Opioid-free total intravenous anesthesia or opioid-free inhalational anesthesia with sevoflurane provide effective and safe anesthesia for bariatric surgery, with comparable pain control and opioid-sparing effects.
Abstract
Background
Opioid-free anesthesia (OFA) is increasingly used in bariatric surgery to prevent opioid-related adverse effects. Although both propofol-based total intravenous anesthesia (TIVA) and volatile anesthesia with sevoflurane are compatible with OFA protocols, their relative opioid-free effectiveness is unclear.
Methods
In this single-center randomized controlled trial, 256 patients undergoing laparoscopic sleeve gastrectomy received either OFA with TIVA (propofol via Schnider TCI model) or OFA with sevoflurane. Both groups received identical nonopioid adjuncts (lidocaine, ketamine, dexmedetomidine). The primary outcome was the incidence of postoperative nausea and vomiting (PONV) within 24 h. Secondary outcomes included pain scores, opioid consumption, hemodynamic stability, and emergence characteristics.
Results
The primary endpoint, postoperative nausea and/or vomiting within 24 h, did not differ between groups and occurred in 80/123 patients (65.0%) in the Sevo group and 86/133 patients (64.7%) in the TIVA group (difference 0.4% points, 95% CI - 11.2 to 11.9; p = 1.000). Rates of postoperative nausea (65.0% vs. 63.2%; p = 0.855) and vomiting (25.2% vs. 26.3%; p = 0.952) were likewise similar. Postoperative pain scores and 24-hour opioid consumption were low and comparable. Hemodynamic events and rescue analgesic requirements were similar. However, prolonged emergence (> 10 min) was more frequent in the TIVA group than in the Sevo group (22.6% vs. 12.2%; difference 10.4% points, 95% CI 1.0 to 19.5; p = 0.044).
Conclusion
Opioid-free total intravenous anesthesia or opioid-free inhalational anesthesia with sevoflurane provide effective and safe anesthesia for bariatric surgery, with comparable pain control and opioid-sparing effects. High PONV incidence persists despite OFA, underscoring the need for enhanced prophylaxis. Emergence was modestly slower with TIVA, which may be related to known limitations of conventional target-controlled infusion models in patients with severe obesity and warrants further study.
TRIAL REGISTRATION
The study was registered at ClinicalTrials.gov (NCT06390046). The record was first posted on April 29, 2024 and the first participant was enrolled on April 30, 2024.
Background
The intraoperative co-administration of lidocaine and dexmedetomidine has been proposed as an opioid-sparing strategy; however, its effectiveness as an intraoperative multimodal analgesia (MMA) strategy remains unclear. We evaluated its effect on postoperative opioid consumption in patients undergoing major laparoscopic gynecologic surgery.
Methods
We conducted a randomized controlled trial comparing intraoperative placebo with lidocaine-dexmedetomidine co-administration in patients undergoing major laparoscopic gynecologic surgery within a standardized Enhanced Recovery after Surgery (ERAS) pathway. Patients were assigned to receive intraoperative placebo or lidocaine at 1.5 mg/kg/h co-administered with dexmedetomidine at either 0.4 or 0.7 μg/kg/h. The primary outcome was 24-h cumulative opioid consumption.
Results
Twenty-four-hour cumulative opioid consumption differed significantly between the groups (P = 0.004). Median morphine-equivalent dose was 16.6 mg (12.1, 22.3) in the control group, 11.3 mg (8.1, 19.5) in the lidocaine-dexmedetomidine 0.4 group, and 11.1 mg (6.8, 16.5) in the 0.7 group, corresponding to relative reductions of 32% and 33% in median consumption, respectively. Both dexmedetomidine doses (0.4 and 0.7 μg/kg/h), when co-administered with lidocaine, were associated with significantly lower opioid consumption than the control group, with no significant differences between the two doses. Pain scores during mobilization were lower in both treatment groups during the first 48 h postoperatively, without an increase in adverse events.
Conclusion
Intraoperative co-administration of lidocaine and dexmedetomidine effectively reduced postoperative opioid consumption and pain during mobilization as an intraoperative MMA strategy within an ERAS pathway. The higher dexmedetomidine dose provided no additional opioid-sparing benefit during the first 24 postoperative hours.
Yu Jeong Bang, Justin Sangwook Ko, R. Kang et al.· Korean Journal of Anesthesio...· 0 citations
Introduction: Opioid-Based Anesthesia (OBA) is a common standard; it carries risks like post-operative nausea and vomiting (PONV) and respiratory issues. Opioid-Free Anesthesia (OFA) offers an alternative that may improve recovery quality, but its efficacy relative to OBA requires more evidence.
Objective: This systematic review aims to compare the effectiveness between OFA and OBA on post anesthesia recovery outcomes.
Methods: This systematic review followed the PRISMA 2020. Article searches were conducted via PubMed, ScienceDirect, SpringerLink, and Wiley using appropriate keywords. Five randomized controlled trials meeting the inclusion criteria were analyzed and assessed for risk of bias using the Cochrane RoB 2 tool.
