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CASE REPORT
Year : 2022  |  Volume : 15  |  Issue : 3  |  Page : 418-420  

Opioid-free anesthesia for patient undergoing breast cancer surgery: A case series


Department of Onco-Anaesthesia and Palliative Medicine, Dr. BRAIRCH, All India Institute of Medical Sciences, New Delhi, India

Date of Submission26-Sep-2020
Date of Decision19-Apr-2021
Date of Acceptance29-Jul-2021
Date of Web Publication28-Jan-2022

Correspondence Address:
Nishkarsh Gupta
Room No. 139, 1st Floor, Department of Onco-Anaesthesia and Palliative Medicine, Dr. BRAIRCH, AIIMS, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_543_20

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  Abstract 


Opioid-based anesthesia is associated with unwanted adverse effects such as postoperative nausea and vomiting, respiratory depression, itching, and urinary retention. Opioid-free anesthesia is a combination of multimodal analgesia that aims to avoid perioperative opioids altogether. Various methods, such as regional blocks, and drugs, such as lignocaine, dexmedetomidine, and ketamine, can be used to evade the use of opioids. Here, in a series of five cases undergoing breast cancer surgery, we attempt to use a combination of analgesic techniques that result in complete avoidance of opioids during the intraoperative period.

Keywords: Case series, oncosurgery, opioid-free anesthesia


How to cite this article:
Sarma R, Gupta N, Kumar V, Bharati SJ. Opioid-free anesthesia for patient undergoing breast cancer surgery: A case series. Med J DY Patil Vidyapeeth 2022;15:418-20

How to cite this URL:
Sarma R, Gupta N, Kumar V, Bharati SJ. Opioid-free anesthesia for patient undergoing breast cancer surgery: A case series. Med J DY Patil Vidyapeeth [serial online] 2022 [cited 2022 May 21];15:418-20. Available from: https://www.mjdrdypv.org/text.asp?2022/15/3/418/336712




  Introduction Top


Breast cancer accounts for around 25%–32% of all female cancers in India.[1] Inadequate postoperative pain control can lead to chronic pain after breast surgery. Although opioid-based analgesia is the mainstay to control pain during intraoperative anesthesia and postoperative recovery period, they have various side effects including respiratory depression, postoperative nausea, vomiting, urinary retention, etc., Their potential role in cancer recurrence has also been studied.[2] Recently, there has been a shift toward anesthesia without administering intraoperative systemic, neuraxial, or intracavitary opioids or opioid-free anesthesia (OFA) to achieve the goals of hypnosis with amnesia and sympathetic stability without the adverse effects of opioids.[3],[4] We present a series of five cases where OFA was successfully used in patients undergoing breast cancer surgery.


  Case Report Top


All the cases were female out of which four underwent modified radical mastectomy and one underwent breast conservation surgery with axillary lymph node dissection. Written informed consent was taken from all of them 1 day before surgery during preanesthetic check-up. They were kept nil per orally as the per American Society of Anesthesiologists (ASA) guidelines.

