Espco plecture jpmbrugge2015

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Who, when why Opioid free anesthesia. Overview of actual use of OFA
worldwide.
Presentation · December 2015
DOI: 10.13140/RG.2.1.3068.6482
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OFA
Brugge 19 Dec 2015
Jan Paul Mulier
Departement of Anesthesiology
AZ Sint – Jan AV Brugge
Belgium
Mulier ESPCOP Brugge 2015 1
Opioid Free Anaesthesia
Who?, When?, Why?, Pos?, Neg?, How?
1150 2015

Patient 2 h post surgery on Ward
No nausea
No pain
No cold
Comfortable
Sufficient awake

Overview
1.  Who is giving OFA today? survey
–  Worldwide, more positive than negative responses
2.  Protocols used to achieve OFA today
3.  What is the outcome effect of OFA vs OA?
1.  Advantages and disadvanges of OFA from survey
2.  50 pat Randomised bariatric surgery
•  It is possible, equal hemodyn stable, less post op analgetics, no cortisol rise, better VAS score
3.  500 pat Prospective Qo40 quality of recovery bariatric surgery
•  ERAS and improvement patient satisfaction
4.  5000 pat Retrospective lap gastric bypass
•  Less major complications

Do you give general anaesthesia without opioids (OFA) (in
the absence of regional anaesthesia) today?
6%
18%
39%
28%
9%
Do you give OFA today? Yes for most patients except
when contra indications.
Yes for a selected group of
patients.
No but reduce opioids (LOA)
for some or all patients.
No but willing to learn more
about it.
No and don’t see the possible
advantages.
623 Answers on survey with 21 questions
Anaesthesiologist who visited Bruges since the OFA introduction in 2011 (307 sent, 89 answers),
Most Belgian anaesthesiologists (2350 sent, 392 answers)
Some anaesthesiologists worldwide (823 sent, 117 answers)
Web based link on ESPCOP site (25 answers)

Response from 623 anaesthesiologists
12%
12%
15%61%
Your work experience.
I am in training
Specialist Anaesthesiologist
for 0 – 5 years
for 6 – 10 years
for more than 10 years
37%
34%
29%
Where do you work?
Public or private hospital
with no academic activity
or research
Public or private hospital
with academic activity or
research
University hospital

OFA is used in 26 countries
Saved from:
http://www.amcharts.com/visited_countries/
Belgium Dutch speaking 56
Belgium French speaking 40
Mexico 4
Nigeria 4
Switserland 4
United Kingdom 4
Brasil 3
Russia 3
South Africa 3
USA 3
Austria 2
Netherlands 2
Poland 2
Algeria 1
Argentina 1
Canada 1
China 1
Denmark 1
Egypt 1
France 1
Greece 1
Israel 1
Malaysia 1
New Zealand 1
Saudi Arabia 1
Turky 1
Missing country 6

How long have you been giving OFA?
23%
32%
20%
25%
For. how long have you performed this opioid free (OFA)
method?
Started this year
More than 1 year
More than 2 year
More than 5 year
33%
37%
30%
Work place of OFA users
Public or private
hospital with academic
activity or research
Public or private
hospital with no
academic activity or
research
University hospital
12%
7%
17%
64%
Workexperience of OFA users
I am in training
Specialist
Anaesthesiologist for 0 –
5 years
Specialist
Anaesthesiologist for 6 –
10 years
Specialist
Anaesthesiologist for
more than 10 years

Patients selected for OFA. (all that apply)
0%
20%
40%
60%
80%
100%
Indicate which patients you select for OFA and LOA
OFA LOA
Other: high PONV risk
pregnant or breastfeeding
free flap surgery
combined with locoregional.
elderly
chronic pain patients
knee and hip to accellerate
mobilisation
Respiratory concerns is the reason today
to avoid opioids

Main reasons why you reduce or avoid opioids
peri-operatively.
0%
20%
40%
60%
80%

What methods do you use to reduce (LOA) or
avoid (OFA) opioids peri-operatively?
0%
20%
40%
60%
80%
100%

When you use additives for general anaesthesia
what do you add (all that apply)
0%
20%
40%
60%
80%
100%

