Opioid free anesthesia (OFA) is deffined as anaesthesiological technique where opioids are not used in the intraoperative period (systemic, neuroaxial or intracavitary). Anaphylaxis caused by opioids (fentanyl) is very rare, and the reaction is presented with hypotension and urticaria. When we have proven allergy to fentanyl, patients’ refusal of placing epidural catheter and refusal of receiving bilateral ultrasound guided transversus abdominis plane block (USG TAPB), we must think of using multimodal nonopioide analgesia. The concept of multimodal balanced analgesia is consisted of giving different analgesic drugs in purpose to change the pathophysiological process which is included in nociception, in way to receive more effective intraoperative analgesia with less adverse effects. This is a case report of a 60-year-old male patient scheduled for laparotomic hemicolectomy, who previously had proven allergy to fentanyl. We have decided to give him an opioid free anaesthesia. Before the induction to anaesthesia, the patient would receive dexamethasone (dexasone) 0.1 mg/kg and paracetamol 1 gr intravenously. The patient was induced into general endotracheal anesthesia according to a standardized protocol, with midazolam 0.04 mg/kg, lidocaine hydrochloride 1 mg/kg, propofol 2 mg/kg and rocuronium bromide 0.6 mg/kg. Anaesthesia was maintained by using sevoflurane MAC 1 in order to maintain mean arterial pressure (MAP) with a value of +/- 20% of the original value. After tracheal intubation, the patient had received ketamine hydrochloride 0.5 mg/kg (or 50 mg ketamine) in bolus intravenously and a continuous intravenous infusion with lidocaine hydrochloride (lidocaine) 2 mg/kg/hr and magnesium sulfate (MgSO4) 1,5 gr/hr. At the end of surgery the continuous intravenous infusion with lidocaine and magnesium sulfate was stopped while the abdominal wall was closed and 2.5 g of metamizole (novalgetol) was given intravenously. VAS score 2 hours after surgery was 6/10 and 1 gr of paracetamol was given and the patient was transferred to the Department. Over the next 3 days, the patient had a VAS score of 4-6/10 and only received paracetamol 3x1g and novalgetol 3x1 gr daily, every four hours.
If the inline PDF is not rendering correctly, you can download the PDF file here.
1. Mulier JP. Why and how to give opioid free anaesthesia (OFA). The Bruges approach. American Society of Anesthesiologists Annual meeting New Orleans 2016.
2. Samuels D Abou-Samra A Dalvi P Mangar D Camporesi EM. Opioid-free Anesthesia Results in Reduced Post-operative Opioid Consumption. J Clin Anesth Pain Med 2017; 1(2): 13.
3. Feldheiser A Aziz O Baldini G Cox BP Fearon KC Feldman LS et al. Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery part 2: Consensus statement for anesthesia practice. Acta Anaesthesiol Scand 2016; 60: 289–334.
4. Oderda GM Evans RS Lloyd J Lipman A Chen C Ashburn M Burke J Samore M. Cost of opioid-related adverse drug events in surgical patients. Journal of pain and symptom management. 2003 Mar 31; 25(3): 276–83.
5. Velayudhan A Bellingham G Morley-Forster P. Opioid-induced hyperalgesia. Continuing Education in Anaesthesia Critical Care & Pain. 2013 Sep 26: mkt045.
6. Sacerdote P Franchi S Panerai AE. Non-analgesic effects of opioids: mechanisms and potential clinical relevance of opioid-induced immunodepression. Curr Pharm Des. 2012; 18(37): 6034–42.
7. Tomar GS Tiwari AK Chawla S Mukherjee A Ganguly S. Anaphylaxis related to fentanyl citrate. J Emerg Trauma Shock. 2012; 5(3): 257–261.
8. Patil SK Anitescu M. Opioid-Free Perioperative Analgesia for Hemicolectomy in a Patient With Opioid-Induced Delirium: A Case Report and Review of the Analgesic Efficacy of the Alpha-2 Agonist Agents. Pain Practice 2012; 12(8): 656–62.
9. Arain SR Ruehlow RM Uhrich TD Ebert TJ. The efficacy of dexmedetomidine versus morphine for postoperative analgesia after major inpatient surgery. Anesth Analg 2004; 98(1): 153–8.
