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Opioid free anesthesia: One center’s experience
Myron Yaster MD and Lynne G. Maxwell MD
As many of the regular readers of the PAAD know, I am extremely skeptical of the need for and the rationale behind opioid free anesthesia, a technique championed by Dr. Tony Anderson1, 2 and others. As discussed previously, the use of intraoperative opioids has absolutely nothing to do with the current opioid epidemic nor the tsunami of opioid overdose deaths.3-5 I just can’t see what advantage there is in avoiding a family of drugs that have been used to treat pain for over 5,000 years.
On the other hand, I always pay attention to, and believe, publications by the first author of today’s PAAD , Dr. Lynn Martin, who will be the recipient of this year’s Society for Pediatric Anesthesia Myron Yaster Life Time Achievement award (and if you haven’t already registered for the annual meeting please do so today!). In today’s PAAD, Martin et al.6 review their experience at the Bellevue Surgery Center, a free standing pediatric ambulatory surgical center (ASC) and at the Seattle Children’s Hospital with opioid free anesthesia. Myron Yaster MD
Martin LD, Franz AM, Rampersad SE, Ojo B, Low DK, Martin LD, Hunyady AI, Flack SH, Geiduschek JM Outcomes for 41 260 pediatric surgical patients with opioid-free anesthesia: One center's experience. Paediatr Anaesth. 2023 Sep;33(9):699-709. PMID: 37300350
Dr. Martin and colleagues have been champions of “utilizing Lean principles to increase value-added care and enhance healthcare outcomes. These principles include standardization of practice, waste minimization, visual tracking of information, respect for staff, and continuous, iterative improvement using Plan-Do-Study-Act (PDSA) cycles. To provide optimal and consistent patient care and track the effects of PDSA cycles, leaders and staff utilize and update standardized anesthesia protocols using evidence and consensus-based decision methods. Compliance with new protocols is facilitated via customized, case-specific templates (or “macros”) built into the anesthesia electronic health record (EHR). Case-specific data are stored in the institutional EHR data warehouse. Clinical teams gain real-time access to this data and analytics using a software solution that aggregates deidentified data from the EHR (AdaptX™). Rapid PDSA cycles of improvement are possible due to the presence of standardized anesthesia protocols and easily accessible data which is regularly reviewed and disseminated to the team.”6 Another example of this type of research by this group involved greening the OR and reducing anesthetic gas wastage (project SPRUCE), which we previously reviewed in the PAAD.7
Martin et al. report on 41 260 pediatric surgical patients cared for over the course of 6 years. Opioid free anesthesia increased from 30% to 98%. “Post Anesthesia Care Unit (PACU) opioid-rescue rates, and postoperative nausea and vomiting (PONV) rescue treatment all decreased concomitantly with opioid free anesthesia.”6 In addition hospital length of stay was reduced for some of the inpatient surgical procedures, such as laparascopic appendectomy. The percentage of patients discharged with an opioid prescription decreased from approximately 25% to 5% and the dose count per prescription dropped from 13 to 9, a nearly 7-fold reduction in absolute opioid doses prescribed. The iterative process of which adjuvant medications used in their anesthetic protocol over successive PDSA cycles is illuminating. Their findings suggest that most pediatric ambulatory and select inpatient hospital procedures are amenable to opioid free anesthesia.
Even more important than their opioid free anesthesia findings was their control of variability in practice which demonstrates once again the power of using lean principles and that major system change is possible. “The use of easily accessible, continuously updated real-world data allowed improvement teams to rapidly complete multiple PDSA improvement cycles.”6
Ok, Martin et al. demonstrated that opioid free anesthesia is possible and produces less PONV, which is a laudable outcome that significantly reduces patient and family distress. I (LM) agree with the authors’ statement “Nausea and vomiting, frequently considered an unavoidable side effect of opioid-based analgesia, is ranked highest by patients in outcomes to avoid, ahead of postoperative pain.” I (MY) remain unconvinced that this is necessary because the fundamental underlying premise that this will lead to less opioid dependence and death was not part of this study, and based on other literature, is unlikely.3-5 On the other hand, Martin et al. did not completely avoid opioids and used them for rescue in the PACU; they avoided them in the OR. Perhaps because their patient population was primarily outpatient surgeries and short-stay inpatient surgeries with relatively low pain burden, both in severity and duration, this might work for many of you. What do you think? Are you and your colleagues moving to opioid free anesthesia? Let us know and Myron will post in a Friday Reader Response.
1. Zhu A, Benzon HA, Anderson TA. Evidence for the Efficacy of Systemic Opioid-Sparing Analgesics in Pediatric Surgical Populations: A Systematic Review. Anesthesia and analgesia. Nov 2017;125(5):1569-1587. doi:10.1213/ane.0000000000002434
2. Ward A, Jani T, De Souza E, Scheinker D, Bambos N, Anderson TA. Prediction of Prolonged Opioid Use After Surgery in Athedolescents: Insights From Machine Learning. Anesthesia and analgesia. Aug 1 2021;133(2):304-313. doi:10.1213/ane.0000000000005527
3. Kharasch ED, Clark JD, Adams JM. Opioids and Public Health: The Prescription Opioid Ecosystem and Need for Improved Management. Anesthesiology. Jan 1 2022;136(1):10-30. doi:10.1097/aln.0000000000004065
4. Kharasch ED, Clark JD. Opioid-free Anesthesia: Time to Regain Our Balance. Anesthesiology. Apr 1 2021;134(4):509-514. doi:10.1097/aln.0000000000003705
5. Kharasch ED, Avram MJ, Clark JD. Rational Perioperative Opioid Management in the Era of the Opioid Crisis. Anesthesiology. Apr 2020;132(4):603-605. doi:10.1097/aln.0000000000003166
6. Martin LD, Franz AM, Rampersad SE, et al. Outcomes for 41 260 pediatric surgical patients with opioid-free anesthesia: One center's experience. Pediatric Anesthesia. 2023;33(9):699-709. doi:https://doi.org/10.1111/pan.14705
7. Hansen EE, Chiem JL, Righter-Foss K, et al. Project SPRUCE: Saving Our Planet by Reducing Carbon Emissions, a Pediatric Anesthesia Sustainability Quality Improvement Initiative. Anesthesia and analgesia. Jul 1 2023;137(1):98-107. doi:10.1213/ane.0000000000006421