Ketamine dose (59 answers)
•  At induction 0,1 to 2 mg/kg (59 answers)
–  Mean 0,4 to 0,6 mg/kg
–  Mediaan 0,5 mg/kg
•  Maintenance 0,15 to 2 mg/kg/h (10 answers)
–  Mean 0,3 mg/kg/h
–  Mediaan 0,25 mg/kg/h
•  Large variation: Why? (1-20)
–  Preventing tolerance (0,2 mg/kg) (hyperalgesia)
to analgesia (0,5 mg/kg)
or anesthesia (2 mg/kg). (hallucinations)

Lidocaine dose (34 answers)
•  At induction 0,6 to 2 mg/kg (59 answers)
–  Mean 1,2 - 1,6 mg/kg/h
–  Mediaan 1 - 1,5 mg/kg/h
•  Maintenance 1 to 5 mg/kg/h (10 answers)
–  Mean 1,25 - 2 mg/kg/h
–  Mediaan 1 - 1,5 mg/kg/h
•  Variation: Why? (1-4)
–  Minimum 1 mg/kg required
–  > 1,5 mg/kg or infusion for long procedures

Clonidine dose (50 answers)
•  At induction 0,5 to 4 mkg/kg (50 answers)
–  Mean 1,6 – 2,5 mkg/kg
–  Mediaan 2 mkg/kg
•  Maintenance 0,3 to 0,6 mkg/kg/h (10 answers)
–  Mean 0,3 mkg/kg/h
•  Post operative ?
–  Bolus 2 x 1 – 2 mkg/kg
•  Large variation: Why? (1-8)
–  From additive (0,5) to strong sympathetic blocker (4)
–  Bradycardia, hypotension does not increase with dose
–  Prolonged sedation if > 2 used for short procedure

Dexmedetomidine dose (11 answers)
•  At induction 0,1 to 1,4 mkg/kg
–  Mean 0,7 – 0,9 mkg/kg/h
–  Mediaan 0,7 mkg/kg/h
•  Maintenance 0,2 to 1 mkg/kg/h
–  Mean 0,3 mkg/kg/h
•  Post operative ?
–  0,1 – 0,2 mkg/kg/h
•  Larger variation than clonidine: Why? (1-14)
–  From additive (0,1) to strong sympathetic blocker (1)
–  Bradycardia, hypotension does not increase with dose
–  Prolonged sedation if > 1 used for short procedure

Problems with OFA
0%
20%
40%
60%
80%
What do you do when a hypertensive/tachycardia
reaction happens during OFA?
0%
20%
40%
60%
80%
100%
What do you do when a hypotension/
bradycardia reaction happens during OFA? (all that
apply)
87%
7%
6%
Have you had any serious adverse events
when reducing opioids (LOA) or working
opioid free (OFA)?
Not until now
Yes but probably not related
to LOA/OFA
Yes and probably related to
LOA/OFA
0
0,2
0,4
0,6
0,8 What do you do when patient has
immediately post operative pain.

Pro & Contra OFA - LOA
0%
20%
40%
60%
80%
100% Disadvantages of LOA OFA
0%
20%
40%
60%
80%
100% Advantages of LOA OFA

Obstacles to adopt OFA?
0%
20%
40%
60%
80%
100%
Insufficient
guidelines.
No training Outcome
not proven
yet.
Other limited data. Not aware
of OFA.
Expensive. outside
prescription
label.
More work.

Opioid free anaesthesia (OFA) in Bruges
started in 2010 - 2011
•  Randomized study, ready for publication on 50
lap gastric bypass patients getting OFA vs. OA.
–  Comparing post operative morphine PCIA
•  Prospective study on 500 lap gastric bypass
patients getting OFA vs. OA. Thesis M Crivits 2014
–  Comparing ERAS evaluation using the Qo40
questionnaire
•  Retrospective analysis 5000 lap gastric bypass
patients getting OFA vs. OA
–  Comparing complications and outcome.