After taking the patients inside operation theater, ASA standard monitors were attached along with bispectral index (BIS). Baseline readings of heart rate (HR), blood pressure and arterial oxygen saturation, and BIS were noted. A peripheral venous line was secured through 20 gauge cannula and intravenous (IV) infusion with plasmalyte initiated. Erector spinae plane block (ESPB) was given in all cases before induction in lateral position. Under all aseptic precautions, a linear ultrasound (USG) transducer (7–12 MHz) probe was placed in a longitudinal orientation, about 2.5–3 cm lateral to the T5 spinous process. The puncture site was infiltrated subcutaneously with 1–2 ml of 2% lignocaine. A 10 cm stimuplex needle (B. Braun Medical Inc) was inserted in a cephalad-to-caudal direction until the tip lay in the interfascial plane between erector spinae muscle and the transverse process. Thirty milliliters of 0.5% ropivacaine was injected after negative aspiration and its spread was confirmed under USG [Figure 1]. Dexmedetomidine infusion 0.5 μg/kg/h was initiated 10 min before induction and continued between 0.3 and 0.7 μg/kg/h based on intraoperative hemodynamics. Magnesium sulfate 40 mg/kg was infused slowly over 10 min after induction in all patients. Anesthesia was induced with propofol 1–2 mg/kg and patient received rocuronium for neuromuscular blockade. After ventilation for three minutes, size three I-gel supraglottic airway was inserted. Intraoperatively, the BIS values were kept in between 50 and 60. In cases one, two, and four, the BIS increased to more than 60 with an increase in HR increased above 20% of baseline. Hence, sevoflurane concentration was increased to maintain anesthesia depth till BIS value was <60. In case three and five, tachycardia occurred with normal BIS range which settled with increase in dexmedetomidine infusion to 1 μg/kg/h in case five. In case three, ketamine 10 mg IV was given in addition to increasing dexmedetomidine infusion to control the HR.
Figure 1: Ultrasound view showing the anatomical landmarks during erector spinae plane block (TP: transverse process, TZ: Trapezius muscle, RMM: Rhomboideus major muscle, ESM: Erector spinae muscle, the arrow points at the pleura)

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All patients received paracetamol 1 g IV intraoperatively. Dexmedetomidine was switched off 10–15 min before skin closure. All the patients were extubated immediately in the operation room.

Postoperative pain measured in numerical rating scale (NRS) (NRS 0–10: 0 – no pain and 10 – worst imaginable pain) showed that it remained <4 at rest and on ipsilateral arm abduction at 90 degrees at immediate and 1 h after extubation [Table 1]. No patient required any extra analgesics apart from paracetamol 1 g given 8 h in the postoperative period. There was no episode of respiratory depression, nausea vomiting, or pruritus in any patient. The patients were discharged the next day from the hospital.
Table 1: Summarizing patients' characteristics

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  Discussion Top


This case series shows that OFA using ESPB with dexmedetomidine infusion is safe, opioid-sparing, and feasible option that provides good perioperative analgesia to the patient.

At present, opioids are the mainstay for intraoperative pain management. Extensive use of opioids is associated with various side effects such as itching, urinary retention, respiratory depression, and postoperative nausea and vomiting. Moreover, in recent years, the use of opioids has been linked to influence cancer recurrence.[2]

Various studies have been done till now in search of an ideal anesthetic technique for breast surgery which provides good analgesia, permits early mobilization, and discharges without any complications. Acute postoperative pain due to poorly controlled intraoperative analgesia is a major risk factor for the development of chronic postsurgical pain. This condition includes paresthesia, intercostobrachial neuralgia, and phantom breast pain and affects about 20%–50% of patients undergoing breast surgery.[5] Various modalities that have been used for pain management in the perioperative period include systemic analgesics such as opioids, nonsteroidal anti-inflammatory drugs or paracetamol with or without regional blocks.

Perioperatively, a stress-free anesthesia is required to block the sympathetic system to achieve hemodynamic and physiologic stability. Drugs such as alpha 2 agonists (clonidine and dexmedetomidine), locoregional anesthetics given intravenously (lidocaine and procaine), magnesium, and gamma-aminobutyric acid modulators (gabapentin) attenuate the sympathetic system. A combination of these drugs may help us minimize the use of opioids. This technique attempts to combine the beneficial effects of multiple analgesics to achieve a synergistic effect of their different modes of action.

