Opiod free anesthesia Mulier

Why and How giving OFA
(Opioid Free Anesthesia) for morbidly obese patients?
Jan Paul Mulier MD PhD
Sint-Jan Brugge-Oostende, Belgium
[email protected]
More info: www.publicationslist.com/jan.mulier
1778
2014
Sint Jans hospitaal
Brugge Jan Beerblock
Sint Jans hospitaal
Brugge Entrance hall
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OFA is not
vivisection!
Oordeel van Cambyses
Gerard David 1498
Perzisch rechter Sisamnes
door koning Cambyses
veroordeeld wegens corruptie
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Key messages
1.
Most important reason to reduce opioids in morbidly obese
patients is to avoid postoperative OSA and to improve post
operative breathing.
2. Many more reasons are described but require outcome studies.
3. Loco-regional anesthesia is the ideal method to avoid opioids.
4. Stress free, hemodynamic stable general anesthesia (without
locoregional) is also possible without opioids using
sympatholytic drugs in a multimodal approach.
5. It is initially more work, cost more and it is difficult to give OFA
but patients feel the difference and love OFA because their
recovery is enhanced after surgery.
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How to avoid opioids?
Loco-regional anesthesia is ideal to avoid opioids
It blocks nociceptive signals travelling to the brain.
When locoregional anesthesia is impossible
Do we have other solutions?
General anesthesia and achieving stress free hemodynamic
stable anesthesia is possible without analgetics.
But why do we use opioids during general anesthesia?
Non opioids analgetics only is often sufficient after OFA
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What happens when
A: block ascending pathway
B: give analgetics
C: block sympathetic and
hormonal reactions
D: give hypnotics
To Pain and Pain reactions?
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Components of general anesthesia
1.
Unconsciousness
1.
2.
Basal nuclei & cerebral cortex
Immobility
1.
Brain stem & Spinal cord & neuromuscular junction
3.
Control of Autonomic reflexes: vagal-sympathetic
4.
Reversibility of the above
5.
Amnesia?
1.
6.
Irrelevant when you’re unconscious
Analgesia (pain)? Not needed
1.
There is NO PAIN, only nociceptive stimulation when you’re unconscious.
(resulting in sympathetic response)
7.
Suppression of Hormonal stress response
8.
Control of Immunologic response
9.
Suppression of Inflammatory response
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Components required after general
anesthesia
1.
Full consciousness
2.
Full mobility
3.
Control of Autonomic reflexes: vagal-sympathetic
4.
Amnesia?
1.
5.
Sometimes required in children or disabled patients
Analgesia (no pain)
1.
Essential after anesthesia for surgery
2.
Avoid a reduction in the pain level (overdosing, inflammation, repetition)
1.
Use no opioids for hemodynamic stabilisation
2.
Work multimodal to reduce dosis of each group of analgetics
3.
Use analgetics with less side effects, with less sensibilisation
6.
Suppression of Hormonal stress response
7.
Control of Immunologic response
8.
Suppression of Inflammatory response
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Why are opioids so successfull?
1. Stress free & Stability
Stress free anesthesia
Suppression of stress hormones
Hemodynamic stability: sympathicus block
Peripheral vasoconstriction:
Reduction in peripheral perfusion
Reduction in cardiac output
Maintaining MAP
No coronary vasoconstriction
Maintaining coronary perfusion
No change in contractility
Synthetic opioids better then opiates (morfine)
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Why was opioid anesthesia successful?
Fentanyl:
Decrease in cardiac output; Increase in SVR,
Slight decrease in HR – MAP and stable!
No lactate production
Moffitt E The Coronary Circulation and Myocardial Oxygenation in Coronary Artery Disease:
Effects of Anesthesia Anesth-Analg 1986;65:395-410
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and
No negative inotropic effects of opioids (except alfentanyl)
Effect of alfentanil, fentanyl, sufentanil, and remifentanil on maximum isometric active force
(left panel) and the peak of the positive force derivative (right panel)
Hanouz J et al. Anesth Analg 2001;93:543-549
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Why are opioids so successfull?
2. Reduction of hypnotics
Opioids blocks ascending nociceptive stimuli,
thereby reducing the concentration of hypnotics (inhaled or IV
anesthetics) required to induce
unconsciousness, immobility and hemodynamic stability
“Mac sparing effect of opioids”
Balanced anesthesia: Hypnotics with opioids.