•  No demographic differences between the two groups with regard to
age, weight, length, BMI, gender, the incidence of pre operative OSAS.
•  No difference in Kalkman score (1. prediction of severe postoperative
pain) and in the Amsterdam Preoperative Anxiety and Information
Scale (2. APAIS).
•  No differences in hemodynamic problems per operative, like
bradycardia, hypotension, tachycardia or hypertension defined as a
change of 20 % with or without a treatment requirement.
•  Kalkman score and APAIS score did not predict morphine use or pain
score.
VAS scores are better with a lower morphine
consumption post operative
2013 R. Wouters; J. P. Mulier
Randomized study in 50 lap RNY patients
Patients got OFA or Opioids per-op only
Same post op drugs: paracetamol and diclofenac
Morphine pump PCIA: VAS score at PACU and at ward first day

Randomized study on 50 pt
Table 1: Postoperative at PACU (Nr of pat)
OA (21) OFA (23) p value
low saturation with O2 mask 8 0 <0.001 z score
obstructive breathing 3 0 0.06 z score
PONV 7 3 <0.001 z score
shivering or having cold 5 0 0.013 z score
VAS score (mean) 4,88 1,66 <0.001 t test
Morphine need (mean in mg) 15,3 4,91 0.004 t test
Table 2: Postoperative at Ward
OA (21) OFA (23) p value
emotional state (9) 7,22 8,11 0.051 z score
physical comfort (12) 7,94 10,39 <0.001 z score
psyche support (7) 6,60 6,73 0.62 z score
physical independence (5) 3,80 4,71 0.007 z score
pain score (7) 4,50 6,11 <0.001 z score
sleep score (4) 2,11 3,30 0.040 z score
total Qo40 score (40) 29,60 35,81 <0.001 z score
cortisol change mg 10,55 3,57 0.029 t test
VAS score (mean) 3,29 2,04 0.016 t test
Morphine need (mean in mg) 18,18 14,73 0.330 t test
0,00
2,00
4,00
6,00
8,00
10,00
12,00
14,00
16,00
18,00
20,00
paza 30
min
paza 60
min
paza 120
min
total morfine
mg
VASmgmorfine
Vas score and morfine at PAZA
OA
OFA
0,00
5,00
10,00
15,00
20,00
25,00
30,00
35,00
40,00
cortisol before anesthesia cortisol after anestehsia
cortisol plasma level
cortisol plasma levels
OA
OFA
M+
Pain VAS

500 patients questioned
day1 post lap RNY OFA vs. OA
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
percentageofpositveanswers
Qo40 Questions that are significant different OFA
versus OA
OFA
OA
* Chi square p < 0,05
*
* *
*
**
*
* *
*
*

Retrospective study using all consecutive lap RNY
(from March 1st 2011 to June 31st 2015: 5061 patients ).
B Dillemans – J Mulier Bariatric Center Bruges
•  A prospectively kept database of all the patients undergoing fully stapled
laparoscopic Roux-en-Y gastric bypass (FS-LRYGB) in a standardized
fashion by a single surgeon or under his direct supervision since May 2004
contains today more than 10 000 consecutive procedures.
•  Low Opioid anesthesia (LOA) by using clonidine started in 2010. In 2011
total opioid free anesthesia (OFA) was given, first by using clonidine and
from 2012 by using dexmedetomidine. Around half of the patients were
selected for opioid free anesthesia (OFA) from the beginning, based on the
attending supervising anesthesiologist and his assumed risk of using
opioids.
•  A small group of patients were still given a low opioid anesthesia (LOA) by
adding only a limited amount of additives in an effort to learn how to
handle the switch to total opioid free anesthesia.
•  Patients given OA: 2451 OFA: 2337 LOA: 264 missing info: 9

All one month follow-up complications after
lap RNY are recorded.
2409 2276
248
83
61
16
0
500
1000
1500
2000
2500
3000
OA OFA LOA
Number of complications in Lap RNY
2011-2015
complications
no complications
typeanesthesie
numberofprocedures
Nonsurgical
complications
percentage
bleedingcomplications
percentage
surgeryrelatedwithout
bleedingcomplications
percentage
OA 2492 40 1,61% 33 1,32% 5 0,20%
OFA 2337 21 0,90% 24 1,03% 12 0,51%
LOA 264 9 3,41% 3 1,14% 2 0,76%
total 5093 70 1,37% 60 1,18% 19 0,37%
p = 0.043
*
*
logis'c regression coef p value
OFA -0,392 0,037
age 0,026 0,001
gender: male 0,413 0,031
Re interven'on 0,634 0,003
OSAS 0,23 0,222
OSAS in OA group 0,001
OSAS in OFA group 0,196
BMI 0,009 0,321
Risk for complications
decreases by OFA
increases by age, male gender, re intervention
BMI no effect, OSAS increases risk in OA

