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Opioid-free anaesthesia may enhance postoperative recovery by reducing opioid-related side effects such as nausea, hyperalgesia or tolerance. The objective was to investigate the impact of multimodal opioid-free general anaesthesia on postoperative nausea, vomiting, pain and morphine consumption compared to the traditional opioid-based approach. This study was conducted as a prospective parallel-group randomised controlled trial. Perioperative Care. 152 adult women undergoing elective inpatient gynaecological laparoscopy. Patients were randomly assigned for opioid-free anaesthesia (Group OF) with dexmedetomidine, esketamine and sevoflurane or to have opioid-based anaesthesia (Group C) with sufentanil and sevoflurane. Primary outcome was the occurrence of nausea within 24 h after surgery. Patients were assessed for the incidence and severity of PONV, postoperative pain and morphine consumption and recovery characteristics. Patients in both groups had comparable clinical and surgical data. 69.7% of patients in the control group and 68.4% of patients in the opioid-free group met the primary endpoint (OR 1.06, 95% Confidence Interval (CI) (0.53; 2.12) p = 0.86). The incidence of clinically important PONV defined by the PONV impact scale was 8.1% (Group C) vs 10.5% (OF); p = 0.57). Antiemetic requirements, pain scores and morphine consumption were equivalent in both groups. Postoperative sedation was significantly increased in group OF (p < 0.001), and the median length of stay at the post-anaesthesia care unit was 69.0 min (46.5–113.0) vs 50.0 (35.3–77.0) minutes in the control group (p < 0.001). Opioid-free multimodal general anaesthesia is feasible but did not decrease the incidence of PONV, or reduce pain scores and morphine consumption compared to an opioid-containing anaesthetic regimen. •This trial assessed opioid-free anaesthesia in comparison to opioid-based anaesthesia for gynaecological laparoscopy.•Both study groups did not differ with respect to postoperative nausea and vomiting, pain or morphine consumption.•Multimodal general anaesthesia was associated with an increased time to discharge from the post-anaesthesia care unit.

To evaluate all available evidence thus far on opioid based versus opioid-free anesthesia and its effect on acute and chronic postoperative pain. Systematic review and meta-analysis of randomized clinical trials. Operating room, postoperative recovery room and ward. Patients undergoing general anesthesia. After consulting MEDLINE, EMBASE and Cochrane database, studies which compared opioid free anesthesia (OFA) with opioid based anesthesia (OBA) were included (last search April 15th 2022). Primary outcomes were acute and chronic pain scores in NRS or VAS. Secondary outcomes were quality of recovery and postoperative opioid consumption. Risk of bias was assessed using the RoB2 tool and a random effects model for the meta-analysis was conducted. We identified 1245 citations, of which 38 studies met our inclusion criteria. There is moderate quality evidence showing no clinically relevant difference of Numeric Rating Scale (NRS) scores or opioid consumption in the postoperative period (pooled mean difference of 0.39 points with a CI of 0.19–0.59 and 4.02 MME with a CI of 1.73–6.30). We found only one small-sized study reporting no effect of opioid-free anesthesia on chronic pain. The quality of recovery was superior in patients with opioid-free anesthesia (mean difference of 8.26 points), however, this pooled analysis was comprised of only two studies. Postoperative nausea and vomiting (PONV) occurred less in opioid-free anesthesia, but bradycardia was more frequent. We concluded that we cannot recommend one strategy over the other. Future studies could focus on quality of recovery as outcome measure and adequately powered studies on the effects of opioid-free anesthesia on chronic pain are eagerly awaited. •Opioid-free and opioid based anesthesia have similar postoperative pain scores.•Postoperative events depend on drugs used as alternatives for opioids.•Bradycardia occurred more when chosen for dexmedetomidine in opioid-free anesthesia.•One strategy cannot be recommended over another.