We have used opioids NOT to “treat intraoperative pain”,
but to facilitate the hemodynamic stability
To reduce the cardia c output without reduction in the coronary
perfusion.
To block the respiration and facilitate the ventilation.
But opioids alone without hypnotics : “Higher chance of awareness”
Lee M, Pain Physician 2011;14: 145
Balanced anesthesia: Opioids with hypnotics
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Propofol Reduces Perioperative Remifentanil Requirements in a Synergistic Manner: Response
Surface Modeling of Perioperative Remifentanil-Propofol Interactions.
Mertens. Anesthesiology. 99(2):347-359, August 2003.
50 % probability
of no responses
to intubation
50 % probability
of no responses
to laryngoscopy
50 % probability
of no responses to
intraabdominal
surgical stimuli
Munster Mulier
50% probability
of the return
to consciousness
© 2003 American Society of Anesthesiologists, Inc. Published by Lippincott Williams & Wilkins, Inc.
12
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Why are opioids so successfull?
3. Reduction of NMB?
Adjuvants to sevoflurane compared to NMB:
Excellent if
sevo + 1 ug/kg Remifentanyl iv 3, 5, 6
sevo + 2 mg/kg prop 9, 10
sevo + 2 mg/kg lidocaine 12
Not sufficient if
sevo alone
sevo + N2O
sevo + alfentanyl
sevo + low dose prop
Opioids sufficient to prevent spont breathing
Opioids insufficient to relax abdominal wall
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Why avoiding opioids?
1. Side effects :
Resp depression,
obstructive breathing,
pruritis,
nausea & vomiting,
ileus, constipation,
urinary retention,
muscle stifness,
addiction,
impaired peripheral perfusion,
sleep disturbance and suppression of REM and SWS …
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Why avoiding opioids?
1.
Side effects:
Resp depression, obstructive breathing, pruritis, nausea & vomiting, ileus, constipation, urinary
retention, muscle stifness, addiction, impaired peripheral perfusion, sleep disturbance …
2.
Opioids alone can not treat all pain problems.
Add non opioid analgesics and additives to treat special pain problems
Pain 2008;137:441
3.
Opioid induced immunosuppression
Possible Negative impact on cancer outcome (pain suppression more important)
Curr Pharm Des. 2012;18:6034
4.
Opioid-induced neurotoxicity.
Clear in neonates. Quid cognitive dysfunction in elderly?
Anesth Analg 2002;94:1229
5.
Acute tolerance and addiction.
Withdrawal syndrome after stopping PCIA with opioids.
6.
Opioid-induced hyperalgesia post operative. “Opioid Paradox”
Agitation, crying in PACU after longduration TIVA for plastic surgery.
Curr Opin Anaesthesiol 2005;18:540
7.
Chronic postsurgical pain syndrome lasting for months.
High incidence if questioned: 10 % to 40% after laparotomy.
Munster MulierLancet 2006;367:1618
15
Main elements of ERAS
No Opioids
per operatief
Opioid free multimodal
Analgesia possible
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Hyperalgesia to opioids….
Intraoperative Remifentanil Increases
Postoperative Pain and Morphine
Requirements
(Guignard, Chauvin: Anesthesiology 2002)
R
No R
Independent Predictive Factors of Severe
Postoperative Pain in the Postanesthesia
Care Unit
The dose of intraoperative opioid !!
(Aubrun, F. et al. Anesth Analg 2008;106:1535)
Intensity of post op pain is proportional to the dose of opioids
given during anaesthesia.
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N eur opsychopharm acology (2007) 32, 2217–2228
& 2007 Nature Publishing Group All rightsreserved 0893-133X/07 $30.00
www.neur opsychopharm acology.or g
Low dose fentanyl after high dose fentanyl:
. No analgetic activity and decreased pain level,
. Effect is stronger after surgery (inflammation)
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Non-Nociceptive Environmental Stress Induces Hyperalgesia,
Not Analgesia, in Pain and Opioid-Experienced Rats
Cyr il Rivat 1, Em ilie Labour eyr as1, Jean-Paul Laulin 1,2, Chloé Le Roy1, Philippe Richebé 1,3 and
Guy Sim onnet * ,1
1
Laboratoire ‘Homéostasie-Allostasie-Pathologie’, Université Victor Ségalen Bordeaux 2, Bordeaux, France; 2Department of Cellular Biology and
Physiology, Université Bordeaux 1, Talence, France; 3Department of Anesthesia and Intensive Care II, Centre Hospitalier Universitaire de
Bordeaux, Bordeaux, France
Ketamine limits the hyperalgesia due to fentanyl
and inflammation.
only if given before first opioid dose.