Complications type after OA OFA LOA
0
5
10
15
20
25
30
35
40
45
LOA
OFA
OA
OFA has more surgery related complications
OA has more respiratory, infectious and bleeding related complications
LOA has more complications on average but group is small

Are the groups comparable?
•  Not randomized prospective database.
•  Variable OA OFA LOA p
•  Male 28,21% 28,07% 24,62% 0,51
•  BMI 40,89 41,18 41,66 0,41
•  Age 41,09 42,19 * 41,27 0,009
•  OSAS 37% 39% * 31% * 0,024
•  Redo 15% 19% * 16% 0,001
•  Not comparable: OFA has more patients with OSAS and redo surgery.
•  OSAS if STOPbang > 3, probably underscored by missing data

Are other outcome variables different?
Not randomized prospective database.
•  Variable OA OFA LOA p
•  Unplanned ICU 0.56% (14) 0.3% (4) 0.38% (1) 0.38
•  No of hospital days 2.73 2.53 * 2.86 0.001
•  1 week revisions 0.36% (9) 0.13 (3) 0.38 (1) 0.10
•  Hospital readmission 0.88% (22) 1.03% (24) 1.89% (5) 0.29
•  Morphine day 0 (SD) 21 mg (0.99) 6 mg (0.48)* 15 mg (1.9)* 0.001
•  No no-opioids postop 1.36% (34) 8.7% (205) 5.6% (15) 0.001
•  OFA patients have a shorter hospitalization and need less or no opioids on the first day.

CURRENT
OPINION Perioperative opioids aggravate obstructive
breathing in sleep apnea syndrome: mechanisms
and alternative anesthesia strategies
Jan P. Mulier
Purpose of review
Opioids induce and increase the severity of most sleep-disordered breathing in all patients, but especially
in morbidly obese patients. Discussed herein are the direct impact and mechanisms of opioids on inducing
and exacerbating obstructive sleep apnea syndrome in normal and morbidly obese patients.
Recent findings
Respiratory depression is a larger problem than obstructive sleep apnea syndrome during the first night
after an opioid anesthesia because of the reduced amount of deep sleep and rapid-eye-movement sleep.
Acute tolerance to the analgesic effects of opioids can be observed after one anesthetic opioid dose,
although tolerance to the side-effects of opioids develops more slowly. Therefore, it makes sense to avoid
all opioids intraoperatively. A recently developed multimodal nonopioid anesthesia method may prevent
development of acute tolerance and facilitate postoperative pain management with less opioids and sleep-
disordered breathing.
Summary
A multimodal nonopioid anesthesia method avoids the necessity for intraoperative opioids, reduces the
need for postoperative opioid use, and improves analgesia with less narcotic.
Keywords
analgesia, anesthesia, obstructive sleep apnea syndrome, opioids
REVIEW
015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this
se patients, with or without OSAS,
quent oxygen desaturation episodes
Curr Opin Anesthesiol 2015, 28:000–000
DOI:10.1097/ACO.0000000000000281
ght ß 2015 Wolters Kluwer Health, Inc. All rights reserved. www.co-a

