Opioid-free general anesthesia works for ENT surgery

Last Updated: 2017-10-24

By Megan Brooks

NEW YORK (Reuters Health) - Using opioid alternatives during general anesthesia for ear, nose and throat surgeries is safe and effective - and reduces the occurrence of post-surgery nausea, report clinicians from TEAMHealth Anesthesia at Select Physicians Surgery Center in Tampa, Florida.

"The opioid-free general anesthesia technique is standard of care at our ENT ambulatory surgery center. Surgeries include tonsillectomy, inner ear surgery, facial plastic surgery and sinus surgery. We have now done nearly 2,000 patients using the technique," Dr. David Samuels, anesthesiologist and medical director for TEAMHealth Anesthesia, told Reuters Health by email.

Fentanyl and other opioids are usually included in the bundle of medications given to patients for general anesthesia during surgery. But they have many side effects including respiratory depression, sedation, nausea/vomiting, constipation and ileus.

Dr. Samuels and colleagues reviewed their experience providing opioid-free intraoperative general anesthesia services to 19 surgeons for 1,009 consecutive patients undergoing head and neck procedures including laryngoscopy, complex facial plastic surgery, middle-ear surgery and nasal or sinus surgery. Instead of opioids, patients received various combinations of magnesium, ketamine, lidocaine and ketorolac, depending on the patient's age and health.

Surgeons and patients reported a high degree of satisfaction with the opioid-free anesthesia protocol as well as with postoperative pain management, according to results presented October 23 in Boston at the American Society of Anesthesiologists annual meeting.

Following surgery, only 11% of patients had nausea, far less than the 50% to 80% of patients who typically experience nausea after surgery, the clinicians point out. In addition, only about a third of patients (36%) requested oral opioid medications for pain in the post-anesthesia care unit.

The benefits to patients of opioid-free general anesthesia are numerous, Dr. Samuels told Reuters Health. "They have less pain in the recovery room and dramatically less opioid-related side effects such as nausea, vomiting, respiratory depression. We also feel that we are making a difference in the opioid epidemic. Many of our patients come to us opioid-naive. As many as 6% to 8% of patients who have major or minor surgery remain on opioids for more than 6 months postop. By keeping opioid-naive patients opioid-naive, we keep patients from the road to addiction," he said.

Dr. Samuels believes other centers can adopt a similar policy. He is in the early stages of developing a program within TeamHealth Anesthesia to do this. "It takes a period of education to surgeons, anesthesiologists, nurse anesthetists, recovery room nursing and patients about the dangers of ubiquitous use of opioids," he said.

"It requires a paradigm shift to no longer give a potent opioid such as fentanyl ubiquitously during general anesthesia," Dr. Samuels added. "Paradoxically, it turns out that potent opioids can lead to increased pain; referred to as opioid induced hyperalgesia. Once the team observes the dramatic results seen in the recovery room the transition occurs quite readily. Of interest, one of the surgeons I work with was initially adamant that all of his patients receive opioids in the operating room. He is now one of the most vocal advocates of the technique."

Dr. Samuels also thinks opioid-free general anesthesia can work for non-ENT surgeries. "I believe the technique can be utilized for nearly any surgery. Two years ago I visited a hospital in Belgium, where the technique is used on various surgeries including bariatric surgery, neurosurgery, back surgery, etc."

The study had no funding, and the authors have no disclosures.

SOURCE: http://bit.ly/29ry2H8

American Society of Anesthesiologists 2017.