Therefore avoid opioids per operative,
if required post op always a low dose ketamine 10 mg giving before.
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Characterization of breathing patterns during patientcontrolled opioid analgesia
Obstruction
Depression
In undisturbed subjects receiving patient-controlled
morphine analgesia after surgery, abnormal breathing
patterns are extremely common.
Cyclical airway obstruction and respiratory depression are associated with
a different pattern of chest wall movement.
Drummond Br. J. Anaesth. August 21, 2013
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Obstructive breathing by opioids -> OSAS: episode of obstruction.
Drummond G B et al. Br. J. Anaesth. 2013;bja.aet259
© The AuthorMunster
[2013]. Published
of
Mulierby Oxford University Press on behalf of the British Journal 21
Anaesthesia. All rights reserved. For Permissions, please email:
[email protected]
Obstructive breathing post op
Existing OSAS
Induced OSAS by Muscle weakness due to
PORC post operative residual curarisation
Avoid opioids duirng and after surgery
Deep sedation after anesthesia
Full reversal and objective control to achieve TOF > 90%
Opioids inhibit the upper respiratory muscles, inducing upper airway collapse
(BANG questionaire)
Avoid long working anesthetics. Do not use benzodiazepines; no clonidine > 150 ug; reduce
dexmedetomidine below 0,2 ug/kg/h; Sevoflurane MAC < 1 or desflurane
Respiratory center depressed
PSV during surgery allows reduction of opioids keeping RR>14
Isono S. Obesity and obstructive sleep apnoea: mechanisms for increased collapsibility
of the passive pharyngeal airway. Respirology. 2012;17(1):32-42.
Wall H, Smith C. BMI and obstructive sleep apnoea in the UK: a crosssectional study of
the over-50s. Prim Care Respir J. 2012;21.
Hillman DR, Platt PR. The upper airway during anesthesia. Br. J Anaesth 2003;91:31-39.
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Recommendations from inflammation perspective:
• Morphine stimulates inflammation
• Inflammation blocks the activity of high dose morphine (4 mg/kg)
• Anti-Inflammatory agents improves the activity of morphine
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• Anti inflammatory agents (or genetic zero inflammation) allows analgesia
at low morphine dose (1 mg/kg).
• Less non-opioid analgetics needed when no opioids or no inflammation.
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Why opioid free for morbidly
obese?
Obesity is a pro inflammatory diseaese
Obesity is frequent associated with OSAS
Obesity increases the work of breathing and induces
atelectasis
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Deep, unobstructed breathing needed
Full awake, no sedation, no premedication
Full NMB reversal, no opioids, sitting up in bed
CPAP if above is not sufficient needed
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Why opioid free for every patient?
Reduction of known side effects, certainly if
OSAS, asthma, COPD, respiratory insufficiency.
Heroine, morphine addiction
Complex regional pain syndrome
Prevent acute and chronic hyperalgesia post operative.
Less analgesics needed and less pain
Less immunosuppression
Effect on oncologic surgery?
Less Sympathetic stress post operative
= Cardiac protection, tromboprofylaxis, peripheral perfusion.
Less inflammation and better tissue perfusion
Effect on wound healing and wound infection?
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Many drugs affect the sympathic system and reduces
opioid use peri-operative
Dexmedetomidine / clonidine
Blaudszun G. Effect of systemic alpha2 agonists on post operative morphine
consumption and pain intensity. Review and meta analysis. . Anesthesiology
2012 ; 116: 1312-22
Ketamine / S-Ketamine
central and venous
Kogler The analgesic effect of magnesium sulfate in patients undergoing
thoracotomyJ Acta Clin Croat. 2009;48:19-26.
Lidocaine
central
Bell RF Perioperative Ketamine for acute post operative pain. the cochrane
library 2010; 11
Mg Sulfate
central
central and cardiac
McCarthy G. Impact of intravenous lidocaine infusion on postoperative analgesia
and recovery from surgery: a systematic review of randomized controlled trials.
Drugs. 2010;70:1149-63.
