Case Report ISSN 2639-846X

Anesthesia & Pain Research

Opioid Free Anesthesia with Goal-Directed Strategies Based on Monitoring

for Spine Surgery in a Patient with Opioid Intolerance: A Case Report
Dornelles Marco1* and Dornelles Larissa2

Correspondence:
*

Cova da Beira University Hospital Centre (CHUCB), Portugal.

1 Marco Dornelles, MD, Anestesiology Assistent, Cova da Beira
University Hospital Centre (CHUCB), Portugal, ORCID: 0000-
Faculty of Medicine, University of Lisbon, Lisbon, Portugal.
2 0003-0761-8009, Tel: (+351) 919459320.

Received: 14 Apr 2021; Accepted: 18 May 2022; Published: 21 May 2022

Citation: Marco D, Larissa D. Opioid Free Anesthesia with Goal-Directed Strategies Based on Monitoring for Spine Surgery in a Patient
with Opioid Intolerance: A Case Report. Anesth Pain Res. 2022; 6(1): 1-4.

ABSTRACT
This study aimed to report the use of a multimodal anesthetic (MA) regimen by combining a panoply of drugs
without opioids for posterior spinal fusion surgery in a patient with Low-back incapacity and opioid intolerance.
The surgery occurred without incidents nor do hemodynamic instabilities, except for a delay in waking up, reverse
with extra doses of decurarizing. On the 13th day, she reported mild pain (VAS 2/10) and was satisfied with the
result of the surgery. This case report highlights the new concept of using manifold drugs through the use a goal-
direct strategies based on monitoring. Furthermore, we emphasize the use of good monitoring, such as ANI and
IGP, for the success of this type of surgery.

Keywords General anesthesia is currently the most widely accepted technique

Analgesia Nociception Index (ANI), Impedance cardiography for innumerous reasons. It enables longer duration surgeries, offers
(ICG), Multimodal analgesia (MA), Opioid free anesthesia (OFA), a secured airway in patients who are often placed in prone position,
Spine surgery. whilst achieving a greater perceived patient compliance. Spine
surgery is associated with severe postoperative pain that can hinder
Abbreviations the postoperative recovery, and it includes a high risk of persistent
MA: Multimodal Anesthetic; NMR: Nuclear Magnetic Resonance; postsurgical pain, with a frequency ranging from 20 % to 40% [1].
VAS: Visual Analogic Scale; LIF: Lumbar Interbody Fusion; Although opioids remain the cornerstone of the management of
ALIF: Anterior Lumbar Interbody Fusion; PLIF: Posterior Lumbar severe acute postoperative pain, intermittent opioid use may result
in inadequate pain relief and substantial opioid-induced adverse
Interbody Fusion; ERAS: Enhanced Recovery After Surgery;
effects, tolerance, and hyperalgesia [2].
ANS: Autonomic Nervous System; OFA: Opioid-Free Anesthesia;
BIS: Bispectral Index; TOF: Train-Of-Four; ANI: Analgesia
Lumbar interbody fusion (LIF) is an established treatment for a
Nociception Index; ICG: Impedance Cardiography; SV: Systolic
range of spinal disorders including degenerative pathologies,
Volume; HR: Heart Rate; CO: Cardiac Output; VET: Ventricular trauma, infection, and neoplasia. At this time LIF is performed
Ejection Time; MAC: Minimum Alveolar Concentration; PACU: using five main approaches but anterior lumbar interbody fusion
Post-anesthesia Care Unit; AHT: Arterial Hypertension; CNS: (ALIF) with the patient positioned in supine position and posterior
Central Nervous System. lumbar interbody fusion (PLIF) with the patient in prone position
remain the more commonly performed techniques [3]. One of the
Introduction main concerns during anterior-posterior spine surgery is to change
Lumbar spine surgery may be performed safely using a variety of the patient anesthetized from the anterior to the prone position
anesthetic techniques. given the possibility of incurring hemodynamic instability.
Anesth Pain Res, 2022 Volume 6 | Issue 1 | 1 of 4
Recently, there has been an emerging interest in multimodal ANI can accurately differentiate between hypertension related to
analgesia (MA) with an increased number of publications an excess of nociception and hypertension response to stress [6].
indexed in PubMed [4] and its use as an appropriate perioperative ICG: Impedance cardiography is a non-invasive technology that
strategy of ERAS (enhanced recovery after surgery) protocols measures the total electrical conductivity of the thorax processing
[5]. The concept of MA was developed based on the knowledge a series of cardio dynamic parameters, such as systolic volume
that postoperative pain is a complex multidimensional sensory (SV); heart rate (HR); cardiac output (CO), and ventricular
experience and a multifactorial phenomenon, which implies a ejection time (VET) [7]. In our case, the CO was monitored during
cognitive perception (pain) and nociception resulting from surgical the surgical procedure and during the change to a prone position
stress response that should not be resolved with opioids alone [2]. and it remained unchanged, with no occurrence of hypotension.
Therefore, instead of using a single medication or technique, a
combination of analgesics of different classes acting on different
target sites of the autonomic nervous system (ANS) may provide
superior pain relief with a lower incidence of adverse effects [2,4].

We report a case of posterior spinal fusion in which a MA regimen

was successfully used to provide opioid-free perioperative
analgesia in a patient with opioid intolerance.