Mulier first popularized this OFA technique in Europe, especially in bariatric surgery cases.[3],[6] There have been reports of abdominal surgeries being conducted by the use of OFA technique with and without using alpha-2 agonists.[7],[8] Hontoir et al. also found that an opioid-free approach in patients undergoing breast surgery improved postoperative recovery.[9] Another study compared opioid free, nerve block-based anesthesia with opioid-based general anesthesia for breast cancer surgery and found that nonopioid nerve block technique is adequate and safe for modified radical mastectomy (MRM) with axillary clearance.[10]

The use of dexmedetomidine which is a selective alpha 2 adrenoceptor agonist decreases the postoperative analgesia requirement and other side effects of opioids such as nausea and vomiting. Its adverse effect like sedation can be mitigated by stopping it well before reversal of muscle relaxant and awakening the patient. Furthermore, the use of ESP block deposits local anesthetics closer to dorsal and ventral rami and covers dermatomes from T2-T9 resulting in superior pain relief.[11] This agrees with the goals of ERAS (enhanced recovery after surgery) protocol which is to provide optimal analgesia that facilitates early recovery and minimizes adverse effect of opioids.[12] OFA has the potential to become an alternative standard of anesthesia practice.


  Conclusion Top


Although opioids are still the basis of general anesthesia, the above case series demonstrates that opioid-free anesthesia can be a considered an effective substitute. Randomized control trial with a large sample size is required to define the impact of such an anesthetic strategy. Till then, a multimodal OFA technique may be designed that can be individualized by anesthetist on a case-to-case basis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Population Based Cancer Registry. National Cancer Registry Programme (NCRP), Indian Council of Medical Research (ICMR). Available from: http://www.ncrpindia.org/. [Last accessed on 2020 Jun 30].  Back to cited text no. 1
    
2.
Afsharimani B, Cabot P, Parat MO. Morphine and tumor growth and metastasis. Cancer Metastasis Rev 2011;30:225-38.  Back to cited text no. 2
    
3.
Mulier J. Opioid free general anesthesia: A paradigm shift?. Rev Esp Anestesiol Reanim. 2017;64:427-30.  Back to cited text no. 3
    
4.
Sultana A, Torres D, Schumann R. Special indications for opioid free anaesthesia and analgesia, patient and procedure related: Including obesity, sleep apnoea, chronic obstructive pulmonary disease, complex regional pain syndromes, opioid addiction and cancer surgery. Best Pract Res Clin Anaesthesiol 2017;31:547-60.  Back to cited text no. 4
    
5.
Gärtner R, Jensen MB, Nielsen J, Ewertz M, Kroman N, Kehlet H. Prevalence of and factors associated with persistent pain following breast cancer surgery. JAMA 2009;302:1985-92.  Back to cited text no. 5
    
6.
Hofer RE, Sprung J, Sarr MG, Wedel DJ. Anesthesia for a patient with morbid obesity using dexmedetomidine without narcotics. Can J Anaesth 2005;52:176-80.  Back to cited text no. 6
    
7.
Veiga de Sa A, Cavaleiro C, Campos M. Haemodynamic and analgesic control in a perioperative opioi-free approach to bariatric surgery-A case report. Indian J Anaesth 2020;64:141-4.  Back to cited text no. 7
    
8.
Toleska M, Dimitrovski A. Is an opioid-free anaesthesia possible without using alpha-2 agonists? Indian J Anaesth 2020;64:428-31.  Back to cited text no. 8
  [Full text]  
9.
Hontoir S, Saxena S, Gatto P, Khalife M, Ben Aziz AM, Paesmans M, et al. Opioid-free anesthesia: What about patient comfort? A prospective, randomized, controlled trial. Acta Anaesthesiol Belg 2016;67:183-90.  Back to cited text no. 9
    
10.
Tripathy S, Rath S, Agrawal S, Rao PB, Panda A, Mishra TS, et al. Opioid-free anesthesia for breast cancer surgery: An observational study. J Anaesthesiol Clin Pharmacol 2018;34:35-40.  Back to cited text no. 10
[PUBMED]  [Full text]  
11.
Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block: A novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med 2016;41:621-7.  Back to cited text no. 11
    
12.
Arsalani-Zadeh R, ElFadl D, Yassin N, MacFie J. Evidence-based review of enhancing postoperative recovery after breast surgery. Br J Surg 2011;98:181-96.  Back to cited text no. 12
    


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