Pregabalin
Ca ion channel blocker GABA
Dexamethasone
inflammation
Tiippana E. Effect of paracetamol and coxib with or without dexamethasone
after laparoscopic cholecystectomy. Acta Anaesthesiol
Scand. 2008;52:673-80
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Total opioid free?
Many studies show a reduction in opioid use per
operative and post operative if a non opioid additive is
added.
If these drugs are combined in a multimodal approach is
it possible to avoid all opioids per operative???
Marc de Kock (UCL Belgium) achieved this already
several years before Dexmedetomidine became
available in Europe using high dose clonidine –low
dose ketamine and esmolol.
433 kg morbidly obese patient with obstructive
sleep apnea and pulmonary hypertension.
Hofer R. Anesthesia using dex-medetomidine without
narcotics. Can J Anaesth. 2005; 52: 176.
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Is opioid free anesthesia possible?
Patient needs a block of the pain stimuli or a block of the
pain effects.
An opioid in an analgesic dose during surgery is insufficient.
An opioid in a high dose works through a symphatic block.
Opioid free is possible because
Patient does not need analgesics during his sleep
Symphatic block is possible with alpha agonists.
Clonidine (catapressan), dexmedetomidine (dexdor)
Very high dose hypnotics is not needed anymore as an
alternative of opioids.
Before 1960 (Fentanyl 1954) only high dose inhalation or
pentothal was possible to suppress hemodynamic reactions.
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Is there a difference between opioid
and opioid free anesthesia?
Both induce sympathetic block with bradycardia and hypotension
The speed of this effect is dependent on drugs and dose.
Remifentanyl > Sufentanyl > Fentanyl >> dexmedetomidine >> clonidine
The duration is opposite to the speed of induction
The drop is dependent on the dose and the drug.
If insufficient hypertension and tachycardia.
Extra dose of remifentanyl is possible, for alpha agonists too
late.
Alpha agonist first induce hypertension, before hypotension,
requiring a slow load up and not possible to react fast.
Risk of rebound hypertension after stopping long term treatment.
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Classical triade
Balanced anesthesia:
TIVA:
Inhalation, opioids, NMB
propofol, opioiden, NMB
1. hypnose
Unconsciousness
Hemodynamic stability
Immobilisation (if needed)
2. analgesia
3. relaxation
Do we need analgesia for hemodynamic stability?
Do we have an other method to achieve this? YES
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Paradigma shift -> OSA & OFA?
OFA:
Inhalatie/propofol
and non opioid analgetica,
local anesthetica iv,
alpha agonists,
1. hypnose
B blokkers
ketamine
Unconsciousness
Hemodynamic stability
Immobilisation (if needed)
2. Symp block
3. relaxation
Analgesia is not needed during anesthesia sleep
But we need sympathetic stability to protect organs.
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Indications for OFA
Obese patients, patients with obstructive sleep apnea syndrome (OSAS)
Asthma, COPD and other pulmonary diseases.
Acute and chronic opioid addiction.
Sufficient analgesia preferential with non-opioids is essential also in long-term
abstinence to avoid relapses.
Huxtable 2011, Bryson 2010, Rundshagen 2010, Jage 2006, Stromer 2013
If heroine addict: substitution
Hyperalgesia problems before.
Is frequent but you have to ask.
Complex regional pain syndromes (CRPS)
Causalgia, Suddeck’s atrophy, Raynaud syndrome and reflex sympathetic
dystrophy.
Chronic Fatigue and Immune Dysfunction Syndrome?
Avoid histamine release, ponv prevention, Mg and K extra,
Oncologic surgery?
Being pain free and stress free more important than immunosupression by
morphine? Imani B Morphine use in cancer surgery Front pharmacol 2011; 2: 46
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Contra indications for OFA
Absolute CI
Allergy to one of the drugs.?, heart block, shock, extreme
bradycardia
Relative CI
Acute Ischemic problems due to coronary stenosis?
Add nicardipine to give Coronary vasodilation
Slower loading of dexmedetomidine to avoid hypertension and
vasoconstriction.
Controlled hypotension with need for dry surgical field by a
low cardiac output.
Add more beta blockers, Mgsulfate
Sympathetic dysfunctional syndromes with orthostatic
hypotension.
Use less dexmedetomidine
Very old patients on B blocker
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Mulier lower
Use
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dose dex, less adaptations
possible
Personal experience
2008 (self) Hypnosis without any medication.