Acute morphine tolerance was
known for a long time but forgotten?
Br. J. Pharmac. Chemother. (1968), 33, 245-256.
ACUTE TOLERANCE TO NARCOTIC ANALGESIC
DRUGS IN RATS
BY
B. M. COX, M. GINSBURG AND 0. H. OSMAN
From the Department of Pharmacology, Chelsea College of Science and Technology, London, S.W3
(Received November 2, 1967)
It has been reported that treatment of rats and mice with actinomycin D, an antibiotic
inhibitor of protein synthesis, diminishes the impairment of the analgesic effect of
morphine normally observed during chronic treatment with the analgesic (Cohen, Keats,
Krivoy & Ungar, 1965). The widespread metabolic disturbances that arise during
prolonged treatment with inhibitors of protein synthesis (Young, Robinson & Sacktor,
1963) make it difficult to interpret this result, and in fact, some of the animals receiving
higher doses of actinomycin died.
In the experiments reported in the present paper it is shown that in rats, tolerance to
morphine and other analgesics given by continuous intravenous infusion develops within
4 hr and this makes it possible to study the effects of actinomycin D on tolerance while
overall metabolism is apparently unimpaired.
METHODS
Preparation of animals for intravenous infusion
Male or female Wistar rats weighing between 130 and 250 g were anaesthetized with ether. A
polyethylene cannula filled with saline was inserted into a jugular vein and the free end was
exteriorized through a stab wound in the skin at the back of the neck. On the next day, solutions
of drugs (details in RESULTS) dissolved in 0.9%1 (w/v) sodium chloride solution were infused into
the conscious animals from a continuous infusion apparatus connected to the jugular vein cannulae
by fine polyethylene tubes. The rate of infusion was 1 ml./hr.
Measurement of analgesia
Analgesia was measured by a modification of the method of Green & Young (1951). A force was
applied to the tip of a rat's tail by the plunger of a syringe connected to a compressed gas supply
(Morton, 1962). Pressure developed within the syringe (which was measured by a U-tube mercury
246 B. M. COX, M. GINSBURG and 0. H. OSMAN
drug treatment, at times after drug administration, and the maximum pressure, respectively.) Pmax
was taken arbitrarily at 36 cm Hg, but in practice pressure stimuli greater than 32 cm Hg were
never used. For example, where an animal with PA=6 responded to a pressure of 32 cm Hg, the
32-6
analgesic index would be -6 =0.87; where such an animal did not respond at 32 cm Hg the index
36-6
was taken as 1.00.
Motor co-ordination test
The time during which rats (tested individually) were able to balance on a rotating horizontal rod
was measured. The P.V.C. covered rod (diameter 25 mm.) was rotating at 1.1 rev/min.
Nitrogen excretion
Measurements of total nitrogen content of urine were made by Kjeldahl's method.
The following drugs were used: morphine HC1, diamorphine HCI, pethidine HCI, etorphine HCl,
actinomycin D (Dactinomycin, Merck, Sharp and Dohme).
RESULTS
Preliminary experiments were carried out to discover a suitable range of infusion rates
of morphine into conscious rats. The criteria chosen were such that, at least initially,
significant levels of analgesia should be produced and that the rates of infusion should
1.0
0.8
x
-04
._
C
S
us
c
do
d
0.6
0.4
0.2
-0.2 F a
' ' ' 'I I
1 2 4 6 8
Time from start of infusion (hr)
Fig. 1. Mean analgesic indices during intravenous infusions of morphine. 0, Morphine 5 mg/kg/hr
(n=4); *, morphine 7.5 mg/kg/hr (n=7); A , morphine 10 mg/kg/hr (n=5); *, 0.9%
sodium chloride solution (n=4).
Morphine Tolerance starts after 2 hours
No analgesic effect after 8 hours
Br. J. Pharmac. Chemother. (1968), 33: 245