Erector spinae plane (ESP) block is a novel regional anesthesia technique and gaining importance for postoperative pain management. Since it was first described, the clinicians wonder if this new simple technique can replace paravertebral block (PVB). We aimed to compare the postoperative analgesic effect of ESP block and PVB with a control group in breast surgeries. Randomized controlled trial. Operating room. Seventy-five ASA I–II patients aged 25–65, who were scheduled to go under elective unilateral breast surgery for breast cancer were included to the study. Patients were randomized into three groups as ESP, PVB, and Control group. Ultrasound (US) guided ESP block and PVB with 20 ml 0.25% bupivacaine was done preoperatively to the patients according to their groups. All patients were provided with iv patient-controlled analgesia device for postoperative analgesia. Morphine consumptions and numeric rating scale (NRS) scores for pain were recorded at 1st, 6th, 12th and 24th hours postoperatively. There was a statistically significant difference between ESP and Control groups (p < 0,001) and between PVB and Control groups (p < 0,001), while there was no difference between ESP and PVB groups (p > 0,05) for 24-hour morphine consumptions. There was a significant difference between PVB and Control groups for NRS at postoperative 1st and 6th hour (p = 0.018 and p = 0.027 respectively). This study has shown that US guided ESP block and PVB provided adequate analgesia in patients undergoing breast surgery and have an opioid sparing effect by reducing morphine consumption. Clinical Trials Registry: NCT03480958. •ESP block provides effective analgesia in breast surgery.•ESP block has lower risk of complications compared to TPV block.•Both ESP block and TPV block have a similar analgesic effect in breast surgery.

BackgroundIncreasing evidence supports a positive relationship between the intensity of early postoperative pain, and the risk of 30-day postoperative complications. Higher pain levels may hamper recovery and contribute to immunosuppression after surgery. This leaves patients at risk of postoperative complications.MethodsOne thousand patients who underwent major abdominal surgery (cytoreductive surgery and hyperthermic intraperitoneal chemotherapy, esophageal, liver, or pancreas surgery) at the Radboud university medical center were randomly selected from eligible patients between 2014 and 2020. Pain scores on day 1, the independent variable of interest, were extracted from the electronic patient files. Outcome measures were 30-day postoperative complications (infectious, non-infectious, total complications and classification according to Clavien-Dindo).ResultsSeven hundred ninety complications occurred in 572 patients within 30 days after surgery, of which 289 (36.7%) were of infectious origin, and 501 (63.4%) complications were non-infectious. The mean duration from the end of surgery to the occurrence of infectious complications was 6.5 days (SD 5.6) and 4.1 days (SD 4.7) for non-infectious complications (p<0.001). Logistic regression analysis revealed that pain scores on postoperative day 1 (POD1) were significantly positively associated with 30-day total complications after surgery (OR=1.132, 95% CI (1.076 to 1.190)), Clavien-Dindo classification (OR=1.131, 95% CI (1.071 to 1.193)), infectious complications (OR=1.126, 95% CI (1.059 to 1.196)), and non-infectious complications (OR=1.079, 95% CI (1.022 to 1.140)).ConclusionsAfter major abdominal surgery, higher postoperative pain scores on day 1 are associated with an increased risk of 30-day postoperative complications. Further studies should pursue whether optimization of perioperative analgesia can improve immune homeostasis, reduce complications after surgery and enhance postoperative recovery.

PurposeEarly postoperative bleeding is a common complication after laparoscopic Roux-en-Y gastric bypass (LRYGB) and is associated with significant morbidity. We aimed to identify predictors of early postoperative bleeding after LRYGB and characterize hemorrhagic events and 30-day postoperative outcomes.Material and MethodsWe conducted a retrospective cohort study regarding all patients submitted to LRYGB in 2019 at a high-volume obesity center. Early postoperative bleeding was defined as any clinically significant evidence of hemorrhage in the early postoperative period. Demographic, preoperative, and intraoperative factors were evaluated for associations with postoperative bleeding. Postoperative outcomes were compared between patients with and without hemorrhage.ResultsOf 340 patients submitted to LRYGB, 14 (4.1%) had early postoperative bleeding. Patients with bleeding had an increased preoperative left hepatic lobe diameter (8.4 vs. 7.3 cm, p = 0.048). Prior cholecystectomy (28.6 vs. 14.5%) and previous bariatric surgery (35.7 vs. 23.9%) tended to be more prevalent among these patients. Bleeding occurred at a median time of 31.2 [IQR 19.7–38.5] h. Thirteen patients presented with intraluminal bleeding and one with extraluminal bleeding. Melena was the most common symptom. All hemorrhages were clinically diagnosed, and 92.9% were managed conservatively. Postoperative bleeding was associated with longer hospital stay (3.5 vs. 2.0 days), higher reintervention (7.1 vs. 0%), and readmission (14.3 vs. 0%), all p < 0.05.ConclusionsBleeding was the most frequent early complication after LRYGB. Patients with hepatomegaly and prior surgeries may have technically challenging LRYGB and should be carefully assessed. Perioperative strategies should be encouraged in high-risk patients to prevent bleeding.