Perfect sympathetic block without pain is possible
2010 Clonidine 300 ug, ketamine 25 mg, metoprolaat 5 mg added to 10 ug
Sufentanyl. Opioid sparing
2011 Clonidine 150 ug, ket 12 mg, lidocaine 1 mg/kg, esmolol infusion and no
sufentanyl, 1,5 MAC inhalation. Opioid free. Low dose morfine + NSAID post
operative.
2012 Dexmedetomidine, ketamine, lidocaine 1,5 -3 mg/kg, Mg Sulfate, bolus
and infusion with 0,7 MAC inhalation. 50 % no morfine post operative.
2013: 90 % of my anesthesias are OFA and rapid awakening. Multimodal
analgesia and if OSAS very low dose dexmedetomidine, lidocaine, magesium
and ketamine: 90 % no morfine needed.
2014: More atention to work anti inflammatory from begin and to protect
peritoneum (dexamethasone, diclofenac, O2, perfusion pressure, insufflation
pressure) and strong fluid limitation to limit wound oedema.
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40,00
cortisol plasma levels
cortisol plasma level
35,00
30,00
25,00
20,00
OA
15,00
OFA
10,00
5,00
0,00
cortisol before
anesthesia
cortisol after anestehsia
Qo40 Questions that are significant different OFA versus OA
100%
percentage of positve answers
90%
*
*
*
*
80%
70%
60%
*
*
*
50%
*
40%
30%
20%
*
*
*
OFA
OA
10%
0%
* Chi square p < 0,05
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Morphine sleep
Inhibition of REM sleep, followed by a rebound in REM
sleep.
Cronin A. Opioid inhibition of rapid eye movement sleep by a
specific mu receptor agonist Br J Anaesth. 1995;74:188-92.
Reduces duration of slow-wave sleep in postoperative
patients.
Its acute administration produced a moderate reduction in
REM (rapid eye movement) sleep.
Shaw IR, Acute intravenous administration of morphine
perturbs sleep architecture in healthy pain-free young adults:
a preliminary study Sleep. 2005;28:677-82.
Single dose of opioids affects sleep architecture in
healthy adults and reduces slow-wave sleep.
Dimsdale JE The effect of opioids on sleep architecture J
Clin Sleep Med. 2007 ;3:33-6.
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Is total opioid free analgesia
possible?
Yes if
Multimodal analgesia is loaded up during anesthesia
Locoregional anesthesia is added
Opioids are seldom required if sufficient loading
up with alpha en non opioid analgesics.
Low dose opioids post operative have less side effects?
Use opioids as analgetics in the lowest dose possible if non
opioid analgesia is not sufficient.
“Opioid paradox” no opioid during anesthesia
=
Less opioids post operative
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•
•
•
•
•
•
• Anti ischemia
• Lower temp
• Humidification
• Lower IAP
• Perfusion pressure
• Anti inflammation
• Dexamethasone
• Non steriodal analgesics
• Fluid restriction
• O2 very low conc
Hypoxia
Hyperoxia 21%
Dissication
Manipulation
IAP x duration lap
Obesity
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How to measure peritoneal
inflammation?
Abdominal Pain and shoulder pain ( not good parameter)
Peritoneal swelling
CO2 absorption with RQ > 1,3 simple to follow
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OFA Problems Peroperative
Vasoconstriction during induction (dex loading)
Pale, white, hypertension, bradycardia
R/ nicardipine 1 mg , wait till prop/inhal is effective
Insufficient sympathetic block
Tachycardia, hypertension
Betablocker, more inhalation, dex, lid extra
Sympathetic block to strong
Bradycardia, hypotension
R/ Ephedrine
Not enough vasoconstriction
Bloody surgical field
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R/ beta blocker
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OFA Problems Postoperative
Not waking up post operative
Lower dose clonidine / stop-reduce dex earlier
Stimulate patient who will suddenly open his eyes and
want to go asleep again.
Wait 15 minutes (Dex) or several hours (Clonidine)
Pain when wakening up
Add morphine 5 mg iv at end surgery
Switch from clonidine to dexmedetiomidine
Did you add keterolac or diclofenac?
Are all multimodal elements given sufficient?
Bradycardia, hypotension
No problem, accept HR 45 and SAP 90.
Ephedrine extra
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Can we monitor
sympathetic block?
