Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Dec 2017
ReviewDo we feel pain during anesthesia? A critical review on surgery-evoked circulatory changes and pain perception.
The difficulty of defining the three so-called components of « an-esthesia » is emphasized: hypnosis, absence of movement, and adequacy of anti-nociception (intraoperative « analgesia »). Data obtained from anesthetized animals or humans delineate the activation of cardiac and vasomotor sympathetic reflex (somato-sympathetic reflex) and the cardiac parasympathetic deactivation observed following somatic stimuli. Sympathetic activation and parasympathetic deactivation are used as monitors to address the adequacy of intraoperative anti-nociception. Finally, intraoperative nociception through the administration of nonopioid analgesics vs. opioid analgesics is considered to achieve minimal postoperative side effects.
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Best Pract Res Clin Anaesthesiol · Dec 2017
ReviewAdditives used to reduce perioperative opioid consumption 1: Alpha2-agonists.
Because of their significant side effects, especially in obese patients, the routine perioperative use of opioids has been questioned recently. Alpha2-agonists are drugs with a considerable analgesic potency with the potential to reduce opioid consumption. Alpha2-agonists bind to alpha2-adrenergic receptors in the CNS and peripherally. ⋯ Intraoperatively, a complete replacement of the synthetic opioid fentanyl by the alpha2-agonist dexmedetomidine has been demonstrated. Although alpha2-agonists have a sedative action, recovery times are not prolonged compared to those of opioids. Cardiovascular side effects such as bradycardia and hypotension have to be observed and treated.
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Best Pract Res Clin Anaesthesiol · Dec 2017
ReviewDifferent protocols used today to achieve total opioid-free general anesthesia without locoregional blocks.
With increasing awareness of both short- and long-term problems associated with liberal perioperative opioid administration, the need for routinely and clinically feasible alternatives is greater than ever. Opioid-free anesthesia-previously reserved for bariatric surgery-is receiving increasing attention in mainstream anesthesia. ⋯ For a concrete clinical perspective, we present in depth our opioid-free protocol for bariatric surgery. However, clinicians must be aware of potential problems related to opioid-free anesthesia.
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Best Pract Res Clin Anaesthesiol · Dec 2017
ReviewSpecial indications for Opioid Free Anaesthesia and Analgesia, patient and procedure related: Including obesity, sleep apnoea, chronic obstructive pulmonary disease, complex regional pain syndromes, opioid addiction and cancer surgery.
Opioid-free anaesthesia (OFA) is a technique where no intraoperative systemic, neuraxial or intracavitary opioid is administered with the anaesthetic. Opioid-free analgesia similarly avoids opioids in the perioperative period. There are many compelling reasons to avoid opioids in the surgical population. ⋯ Non-opioid adjuvants such as NSAIDS, paracetamol, magnesium, local anaesthetic infiltration and high-dose steroids are added in the perioperative period to further achieve co-analgesia. Loco-regional anaesthesia and analgesia are also maximised. It remains to be seen whether OFA and early postoperative analgesia, which similarly avoids opioids, can prevent the development of hyperalgesia and persistent postoperative pain syndromes.
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Best Pract Res Clin Anaesthesiol · Dec 2017
ReviewOpioid-free anesthesia opioid side effects: Tolerance and hyperalgesia.
Opioids are the most potent drugs used to control severe pain. However, neuroadaptation prevents opioids' ability to provide long-term analgesia and produces opposite effects, i.e., enhancement of existent pain and facilitation of chronic pain development. Neuroadaptation to opioids use results in the development of two interrelated phenomena: tolerance and "opioid-induced hyperalgesia" (OIH). ⋯ Conversely, observations of improved patient's recovery after opioid-sparing anesthesia techniques stand as an indirect evidence that perioperative opioid administration deserves caution. To date, perioperative OIH has rarely been objectively assessed by psychophysics tests in patients. A direct relationship between the presence of perioperative OIH and patient outcome is missing and certainly deserves further studies.