D Rasador, Heitor J S Medeiros, Eric Slawka, Lucca Gesteira, Lucas C Pereira, and Sara Amaral.
    • Dignity Health St. Joseph's Hospital, Phoenix, AZ, USA.
    • Can J Anaesth. 2024 Nov 5.

    PurposeOpioid anesthesia is commonly employed in minimally invasive surgeries but is associated with adverse effects, including postoperative nausea and vomiting (PONV). Opioid-free anesthesia aims to mitigate these issues. We conducted a systematic review, meta-analysis, and trial sequential analysis (TSA) comparing opioid and opioid-free anesthesia in minimally invasive abdominal surgeries.MethodsWe searched the Cochrane Central Register of Controlled Trials, MEDLINE, and Embase for randomized controlled trials (RCTs) comparing these approaches. Our primary outcomes were adverse effects (PONV, bradycardia), while secondary outcomes were pain, opioid consumption, and postanesthesia care unit (PACU) length of stay (LOS). We performed a TSA to investigate the conclusiveness of the results.ResultsWe included 26 RCTs encompassing 2,025 patients, with 1,009 (49%) in the opioid-free anesthesia group. Opioid-free anesthesia reduced PONV significantly (risk ratio, 0.55; 95% confidence interval [CI], 0.40 to 0.74; P < 0.001), but we found no significant differences in bradycardia rates. We found nonclinically relevant higher pain scores for opioid anesthesia (mean difference [MD], -0.9; 95% CI, -1.7 to -0.2; P = 0.01) and opioid consumption at 2 hr post surgery (MD, -5.4 mg oral morphine equivalents; 95% CI, -9.1 to -1.8; P = 0.004). We also noted a reduced time to first analgesia (MD, 88 min; 95% CI, 18 to 159; P = 0.01). We found no differences in PACU LOS. The TSA confirmed the sample size's adequacy in showing PONV reduction with opioid-free anesthesia.ConclusionOpioid-free anesthesia showed a significant reduction in PONV and a decrease in opioid consumption during the first 2 hr postoperatively, suggesting it can be an alternative to opioid anesthesia in minimally invasive abdominal surgeries.Study RegistrationPROSPERO ( CRD42023492385 ); first submitted 18 December 2023.© 2024. Canadian Anesthesiologists' Society.

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    pearl
    1

    Opioid-free anesthesia for laparoscopic abdominal surgery is associated with significant PONV reduction.

    Daniel Jolley  Daniel Jolley
    summary
    0

    A comprehensive meta-analysis from Da Silveira examines whether minimally invasive abdominal surgery can be effectively managed without intraoperative opioids. Da Silveira and colleagues analysed 26 randomised controlled trials involving 2,025 patients, comparing traditional opioid-based anaesthesia with opioid-free techniques using alternatives like dexmedetomidine, ketamine, and lidocaine.

    The results are compelling: opioid-free anaesthesia reduced postoperative nausea and vomiting by 45% (from 24% to 13%) without compromising pain control or increasing recovery time.

    Notably, concerns about bradycardia with dexmedetomidine proved unfounded, with no significant difference in rates between the groups. The study also found slightly lower immediate postoperative pain scores and reduced opioid requirements in the first two hours after surgery.

    While these findings strongly support opioid-free techniques for laparoscopic surgery, the authors note important caveats. The included trials used varying combinations of agents, making it difficult to recommend a standardised approach. Successfully implementing opioid-free anaesthesia requires expertise with multiple alternative agents and techniques - but the benefits, particularly in reducing post-operative nausea and vomiting, may be worth the learning curve.

    Daniel Jolley  Daniel Jolley
     
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