Clinical signs of insufficient block are
tachycardia, hypertension, sweating
Indirect clinical signs are
movement, tearing, hypnotic indices
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Devices
Variables based on electroencephalography
CVI: Composite Variability Index: BIS value variation
qNOX: EEG variability index: qCON value variation
Variables using autonomic tone/response
SPI: Surgical plethysmographic index
SC: Stress conductor detector: skin conductance
ANI: Analgesia Nociception Index: heart rate variability
Reflex pathways
CARDEAN: CARdiovascular DEpth of Analgesia: impact of blood
pressure on heart rate (baroreceptor reflex)
RPD: reflex pupillary dilatation: Pupillometry
RIII-reflex threshold: the EMG signal of the biceps muscle after
simulation of the ipsilateral sural nerve.
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Can we monitor
sympathetic block?
A: patient is asleep with sevoflurane 1 MAC,
dexmedetomidine 0,3 ug/kg (not full loaded yet).
B: patient is further loaded up with dexmedetomidine 1
ug/kg IBW
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SPI versus entropy
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Monitoring hypnosis
during OFA
Depth of hypnosis can be measured by
electroencephalographic derived parameters. (BIS,
entropy, qCON)
This is certainly valuable, certainly when you start
OFA but is of equal importance when you use high
dosis opioids to block every sympathic reaction like
tachycardia, hypertension, sweating.
Important when you block sympathetic reaction.
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Monitoring analgesia
during OFA
Depth of analgesia cannot be measured directly.
Without analgetics but with sympathicolytics these
monitors measure the sympathicus intensity
indicating that they should be called sympathicus
tonometers instead of analgesiometer.
The EEG derives monitors are linked to hypnosis and
do not measure independently.
The problem of sympathicus tonus is that this
depends on the surgical stimulation level on one side
and on the blocking agents on the other side.
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Less post op side effects but…
No Resp depression,
No obstructive breathing,
No pruritis,
Less nausea & vomiting, (inhalation easier than propofol)
No ileus,
No constipation,
NO urinary retention,
But freq spont urinating when waking up:
woman >> man voiding before induction
No muscle stifness,
No addiction,
No impaired peripheral perfusion …
But surgical field is not dry in controlled hypotension.
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OFA induction
Symphatetic block: 5 min before induction
Dexmedetomidine: 0,3 ug/kg IBW (20 ug)
Local anesthetics iv: 1 min before induction (hypnotic and rapid
stress block)
Lidocaine: 1,5 mg/kg IBW (100 mg)
Hypnotics iv: induction (hypnotic and stress block)
Propofol 2,5 mg/kg IBW (200 mg)
Hemodynamic stabilisation (rapid preload reduction)
MgSulfate 40 mg/kg IBW (2,5 gr)
NMDA block (analgetic and blocking hyperalgesia by opioids)
Ketamine 10 - 25 mg bolus or slow infusion
Anti-inflammatory agents before surgery
Dexamethasone 10 mg, Diclofenac 75 mg
Have B blocker, Ca antagonist, ephedrine and phenylephrine at hand
Metoprolaat 1-5 mg, Nicardipine 1-5 mg, Ephedrine 3-9 mg, Phenylephrine 10-30 ug
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OFA maintenance
Symphatetic block
Dexmedetomidine: 0,5 to 1 ug/kg/h. Long half time
Clonidine 150 ug loading up very long half time
Local anesthetics
Lidocaine 1 % 1 – 3 mg/kg/h
high dose has prolonged hypnotic effects
Procaine 0,1 % 1 – 6 mg/kg/h
shorter half time
Toxic dose is probably very high > 10 mg/kg
Inhalation anesthesia
Sevoflurane, Desflurane 0,6 – 0,8 MAC with BIS around 40%.
Propofol infusion higher dose than TIVA required, difficult and BIS needed.
