Opioid-free Perioperative Pain Management D. John Doyle MD PhD Chief, Department of General Anesthesia Cleveland Clinic Abu Dhabi Professor of Anesthesiology Cleveland Clinic
Much of what is known about opioid-free perioperative pain management comes to us from the Enhanced Recovery literature.
Nonopiate Pain Management • Local and regional anesthesia • Systemic lidocaine • Acetaminophen • NSAIDS (e.g., ketorolac) • Corticosteroids • Ketamine • Magnesium • α2 Adrenoceptor Agonists (clonidine and dexmedetomidine ) • Gabapentinoids(gabapentin and pregabalin) • Corticosteroids http://www.medscape.com/viewarticle/811736_7
Lidocaine Recent literature suggests that an adjunctive intraoperative lidocaine infusion (100 mg intravenously prior to incision and then 1‐2 mg/kg/hour ) aids in patient recovery after surgery, presumably as a result of its newly discovered anti-inflammatory properties.
POI = postoperative ileus http://slideplayer.com/slide/6079619/
Intravenous Lidocaine Contraindications • First and second degree heart conduction blocks could be aggravated or progress into a higher degree of heart block with lidocaine administration. • Cardiovascular instability and concomitant use of alpha agonists (e.g., clonidine) or beta blockers (e.g., metoprolol, labetolol) are relative contraindications. • Allergies to other amide local anesthetics (bupivacaine). • Allergy to Novacaine (procaine) is not a contraindication as Novacaine is an ester local anesthetic. • (Safety Warning: bupivacaine and ropivacaine are never given intravenously). http://prc.coh.org/FF%20LidoIVPer12-10.pdf
Intravenous Lidocaine Contraindications Unstable coronary disease Recent MI Heart failure Heart block Electrolyte disturbances Liver disease Cardiac arrhythmia disorders Seizure disorders https://www.mc.vanderbilt.edu/documents/periopservices/files/Lidocaine%20Infusion%20PP%20for%20HR-PACU.pdf
May One Give a Lidocaine Infusion on a General Care Floor? Must be approved by the Pharmacy and Therapeutics Committee (similar issue for ketamine). IV lipid emulsion (20%) therapy should be available (lipidrescue.org).
Intravenous Lidocaine References • Groudine, S.B., Fisher, H.A.G., Kaufman, R.P., Patel, M.K., Wilkins, L.J., Mehta, S.A., Lumb, P.D. (1998). Intravenous lidocaine speeds the return of bowel function, decreases postoperative pain, and shortens hospital stay in patients undergoing radical retropubic prostatectomy. Anesthesia and Analgesia; 86:235‐239. • Herroeder, S., Pecher, S., Schonherr, M.E., Kaulitz, G., Hanenkamp, K., Friess, H., Bottiger, B.W., Bauer, H., Dijkgraaf, M.G.W., Durieux, M.E., Hollman, M.W. (2007). Systemic lidocaine shortens length of hospital stay after colorectal surgery. Annals of Surgery, 246(2), 192‐200. • Kaba, A., Laurent, S.R., Detroz, B.J., Sessler, D.I., Durieux, M.E., Lamy, M.L., Joris, J.L. (2007). Intravenous lidocaine infusion facilitates acute rehabilitation after laparoscopic colectomy. Anesthesiology, 106:11‐18. • Koppert, W., Weigand, M., Neumann, F., Sittl, R., Schuettler, J., Schmelz, M., Hering. (2008). Perioperative intravenous lidocaine had preventive effects on postoperative pain and morphine consumption after major abdominal surgery. Anesthesia and Analgesia, 98:1050‐1055. • Martin, F., Cherif, K., Gentilli, M.E., Enel, D., Abe, E., Alvarez, J.C., Mazoit, J.X., Chuvin, M., Bouhassira, D., Fletcher, D. (2008). Lack of impact of intravenous lidocaine on analgesia, functional recovery, and nociceptive pain threshold after total hip arthroplasty. Anesthesiology, 109:118‐123. • Yardeni IX, Beilin B, Mayburd E, Levinson Y, Bessler H. the effect of perioperative intravenous lidocaine on postoperative pain and immune function. Anesthesia &Analgesia 2009;109(5):1464‐1469.
Ketamine Ketamine is an NMDA receptor antagonist, but it also acts at other sites (including opioid receptors and monoamine transporters). Ketamine comes as a racemic mixture consisting two enantiomers, R- and S-ketamine. Pure S-ketamine (availabale in Europe) is reported to be less prone to psychomimetic side effects, such as derealisation and hallucinations. Posterior spine fusion study Give 0.2 mg/kg on induction of general anesthesia and then 2 mcg/kg/hourfor the next 24 hours. “Perioperative infusion of subanesthetic ketamine was effective in reducing pain in narcotic-tolerant patients after posterior spinal fusions. It reversed unacceptable levels of pain in patients resistant to conventional narcotic treatment.” http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2504281/
Journal of Anaesthesiology Clinical Pharmacology | April-June 2016 | Vol 32 | Issue 2
3-Day Ketamine Treatment for Complex Regional Pain Syndrome https://www.youtube.com/watch?v=IGqo5NBr_xw https://www.youtube.com/watch?v=piiBg1K-bm0 Rapid Relief from Treatment Resistant Depression with Oral Ketamine https://www.youtube.com/watch?v=7A26miRlYBc
Gabapentin and Pregabalin “Gabapentinoids mainly act on the α-2-δ-1 subunit of pre-synpatic calcium channels and inhibit neuronal calcium influx. This results in a reduction in the release of excitatory neurotransmitters such as glutamate, substance P, and calcitonin gene-related peptide from primary afferent nerve fibres thus suppressing neuronal excitability after nerve or tissue injury. ” http://www.medscape.com/viewarticle/811736_3
Magnesium Systemic administration of perioperative magnesium reduces postoperative pain and opioid consumption. De Oliveira GS Jr, Castro-Alves LJ, Khan JH, McCarthy RJ. Perioperative systemic magnesium to minimize postoperative pain: a meta-analysis of randomized controlled trials. Anesthesiology. 2013 Jul;119(1):178-90.
Dexamethasone Single dose IV dexamethasone at doses over 0.1 mg/kg is an effective adjunct to reduce postoperative pain and opioid consumption after surgery. De Oliveira GS Jr, Almeida MD, Benzon HT, McCarthy RJ. Perioperative single dose systemic dexamethasone for postoperative pain: a meta-analysis of randomized controlled trials. Anesthesiology. 2011 Sep;115(3):575-88.
“In summary, we found that perioperative single-dose dexamethasone was associated with small but statistically significant reductions in postoperative pain, postoperative opioid consumption, need for rescue analgesia, PACU stays, and a longer time to first analgesic dose. The effect on postoperative opioid consumption was not dose-dependent. In addition, we found no increased risk of infection or delayed wound healing, although dexamethasone was associated with slight hyperglycaemia on the first postoperative day.”
Dexmedetomidine Sixty-four patients scheduled for abdominal hysterectomy under general anesthesia were divided into two groups that were maintained using propofol/remifentanil/dexmedetomidine (PRD) or propofol/remifentanil/ saline (PRS). During surgery, patients in the PRD group had a lower bispectral index (BIS) value, which indicated a deeper anesthetic state, and a higher sedation score immediately after extubation than patients in the PRS group