Results: OFA significantly reduced the incidence of PONV across all studies. OFA also demonstrated equivalent or better analgesia quality in the early postoperative period with lower rescue opioid consumption and showed good hemodynamic stability. However, no significant difference was found in the duration of surgery between the two groups.
Conclusion: OFA shows potential as a superior anesthetic strategy compared to OBA in aspects of postoperative recovery, particularly in reducing PONV and additional opioid consumption without compromising analgesia quality. The implementation of OFA has the potential to be integrated into Enhanced Recovery After Surgery (ERAS) protocols. Further studies with larger samples and standardized protocols are needed to strengthen these findings.
Dewi Ainur Rohmah, M. Lestari, Emma Novita· Indonesian Journal of Anesth...· 0 citations
Background Opioid-free anesthesia (OFA) has been proposed to reduce opioid-related adverse effects, although its impact on overall postoperative recovery remains uncertain. We evaluated whether OFA improves postoperative quality of recovery compared with opioid-based anesthesia (OA) in elderly patients undergoing laparoscopic abdominal surgery. Methods In this single-center randomized controlled trial, 200 patients aged ≥60 years undergoing elective laparoscopic abdominal surgery were randomized to receive either OFA (dexmedetomidine, esketamine, and lidocaine) or conventional OA. The primary outcome was quality of recovery measured using the QoR-15 questionnaire at 24 h after surgery. Secondary outcomes included postoperative nausea and vomiting (PONV), pain scores, opioid consumption, gastrointestinal recovery, sleep quality, chronic postsurgical pain, hemodynamic events, extubation time, PACU length of stay, and hospital length of stay. Results A total of 195 patients completed the study (OFA, n = 98; OA, n = 97). QoR-15 scores at 24 h were higher in the OFA group (110 ± 12 vs. 106 ± 15, mean difference 4 points, 95% CI 2–8; p = 0.002). However, the observed difference was below the prespecified threshold for clinical significance and was no longer present at 48 or 72 h. OFA reduced the incidence of PONV during the first 72 postoperative hours and modestly reduced postoperative opioid consumption. Gastrointestinal recovery occurred earlier with OFA, whereas pain scores were largely similar between groups except during the immediate PACU period. OFA was associated with longer extubation times, prolonged PACU stay, and a higher incidence of intraoperative hypertension. Hospital length of stay and postoperative delirium were similar between groups. Although chronic postsurgical pain at 3 months was less frequent in the OFA group, this secondary finding should be considered exploratory. Conclusion In elderly patients undergoing laparoscopic abdominal surgery, OFA reduced postoperative nausea and vomiting and modestly accelerated gastrointestinal recovery. However, it did not result in a clinically meaningful improvement in overall postoperative recovery as measured by the QoR-15 and was associated with delayed emergence, prolonged PACU stay, and more frequent intraoperative hypertension. These findings suggest that the principal benefit of OFA in this setting may be reduction of opioid-related adverse effects rather than substantial enhancement of global postoperative recovery.
Qianchuan Zhao, Yang Wang, Fujian Huang et al.· Frontiers in Medicine· 0 citations
Introduction Propofol-based total intravenous anesthesia (TIVA) with remifentanil is widely used for general anesthesia but is frequently associated with hypotension and bradycardia. Remimazolam, an ultra–short-acting benzodiazepine, provides rapid onset and offset, with the additional advantage of reversal by flumazenil, and may result in less hemodynamic depression. Previous randomized studies have largely focused on the induction phase or the incidence of hypotension, with limited data on continuous intraoperative hemodynamic changes during laparoscopic gynecologic surgery. The study is designed to compare prospectively the intraoperative hemodynamic profiles of remimazolam-based versus propofol-based TIVA in patients undergoing robotic gynecologic surgery in the Trendelenburg position. Methods and Analysis This prospective, single-center, randomized, single-blind, parallel-group superiority trial will be conducted at CHA Ilsan Medical Center, a secondary care university-affiliated hospital. In total, 58 adult patients (aged 19–65 years, American Society of Anesthesiologists physical status I–II) scheduled for elective robotic laparoscopic hysterectomy under general anesthesia will be enrolled and randomly assigned (1:1) to receive either remimazolam- or propofol-based total intravenous anesthesia, both in combination with remifentanil. Continuous invasive mean arterial pressure (MAP) will be monitored using a FloTrac™ sensor (Edwards Lifesciences, Irvine, CA, United States). The primary outcome will be the time-weighted average MAP (TWA-MAP), analyzed using analysis of covariance adjusted for baseline MAP. Secondary outcomes will include the area under the curve for hypertensive and hypotensive burden, as well as the incidence of adverse hemodynamic events, including hypotension, hypertension, bradycardia, and tachycardia. Generalized estimating equations (GEE) will be used to evaluate hemodynamic and respiratory parameters across predefined time points. Discussion This trial is expected to provide prospective, randomized evidence to compare continuous intraoperative blood-pressure trajectories between remimazolam- and propofol-based TIVA during robotic gynecologic surgery. It is anticipated that the findings will clarify the relative hemodynamic stability of these anesthetic agents under the combined physiological challenges of Trendelenburg positioning and pneumoperitoneum. The findings may inform anesthetic drug selection and intraoperative blood pressure management strategies, enhancing cardiovascular stability and improving postoperative outcomes. Clinical Trial Registration ClinicalTrials.gov, identifier NCT07251101.