NMDA block (if opioids might get used or extra analgesia needed)
Ketamine 50 mg over 12 h
MgSulfate 2,5 - 10 mg/kg IBW/h
Paracetamol 6 gr/24h
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HR, Sat, NIBP, etCO2
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02%, BIS, TOF, PTC, airw pres
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Peak airway pressures in mmHg
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Problems Peroperative
Vasoconstriction during induction (dex loading)
Pale, white, hypertension, bradycardia
Give 20 ug dex 5 min before induction and wait, measure SAP
Start induction if sap rises, give nicardipine 1 mg first if too high
Insufficient sympathetic block
Tachycardia, hypertension
Betablocker, more inhalation, lidocaine extra
Give loading early before surgery starts, at incision is it too late
Sympathetic block to strong
Bradycardia, hypotension
R/ Ephedrine, reduce dexmedetomidine
Not enough vasoconstriction
Bloody surgical field due to vasodilation
R/ beta blocker to lower cardiac output
55
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OFA Post operative
non steroidal anti-inflammatory agents
Loading before pneumoperitoneum
Paracetamol 2 -3 gr loading 1 gr/6h
Diclofenac 150 mg loading, 2x75 mg/day
Or Keterolac 40 mg loading, 3 x 10 mg/day
Local wound infiltration (calculate toxic dose!)
and choice between
give low dose morphine (5 mg) or
keep infusion of sympathicolytica (ket dex lido Mg) at low dose without
deep sedation
Ketamine 0,05 mg/kg/h
Procaine 1 mg/kg/h
Mgsulfate 2,5 mg/kg/h
Dexmedetomidine 0,1 – 0,2 ug/kg/h
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Use opioids again correct as last choice
analgetic and never as anesthetic.
It is difficult to start
It requires more work to to prepare drugs
and to monitor
Listen to your patients and learn from errors
You feel comfortable only after several years
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Conclusion
1.
Most important reason to reduce opioids in morbidly obese
patients is to avoid postoperative OSA and to improve post
operative breathing.
2. Many more reasons are described but require outcome studies.
3. Loco-regional anesthesia is the ideal method to avoid opioids.
4. Stress free, hemodynamic stable general anesthesia (without
locoregional) is possible without opioids using sympatholytic
drugs in a multimodal approach.
5. It is initially more work, cost more and it is difficult to give OFA
but patients feel the difference and love OFA because their
recovery is enhanced after surgery.
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58
1. Key points in pre operative planning:
• Record body mass index BMI and total body weight
• 10% pre operative body weight reduction is important
(TBW) on operating list. If central obesity (weight >half
if visceral obesity. Improves respiratory function and
height), lookThe
forEuropean
metabolic
syndrome.
laparoscopic surgical access.
Society for Perioperative Care of the Obese Patient
• Metabolic syndrome = visceral obesity plus diabetes,
ΣΤΟΠΒΑΝΓ θυεστιονναιρε 5 ορ Οβεσιτψ
dyslipidaemia, hypertension. These are the
ρ high risk patients.
Ηψποϖεντιλατιον Σψνδροµ ε (ΟΗΣ) (παΧΟ2 >45µ µ Ηγ)
Ατριαλφιβιλλατιον, λονγ ΘΤ , ηεαρτ φαιλυρε, πυλµ οναρψ
-> regional or opioid free anaesthesia or postoperative
hypertension or a cardiomyopathy?
CPAP.
Key points to remember in anaesthesia
for the morbidly obese patient.
2. Key points in anaesthesia induction.
1. Key points in pre operative planning:
• HELP:30 degree• Record
headbody
up mass
position,
add
ramping
device or • 10% pre operative
Μαλλαµ
πατι
ανδ
λαργεisνεχκ
χιρχυµ φερενχε = διφφιχλτ
index BMI
and total
body weight
body
weight
reduction
important
if viscerallaryngoscopy
obesity. Improves respiratory
function and
bag under thorax.(TBW) on operating list. If central obesity (weight >half
/intubation.
height), look for metabolic syndrome.
laparoscopic surgical access.
• Pre-oxygenation• Metabolic
and 10syndrome
cmH2O
CPAP
the
Facemask
ventilation
is frequently problematic –needs
= visceral
obesityuntil
plus diabetes,
ΣΤΟΠ•ΒΑΝΓ
θυεστιονναιρ
ε 5 ορ Οβεσιτψ
dyslipidaemia, hypertension. These are the
ρ high risk patients.
Ηψποϖεντιλ
ατιονhands
Σψνδροµ εventilation
(ΟΗΣ) (παΧΟ2 and
>45µ µairways.
Ηγ)
intubation.
two
Ατριαλφιβιλλατιον, λονγ ΘΤ , ηεαρτ φαιλυρε, πυλµ οναρψ
-> regional or opioid free anaesthesia or postoperative
• Know the correct
dosingorscalars
υfor induction agents and CPAP. • Avoid laryngeal and supraglottic devices, endotracheal
hypertension
a cardiomyopathy?
muscular relaxants.
tubes should be the default airway.