Remifentanyl tolerance in 90 min
No analgesic effect after 3 h
Rapid Development of Tolerance to Analgesia During
Remifentanil Infusion in Humans
H. Ronald Vinik, MD*, and Igor Kissin, MD, PhDt
*Department of Anesthesiology, University of Alabama at Birmingham, Birmingham, Alabama; and tDepartment of
Anesthesia, Harvard Medical School, Brigham and Women’s Hospital, Boston, Massachusetts
Studies in experimental animals have demonstrated a
rapidly developing acute tolerance to the analgesic ef-
fect of opioids administered by continuous IV infusion.
The aim of the present study was to determine whether
acute tolerance plays an important role in the analgesic
effect of remifentanil provided by IV infusion to hu-
mans. The analgesic effect of remifentanil, infused at a
constant rate of 0.1 pg *kg-’ * min-’ for 4 h, was evalu-
ated by measuring pain tolerance with thermal (2°C
water) and mechanical (pressure) noxious stimulations
in 13 paid volunteers. The constant-rate infusion of
remifentanil resulted in a threefold increase in pain tol-
erance with both tests. After reaching its maximum in
60-90 min, the analgesic effect of remifentanil began to
decline despite the constant-rate infusion, and after 3 h
of infusion, it was only one fourth of the peak value. A
comparative rate in the development of acute tolerance
measured in terms of time to 50% recovery during infu-
sion was 129 + 27 min (mean + SD) with the cold water
test and 138 + 39 min with the pressure test. We con-
clude that the development of tolerance should be in-
cluded in the calculations for target-controlled infu-
sions. Implications: Our study shows that tolerance to
analgesia during remifentanil infusion is profound and
develops very rapidly. The administration of opioids
during anesthesia based on target-controlled infusions
should include corrections for the development of
tolerance.
(Anesth Analg 1998;86:1307-11)
S
tudies of constant-rate IV infusions of opioids in
dogs and rats have demonstrated a profound
decrease in analgesia within 2-8 h after the be-
ginning of the infusion (l-4). The analgesic effect of
morphine declines profoundly, despite the absenceof
a decrease in morphine brain concentration (3). This
based on models of tolerance development. The aim of
the present study was to determine whether acute
tolerance plays an important role in the analgesic ef-
fect of remifentanil administered by IV infusion to
humans.
usly applied to the tibia, and the volunteer was
ked to report when the pain became intolerable. The
ration of the volunteer’s tolerance to the pain stim-
us was recorded. The pain stimulus was discontin-
d after a maximum of 60 s. Pain in the tibia was
ed immediately after cessation of the pressure (ver-
l scale from 0 to 10). Sedation was assessedby the
lunteers by estimating drowsiness on a scalefrom 0
10 (0 = alert, 10 = very sleepy).
The testing session began with measurement of
seline pain tolerance values. Pressure tests were
rformed first, followed by cold water tests 5 min
er. For the first 30 min, each volunteer received an
usion of isotonic sodium chloride solution, fol-
wed by repeated measurements of pain tolerance.
he volunteer was blinded to the contents of the in-
sion. If both cold and pressure tolerance increased
>30%, the subject was excluded from the study,
nd remifentanil was not administered. The aim of the
otonic sodium chloride infusion was to eliminate
acebo responders. Of the 13 volunteers, 2 were ex-
uded becauseof the response to the isotonic sodium
loride infusion.
Immediately after the second pain tolerance meas-
ement, remifentanil was infused at a constant rate of
1 pg * kg-r * min-i and maintained for 4 h. Meas-
ements of all variables were performed every
min for 2 h and hourly thereafter.
Cold water and pressure test responseswere treated
s continuous variables. The time to 50% recovery
reached its peak in 60-90 min. After reaching a maximal
analgesicresponse,analgesiabegan to decline in eight of
nine subjectsdespite the continuing infusion of remifen-
tanil (Fig. 1). In one such subject,the cold water test was
tolerated beyond the cutoff limit (180s) until the end of
remifentanil infusion. Therefore, the possibility for the
development of tolerance to analgesiawas questionable.
However, with the pressure test, the same subject dem-
onstrated a decline in analgesiaafter the peak response
to remifentanil infusion. After 3 h of remifentanil infu-
sion, the analgesicresponseto the cold water testwas, on
average, only one fourth of the peak value. Comparative
degrees of the analgesia reduction during remifentanil
~~.:‘:11(1 ~1
2 IO-
c” o- Remifentanil O.lpg.kg-‘.min-1
1 I I I I I I I I
-30 0 30 60 90 120 150 180 210 240
Time (min)
Figure 1. Time course of the analgesic effect of remifentanil
(constant-rate infusion of 0.1 mg . kg-’ . min-I) as determined by
using a cold water pain tolerance test. “P < 0.0001 versus Time 0; bP
< 0.05 versus 90 min; ‘P < 0.0001 versus 90 min.
Anesth Analg 1998;86:1307
Reason why after TIVA:
•  Crying of pain if no opioid is continued
even when minor or not painfull surgery
•  Shivering and need for bair hugger
•  Vomiting requiring propofol and ondansetron

Have OSAS patients more
complications after OA vs. OFA?
•  Not randomized prospective database.
•  Variable No OSAS OSAS p
•  OA 2.02% (31) 5.05% (44)* 0.001
–  OFA 1.95% (27) 2.49% (22) 0.39
•  LOA 4.62% (8) 5.19% (4) 0.67
•  Under standard OA, OSAS patients have a significant higher complication
rate.
•  Under OFA, OSAS patients have not a higher complications rate compared to
non OSAS patients.
•  LOA has a larger complication rate, the group is smaller and shows a
learning curve!
•  OFA is difficult in the beginning and requires an effort to learn.