10. Collard V Mistraletti G Taqi A Asenjo JF Feldman LS Fried GM Carli F. Intraoperative esmolol infusion in the absence of opioids spares postoperative fentanyl in patients undergoing ambulatory laparoscopic cholecystectomy. Anesth Analg 2007; 105(5):1255–62.
11. Fabricio TM Mariana CR Jordana AA Luise AC. Systemic Lidocaine for Perioperative Analgesia: A Literature Review. Short name. J Anest&Inten Care Med 2015; 1 (1): JAICM. MS.ID.55551.
12. Vigneault L Turgeon AF Côté D Lauzier F Zarychanski R Moore L McIntyre LA Nicole PC Fergusson DA. Perioperative intravenous lidocaine infusion for postoperative pain control: a meta-analysis of randomized controlled trials. Can J Anesth 2011; 58(1): 22–37.
13. Bakan M Umutoglu T Topuz U Uysal H Bayram M Kadioglu H Salihoglu Z. Opioid-free total intravenous anesthesia with propofol dexmedetomidine and lidocaine infusions for laparoscopic cholecystectomy: a prospective randomized double-blinded study. Rev Bras Anestesiol 2015; 65(3): 191–9.
14. Grape S Tramèr MR. Do we need preemptive analgesia for the treatment of postoperative pain? Best Pract Res Clin Anaesthesiol. 2007; 21: 51–63.
15. Arslan M Celep B Çiçek R Kalender HÜ Yilmaz H. Comparing the efficacy of preemptive intravenous paracetamol on the reducing effect of opioidusage in cholecystectomy. J Res Med Sci. 2013 Mar; 18(3): 172–177.
16. De Oliveira GS Almeida MD Benzon HT Mc-Carthy RJ. Perioperative Single Dose Systemic Dexamethasone for Postoperative pain: A Meta-analysis of Randomized Controlled Trials. The Journal of the American Society of Anesthesiologists 2011; 115(3): 575–88.
17. Waldron NH Jones CA Gan TJ Allen TK Habib AS. Impact of perioperative dexamethasone on postoperative analgesia and side-effects: systematic review and meta-analysis. Br J Anaesth 2013; 110(2): 191–200.
18. Loftus RW Yeager MP Clark JA Brown JR Abdu WA Sengupta DK Beach ML. Intraoperative ketamine reduces perioperative opiate consumption in opiate-dependent patients with chronic back pain undergoing back surgery. The Journal of the American Society Of Anesthesiologists. 2010 Sept 1; 113(3): 639–46.
19. Thomas M Tennant I Augier R Gordon-Strachan G Harding H. The role of pre-induction ketamine in the management of postoperative pain in patients undergoing elective gynaecological surgery at the University Hospital of the West Indies. West Indian Med J 2012; 61(3): 224–9.
20. Garcia-Navia JT Tornero López J Egea-Guerrero JJ Vilches Arenas Á Vásquez Gutiérrez T. Effect of a single dose of lidocaine and ketamine on intraoperative opioids requirements in patients undergoing elective gynecological laparotomies under general anesthesia. A randomized placebo controlled pilot study. Farm Hosp 2016; 40(1): 44–51.
21. Harvey KP Adair JD Isho M Robinson R. Can intravenous lidocaine decrease postsurgical ileus and shorten hospital stay in elective bowel surgery? A pilot study and literature review. Am J Surg 2009; 198(2): 231–6.
22. Levaux CH Bonhomme V Dewandre PY Brichant JF Hans P. Effect of intra-operative magnesium sulphate on pain relief and patient comfort after major lumbar orthopaedic surgery. Anaesthesia 2003; 58(2): 131–5.
23. Viscomi CM. Postoperative analgesia: elements of successful recovery. Anesthesiology. 2013: 55(25).
24. Ryu JH Kang MH Park KS Do SH. Effects of magnesium sulphate on intraoperative anaesthetic requirements and postoperative analgesia in gynaecology patients receiving total intravenous anaesthesia. Br J Anaesth 2008; 100(3): 397–403.
25. Hodgson E. Sticky concepts in anaesthetic practice. FMM. 2015.
26. Mulier JP. Perioperative opioids aggravate obstructive breathing in sleep apnea syndrome: mechanisms and alternative anesthesia strategies. Current Opinion in Anesthesiology. 2016; 29(1): 129–33.