2. Key points in anaesthesia induction.
• HELP:30 degree head up position, add ramping device or
3. Key points in
anaesthesia maintenance.
bag under thorax.
•
Μαλλαµ πατι ανδ λαργε νεχκ χιρχυµ φερενχε = διφφιχλτ
laryngoscopy /intubation.
• Pre-oxygenation and 10 cmH2O CPAP until the
• Facemask ventilation is frequently problematic –needs
Lung recruitment
ι
maneuvers after intubation followed by two hands
• Prefer
loco
regional anaesthesia.
ventilation
and airways.
intubation.
Know
the
correctοξψγεν
dosing scalars
υfor induction
agents
and
• Avoid laryngeal
and supraglottic
devices, endotracheal
συφφιχεντ Π
ΕΕΠ • εϖ
εν
ωηεν
σ
ατυρ
ατιον
ισ
νορ
µ
αλ
.
sedatives
and
opioids.
muscular relaxants.
tubes should be the default airway.
• Lung protective ventilation and beach chair position
when possible.
3. Key points in anaesthesia maintenance.
• Prefer water-soluble
short
acting
drugs
that arefollowed
easy by
to
• Lung recruitment
ι
maneuvers
after intubation
συφφιχεντ Π
ΕΕΠ εϖεν ωηεν οξψγεν σατυρατιον ισ νορµ αλ.
dose and to monitor.
• Lung protective ventilation and beach chair position
when possible.
• Prefer water-soluble short acting drugs that are easy to
dose and to monitor.
4. Key points in anaesthesia emergence.
Key points
in anaesthesia
emergence.
• Use Pressure 4.
Support
Ventilation
and evaluate
breathing
• Use Pressure Support Ventilation and evaluate breathing
frequency.
frequency.
• Be sure to have •full
neuromuscular
blockade
Be sure
to have full neuromuscular
blockadereversal.
reversal.
Emptyavoid
stomachsuctioning
and avoid suctioning
endotracheal tube
• Empty stomach•and
endotracheal
tube
Avoid long working
• Monitor the neuromuscular blockade (TOF and PTC ) toι
προϖιδε συφφιχεντ δεπτη ιφ υσε νευροµυ σχυλαρ βλοχκι νγ αγεντσ.
• Monitoring
anaesthesia
depth limits the anaesthetic load
• Prefer loco
regional anaesthesia.
Avoid long working
sedatives and
and opioids.
avoids awareness.
• Monitor the neuromuscular blockade (TOF and PTC ) toι
προϖιδε συφφιχεντ δεπτη ιφ υσε νευροµυ σχυλαρ βλοχκι νγ αγεντσ.
• Monitoring anaesthesia depth limits the anaesthetic load
and avoids awareness.
(if needed follow with recruitment).
(if needed
follow with recruitment).
• Extubation
under CPAP in beach chair position when
• Extubation under CPAP in beach chair position when
fully awake.
fully awake.
• Avoid sedation
and sedation
use the lowestand
level use
of opioids.
• Avoid
the lowest level of opioids.
5. Key points in postoperative care.
• Continue
with CPAP mask if used before
surgery.
5. Key points in
postoperative
care.
• Beach chair
ι position or better sitting up to 60°.
tromboprophylaxis.
• Look for SpO2 desaturations and hypercarbia.
• Be aware of rhabdomyolysis when prolonged sur gery in
the sittingtromboprophylaxis.
position.
Συφφιχεντ παι ν ανδ Π
εατµ εντ.
• Continue with CPAP
if ΟΝς
usedτρand
before
• Promotemask
early mobilization
providesurgery.
• Beach chair
ι position or better sitting up to 60°.
• Look for SpO2 desaturations and hypercarbia.
points
to remember
in anaesthesia
Συφφιχεντ παι νKeyανδ
Π
ΟΝς
τρεατµ
εντ. for the morbidly obese patient © www.Espcop.org
aware of rhabdomyolysis when prolonged sur gery in
Munster Mulier
59 • Be
Nightingale, Michael Margarson, Paolo Pelosi, Thomas Gazynski,
Luc de Baerdemaeker, Jan Mulier
• Promote earlyClaire
mobilization
and provide
the
sitting position.
Opioid free anesthesia
More info in Brugge
[email protected]
www.publicationslist.com/jan.mulier
Munster Mulier
60