Opioid-free Perioperative Pain Management

1. Opioid-free Perioperative Pain Management D. John Doyle MD PhD Chief, Department of General Anesthesia Cleveland Clinic Abu Dhabi Professor of Anesthesiology Cleveland Clinic

2. Much of what is known about opioid-free perioperative pain management comes to us from the Enhanced Recovery literature.

3. 17 Elements to ERAS

4. 8 ERAS Elements Pertain Specifically to Anesthesia

7. 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

9. http://www.medscape.com/viewarticle/811736_5

10. Paracetamol

11. 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.

12. POI = postoperative ileus http://slideplayer.com/slide/6079619/

13. 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

14. 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

15. 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).

18. 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.

19. 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/

20. http://www.ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=247&seg_id=4803http://www.ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=247&seg_id=4803

24. Journal of Anaesthesiology Clinical Pharmacology | April-June 2016 | Vol 32 | Issue 2

25. Therapy For Depression And Chronic Pain

26. 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

27. 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

28. 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.

31. 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.

32. “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.”

33. 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