Jung-Min Lee, Joohyun Lee, S. Kang et al.· Frontiers in Pharmacology· 0 citations
OBJECTIVE
To evaluate whether an opioid-sparing anesthesia strategy (OSA), based on opioid-free anesthesia (OFA), improves early postoperative recovery quality and optimizes functional outcomes after total knee arthroplasty (TKA), compared with conventional opioid-based anesthesia (OBA).
DESIGN
A randomized controlled trial with blinding of patients, surgeons, and outcome assessors.
SETTING
Single center, July 2025 to February 2026.
PATIENTS
98 adult patients scheduled for elective unilateral TKA.
INTERVENTION
Patients were randomized to the OSA or OBA group. The OSA regimen used esketamine and dexmedetomidine as the primary analgesic backbone, whereas the OBA regimen was opioid-based. Both groups received preoperative femoral nerve block and were administered oxycodone at skin incision and closure. Postoperatively, both groups received the same multimodal analgesia and patient-controlled analgesia.
MEASUREMENTS
The primary outcome was the 24-h postoperative Quality of Recovery-15 (QoR-15) score. Secondary outcomes included 48-h QoR-15; Oxford Knee Score (OKS) and EQ-5D-3L at 1 and 3 months; high pain at 1 month and chronic postsurgical pain at 3 months. Exploratory outcomes included postoperative C-reactive protein (CRP), and postoperative nausea and vomiting (PONV), among others.
RESULTS
At 24 h postoperatively, QoR-15 was higher in the OSA group than in the OBA group (118.4 ± 11.5 vs 113.3 ± 12.2; adjusted difference 5.12, 95% CI 0.51-9.74; P = 0.029), and this advantage persisted at 48 h (adjusted difference 5.54, 95% CI 1.57-9.52; P = 0.007). The OSA group had a lower incidence of PONV (P = 0.025) and lower postoperative CRP levels (P = 0.001). At 1 month, OKS was higher in the OSA group (adjusted difference 2.31, 95% CI 0.34-4.27; P = 0.022), with no significant differences in other secondary outcomes.
CONCLUSION
In TKA, this OFA-based OSA strategy improved early postoperative QoR-15 scores. However, the QoR-15 difference did not reach the minimal clinically important difference, so its clinical relevance remains uncertain.
Jingwang Liu, Jiaxin Liu, Peng Liu et al.· Journal of clinical anesthes...· 0 citations
Abstract Background Postoperative nausea and vomiting (PONV) is common after craniotomy, and the prevalence is much higher after infratentorial surgeries. Total intravenous anesthesia (TIVA) has been widely reported to reduce PONV compared with inhalation anesthesia (INHA). However, randomized controlled clinical trials on the incidence of PONV following infratentorial craniotomies are inconclusive. This study assessed the effect of TIVA with propofol and fentanyl compared with INHA with sevoflurane and fentanyl on PONV after infratentorial craniotomies. Materials and Methods Sixty-two patients were randomized to receive either TIVA or INHA. The primary outcome was the cumulative 24-hour PONV incidence. Secondary outcomes included 48-hour PONV incidence, rescue antiemetic requirements, intraoperative brain relaxation, hemodynamic stability, and emergence times. Results The cumulative 24-hour PONV incidence was comparable between TIVA and INHA: 64.52 versus 77.42% (relative risk = 0.74; 95% confidence interval, 0.46–1.22; p = 0.263). However, the TIVA group exhibited significantly lower PONV incidences during the early postoperative period at 0, 0.5, 1, and 2 hours ( p < 0.05) and required significantly lower doses of norepinephrine to maintain hemodynamic stability ( p = 0.009). Subgroup analysis for microvascular decompression of cranial nerves similarly showed no significant difference ( p = 0.402). Brain relaxation, blood loss, time to extubation, and antiemetic requirements did not differ between groups. Conclusion TIVA with propofol and fentanyl for infratentorial craniotomy did not influence cumulative 24-hour PONV incidence, antiemetic requirements, recovery time, brain relaxation, and blood loss compared with the INHA. However, the TIVA group had a lower early 2-hour PONV incidence and was associated with less intraoperative vasopressor requirement.
Apisara Wongwaikijphaisant, Nisarat Archawakom, L. Tuchinda· Journal of Neuroanaesthesiol...· 0 citations