OFA induction
s  Sympathetic block: 10 min before induction
s  Dexmedetomidine: 0,3 ug/kg IBW (20 -30 ug) further loading to 0,5 after
intubation
s  Local anesthetics iv: 1 min before induction (hypnotic and
rapid stress block)
s  Lidocaine: 1,5 mg/kg IBW (100 mg)
s  Hypnotics iv: induction (hypnotic)
s  Propofol 2,5 mg/kg IBW (200 mg)
s  Hemodynamic stabilization (cave preload reduction)
s  Mg Sulfate 40 mg/kg IBW (2,5 gr)
s  NMB if needed for anesthesia or surgery
s  Anti-inflammatory agents before surgery (lap) corticoiden, NSAID
s  Dexamethasone 10 mg, Diclofenac 75 - 150 mg
s  NMDA block (analgesic and blocking hyperalgesia by opioids)
s  Ketamine 10 - 25 mg bolus or slow infusion or at end operation
s  Have B blocker, Ca antagonist, ephedrine and phenylephrine ready
s  Metoprolaat 1-5 mg, Nicardipine 1-5 mg, Ephedrine 3-9 mg, Phenylephrine 10-30
ug

OFA maintenance
•  Sympathetic block
–  Dexmedetomidine: 0,5 ug/kg/h. (long half life) stop when 1 ug/kg is reached
–  Or Clonidine 150 300 ug loading up (very long half life)
•  Local anesthetics
–  Procaine 0,1 % 2 mg/kg/h short half life and safer except allergic reactions
–  (or Lidocaine 1 % 1 – 3 mg/kg/h high dose has prolonged hypnotic effects)
–  Toxic dose lidocaine is probably very high > 10 mg/kg
•  Mg Sulfate 2,5 mg/kg IBW/h
•  Inhalation anesthesia
–  Sevoflurane, Desflurane 0,8 – 1 MAC with BIS around 40%.
–  Propofol infusion higher dose than TIVA required, difficult and BIS
needed.
•  NMDA block (if opioids might get used post op)
–  Ketamine 50 mg over 12 h
•  Paracetamol 4 gr/24h post op

Opioids are not generally accepted
anymore!
Balanced anesthesia: TIVA:
Inhalation, opioids, NMB propofol, opioids, NMB
34
1. hypnosis
2. Sympathetic block 3. relaxation
Unconsciousness
Hemodynamic stability
Immobility (relative)
We don’t need analgetics to achieve hemodynamic stability
Direct sympathetic block is possible.
Mulier ESPCOP Brugge 2015

Conclusion
Patients love OFA as ERAS improves,
nurses see the difference on the ward
Every change is difficult, requires more work and increases risks.
You will never see the difference
if you do follow your patient post-operative.

LIVE
OPIOID FREE
ANAESTHESIA
December 18th 2015
AZ Sint-Jan AV
Ruddershove 10
Bruges, Belgium
Flyer_Escop_6_18-12-2015.indd 1 19/05/15 20:02
December 19th 2015
Crowne Plaza, Burg 10
Bruges, Belgium
6th
ESPCOP
meeting
Following the advice in using less peri-operative opioids in morbidly obese
patients, it has now become time to discuss “from low-opioid to opioid
free” anaesthesia (OFA).
Why, how and when do we use low-opioid or opioid free anaesthesia
combined with post-operative multimodal analgesia in morbidly obese
patients?
Flyer_Escop_6_19-12-2015.indd 1 19/05/15 20:03
Mulier ESPCOP Brugge 2015
ESA Mulier 2015
www.ESPCOP.org
36

7th ESPCOP Meeting
December 17th 2016
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