BackgroundNeuraxial anesthesia when compared with general anesthesia has shown to improve outcomes following lower extremity total joint arthroplasty. It is unclear whether these benefits are present in outpatient surgery given the selection of healthier patients.ObjectiveTo compare the effects of neuraxial versus general anesthesia on outcomes following ambulatory hip and knee arthroplasty.MethodsMulticentered retrospective cohort study in ambulatory hip or knee arthroplasty patients between January 2017 and December 2019. Primary endpoint examined 30-day major postoperative complications (mortality, myocardial infarction, deep venous thromboembolism, pulmonary embolism, stroke, and acute renal failure).ResultsOf 11 523 eligible patients identified, 10 003 received neuraxial anesthesia, while 1520 received general anesthesia. 30-day major complications did not differ between neuraxial anesthesia and general anesthesia groups (1.8% vs 2.3%; aOR=0.85, CI: 0.56 to 1.27, p=0.39). There was no difference in 30-day minor complications (surgical site infection, pneumonia, urinary tract infection; 3.3% vs 4.1%; aOR=0.83, CI: 0.62 to 1.14, p=0.23). The neuraxial group demonstrated reduced pain and analgesia requirements and had less postoperative nausea and vomiting (PONV). Median recovery room length of stay was shorter by 52 min in the general anesthesia group, but these patients were more likely to fail same day discharge (33% vs 23.4%; p<0.01).ConclusionAnesthesia type was not associated with an increased risk for complications. However, neuraxial anesthesia improved outcomes that predict readiness for discharge: patients had less pain, required less opioids, and had a lower incidence of PONV, thus improving the rate of same day discharge.Trial registration number NCT04203732.

Introduction In current study we assessed the effect of transcutaneous electrical acupoint stimulation (TEAS) on the quality of early recovery in patients undergoing gynecological laparoscopic surgery. Methods Sixty patients undergoing gynecological laparoscopic surgery were randomly assigned to TEAS (TEAS group) or control group (Con group). TEAS consisted of 30 min of stimulation (12–15 mA, 2/100 Hz) at the acupoints of Baihui (GV20), Yingtang (EX-HN-3), Zusanli (ST36) and Neiguan (PC6) before anesthesia. The patients in the Con group had the electrodes applied, but received no stimulation. Quality of recovery was assessed using a 40-item questionnaire as a measure of quality of recovery (QoR-40; maximum score 200) scoring system performed on preoperative day 1 (T0), postoperative day 1 (T1) and postoperative day 2 (T2); 100-mm visual analogue scale (VAS) scores at rest, mini-mental state examination (MMSE) scores, the incidence of nausea and vomiting, postoperative pain medications, and antiemetics were also recorded. Results: QoR-40 and MMSE scores of T0 showed no difference between two groups (QoR-40: 197.50 ± 2.57 vs. 195.83 ± 5.17), (MMSE: 26.83 ± 2.74 vs. 27.53 ± 2.88). Compared with the Con group, QoR-40 and MMSE scores of T1 and T2 were higher in the TEAS group ( P  < 0.05) (QoR-40: T1, 166.07 ± 8.44 vs. 175.33 ± 9.66; T2, 187.73 ± 5.47 vs. 191.40 ± 5.74), (MMSE: T1, 24.60 ± 2.35 vs. 26.10 ± 2.78; T2, 26.53 ± 2.94 vs. 27.83 ± 2.73). VAS scores of T1 and T2 were lower ( P  < 0.05) in the TEAS group (T1, 4.73 ± 1.53 vs. 3.70 ± 1.41; T2, 2.30 ± 0.95 vs. 1.83 ± 0.88); the incidence of postoperative nausea and vomiting (PONV), remedial antiemetics and remedial analgesia was lower in the TEAS group ( P  < 0.05) (PONV: 56.7% vs. 23.3%; incidence of remedial antiemetics: 53.3% vs. 23.3%; incidence of remedial analgesia: 80% vs. 43.3%). Conclusion The use of TEAS significantly promoted the quality of early recovery, improved MMSE scores and reduced the incidence of pain, nausea and vomiting in patients undergoing gynecological laparoscopic surgery. Trial registration ClinicalTrials.gov, NCT02619578. Registered on 2 December 2015. Trial registry name: https://clinicaltrials.gov

