From Dr. Ben Blackman, Anaesthetic Staff Specialist (equivalent of Attending) in Brisbane, Australia, working in mixed adult and paediatric practice.
Just thought I’d share my opinion with you on opioid-free anaesthesia. It’s not something that has gained a lot of traction here in Australia. We do have some significant issues with chronic opioid dependence and persistent postoperative opioid use but not to the extent seen in the US as far as I understand. I’d absolutely share your scepticism regarding intraoperative OFA’s ability to reduce persistent use; although our discharge prescriptions no doubt make a difference.
However, I think anaesthetists do have something to learn from proponents of OFA. As creativity is often boosted by constraint, OFA is obliged to maximise multimodal analgesia using a wide range of receptor targeting and often with the addition of regional blocks. I often wonder if the benefits seen in OFA studies are more related to what providers are giving (diligent pursuit of opioid alternatives) than the opioids they are avoiding. I would like to see studies directly comparing a very generous multimodal approach alone vs the same generous multimodal approach also including opioids.
Reading about OFA has made me consider the more frequent use of adjuncts such ketamine, magnesium, dexamethasone and dexmedetomidine on top of traditional simple analgesics and regional analgesia (I’m sceptical of IV lidocaine when only given intraop, what gabapentinoids can provide, or using esmolol to facilitate intubation but those are other topics). I haven’t as yet seen the harm of combining this with limited doses of opioids, judicious remifentanil, or intrathecal morphine, and being able to limit opioid doses can reduce their side effects.
The arc of history so often follows the Hegelian triad; a thesis is proposed, its opposite is argued for (antithesis) and then a synthesis is formed- a middle ground. I’d propose that the best way to provide analgesia to our patients and minimise the side effects of our interventions is not loads of opioids, or loads of non-opioid drugs, but a moderate amount of each.
From Bevan Londergan
At Vanderbilt children’s we have cardiac anesthesia care for all transcatheter ductal stent cases. We largely have cardiac anesthesia cover all cath lab cases so it’s not a big logistical change, but on the occasional days when we have a noncardiac person covering one of our cath labs, they would be swapped out for a case like this.
From Andy Matisoff, MD Division of Cardiac Anesthesia, The Hospital for a Sick Children
Great paper by the team from BCH. Another thing to consider is that many cardiologists prefer a CT angiogram to look at ductal anatomy before placing a stent. With older Ct scanners this often requires a breath hold and possibly a general anesthetic in a newborn with ductal dependent circulation. Is this performed by the cardiac anesthesia team or can the general team cover this too? With the shortage of peds cv anesthesiologists more data or guidelines are needed to determine which cases benefit most from having a CV anesthesiologist, if at all.
Division of Cardiac Anesthesia
The Hospital for a Sick Children