Background As societies age, increasing numbers of older adults undergo surgeries with anesthesia. Postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) frequently occur in older surgical patients. Most of these patients already have preoperative mild cognitive impairment (MCI). However, the correlation between MCI and POD remains unclear. This study aimed to determine the incidence of POD in elderly patients with and without preexisting MCI. Methods A prospective study enrolled patients aged 60 years and above scheduled for major surgeries between December 2017 and April 2022. Preoperative MCI was determined by a Montreal Cognitive Assessment (MoCA) score between 18 and 24. POD was diagnosed using criteria from the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). POCD was characterized by a MoCA score reduction of 2 or more points from the preoperative score. The primary outcome was the incidence of POD within the first 72 h postoperatively. Secondary outcomes encompassed other postoperative complications, including POCD. Results The study comprised 223 elderly patients with MCI and 56 without MCI. The incidence of POD was 16.6% in the MCI group and 14.3% in the non-MCI group ( P  = 0.839). POCD occurred in 24.3% of MCI patients and 50% of non-MCI patients ( P  = 0.001). There were no significant differences in other postoperative complications between the groups. Postoperatively, the MCI group notably declined in visuospatial, attention, and orientation domains, while the non-MCI group declined in all domains except delayed recall. Conclusions The incidence of POD was similar in the MCI and non-MCI groups. However, the non-MCI group demonstrated a higher incidence of POCD than the MCI group. This was identified by a reduction in postoperative MoCA scores for the visuospatial, naming, attention, language, abstraction, and orientation domains. These findings underscore the importance of postoperative cognitive assessments for both elderly patients with preexisting MCI and those with previously intact cognitive functions. Trial registration This trial was retrospectively registered in the Thai Clinical Trials Registry on 15/01/2019 (registration number: TCTR20190115001).

BackgroundThe population undergoing cardiac surgery confronts challenges from uncontrolled post-sternotomy pain, with possible adverse effects on outcome. While the parasternal block can improve analgesia, its coverage may be insufficient to cover epigastric area. In this non-blinded randomized controlled study, we evaluated the analgesic and respiratory effect of adding a rectus sheath block to a parasternal block.Methods58 patients undergoing cardiac surgery via median sternotomy were randomly assigned to receive parasternal block with rectus sheath block (experimental) or parasternal block with epigastric exit sites of chest drains receiving surgical infiltration of local anesthetic (control). The primary outcome of this study was pain at rest at extubation. We also assessed pain scores at rest and during respiratory exercises, opiate consumption and respiratory performance during the first 24 hours after extubation.ResultsThe median (IQR) maximum pain scores (on a 0–10 Numeric Rate Scale (NRS)) at extubation were 4 (4, 4) in the rectus sheath group and 5 (4, 5) in the control group (difference 1, p value=0.03). Rectus sheath block reduced opioid utilization by 2 mg over 24 hours (IC 95% 0.0 to 2.0; p<0.01), reduced NRS scores at other time points, and improved respiratory performance at 6, 12, and 24 hours after extubation.ConclusionThe addition of a rectus sheath block with a parasternal block improves analgesia for cardiac surgery requiring chest drains emerging in the epigastric area.Trial registration numberNCT05764616.

Purpose To investigate the association between intravenous methylprednisolone administration and the risk of surgical site infection (SSI) following posterior lumbar fusion (PLF) surgery. Methods This retrospective, single-center study analyzed data from 800 adult patients who underwent elective PLF surgery at our institution. Patients were classified according to postoperative intravenous methylprednisolone administration. Univariate and multivariable logistic regression, and subgroup analysis were used to assess the association between methylprednisolone administration and SSI risk, as well as its impact on postoperative pain management. Results Our analysis showed no significant association between intravenous methylprednisolone administration and the development of a SSI after PLF. Subgroup analyses suggested that methylprednisolone was potentially protective in patients with a body mass index (BMI) < 25 kg/m 2 . In addition, patients treated with methylprednisolone had significantly lower pain scores in the early postoperative period, and lower incidence of postoperative nausea and vomiting (PONV) compared to patients not treated with methylprednisolone. However, there was no significant difference in pain scores between the 2 groups at 4 weeks postoperatively. Conclusions This study suggests that intravenous methylprednisolone administration may not increase the risk of SSI after single-level PLF. In addition, it appears to have a beneficial effect on postoperative pain management and PONV, especially during the early recovery phase.