Case Presentation
We report a 48-year-old woman with a history of lower back
discomfort, since 2016 that worsened over time. In 2019, she
experienced movement limitations in her left leg and paresthesia
on the same side. In 2020, she was diagnosed by NMR with a
herniated disc between L5-S1 and progressively became unable
to perform basic home activities. Over the last years, she relied
excessively on analgesics drugs and opioids, thus finally
developing an opioid intolerance. Currently, she uses AINES
(ibuprophen), acetoaminophen, ansiolityc drugs (midazolam) and Figure 1: The Opioid Free Anesthesia goal-directed strategies are based
gabapentinoids to relief her pain. Surgery was indicated as only on monitoring: ECG; ANI; ICG; TOF; BIS.
choice for dealing with her chronic pain. At preoperative the patient
[Analgesia Nociception Index (ANI); Impedance cardiography (ICG);
was assessed to identify reasons for drugs exclusion such as allergy,
Acceleromyograph (by using Train-Of-Four [TOF] ratio; Bispectral
age, or previous intolerance to any agent. She has as comorbidity
Index (BIS)].
of controlled arterial hypertension and no other medical history
besides the current complaint (ASA II). She weighed 90 Kg Prior to the procedure, the patient reported a Visual Analog
with 167 cm of height, having a body mass index of 32.3 Kg/ Score (VAS) of 4/10 pain. Before induction, it was administered
m2 classifying as grade I obesity. Patient reported unpleasant Magnesium Sulphate 2g (23mg/Kg), Tranexamic acid 900mg
experiences with opioids in the past, which were complicated by (10 mg/Kg) for 15 min. each, and dexamethasone (4mg). After 3
nausea, vomiting, drowsiness, and intestinal difficulties and she minutes of preoxygenation anesthesia was induced with droperidol
refused to consider any peri and postoperative opioid therapy. We (1,25mg), midazolam (2mg), lidocaine (60mg), ketamine
proposed multimodal opioid-free anesthesia (OFA) to minimize (30mg), and propofol (200mg). Muscle relaxation was obtained
and ideally eliminate the need for postoperative opioid analgesia. with rocuronium (40 mg) and the patient was maintained with
She signed the informed consent with those exceptions and agreed sevoflurane (MAC 1%), N2O, and an oxygen mixture (BIS 40-
with the proposed anesthesia. 60). A lidocaine infusion was started immediately after induction
and ran at 2mg/Kg/h (0,1mg/Kg) until extubation when it was
In the operating room, routine monitoring of noninvasive blood changed to 1mg/Kg/h (0,05mg/Kg) in the Post-anesthesia care unit
pressure, electrocardiogram, oxygen saturation, Bispectral Index (PACU). The usual precaution necessary for a prone position (eyes,
(BIS), acceleromyograph (by using Train-Of-Four [TOF] ratio) nose, arms, breasts, genitals, etc.) was taken, and light anesthesia
was established, and a urinary catheter was placed to control during the change was maintained to avoid hypotension. This
urinary output. We also used the following specialty monitoring process was controlled by ICG and no hemodynamic instability
(Figure 1). ANI: Analgesia Nociception Index monitor (MDMS, occurred. Our goal-directed antinociception protocol was the
Loos, France) works based on raw ECG data that is derived from following: Mean blood pressure, Bispectral Index, TOF, and ANI
the use of two ANI electrodes applied on the chest. The values were set to be greater than 70 mmHg, between 40 and 60, up to
between zero to 100 are displayed and reflect predominance in 1, and between 50 and 70, respectively and with these targets
parasympathetic tone, with low numbers being low tone and high (2,4,5): If ANI »60 plus arterial hypertension (AHT) then we use
numbers being high parasympathetic predominance. In addition, Esmolol (10 mg); If ANI «60 plus AHT then we use Ketamine

Anesth Pain Res, 2022 Volume 6 | Issue 1 | 2 of 4

(20mg). If BIS »60 then we use Propofol (bolus 50 mg); If ICG Esmolol [2,4]. As a side effect or limitation of our procedure, we
reduction: increased crystalloids; reduced Lidocaine; use of highlight a prolongation of the patient's recovery of consciousness,
Ephedrine or Phenylephrine. If TOF » 1: Rocuronium bolus (20 possibly due to the additive effect of Magnesium with successive
mg). The patient received IV acetaminophen (1g) before incision doses of rocuronium, which was promptly recovered with a new
and dexamethasone (4mg), ketorolac (30mg) and ondansetron administration of sugammadex (a total of 400mg). In many MA
(4mg) associated with anesthetic infiltration of the operative protocols, dexmedetomedine is part of the procedures but was
wound at the end of surgery. After the detection of a TOF ratio of not used due to associated hemodynamic problems, namely
0% with the neuromuscular monitor, sugammadex (2 mg.kg-1) hypotension and bradycardia that could cause serious alterations
was administered as a reversal agent. However, the patient was to the patient during the prone position [8]. The use of our
still unconscious (BIS: 56), but she was spontaneous breathing protocol in a few cases is a limitation of the technique, as well
although TOF ratio was 100%. Following a second sugammadex as the utilization of multiple interventions drugs simultaneously,
dose (total of 400 mg) administration the patient regained makes it challenging to know which drug or drugs intervention
consciousness (BIS: 90) and was extubated in the operating room. is responsible for the observed effect. Despite these limitations,
She arrived at the PACU with a blood pressure of 130/65 mmHg, our case study showed that might prove advantageous in opioid-
heart rate of 67 bpm, and pulse oximetry of 96% with mask intolerant patients and highlights the new concept of using
oxygen at 2 L/min. manifold drugs through the use a goal-direct strategies based on
monitoring.
At the PACU the patient remained drowsy but alert when
stimulated and she was discharged 150 minutes after admission Conclusion
with no complaints (VAS 2/10). Aside from a two-hour infusion of This case report demonstrates that the combination of non-opioid
lidocaine (1mg/Kg/h), acetaminophen (1g) and metamizole (2g) analgesics is a good option of the MA in spine surgery and in
were administered as analgesics. During the following days the opioid-intolerant patients. However, current knowledge is based on
patient received oral acetaminophen 1 g 6-hourly and metamizole studies exploring many different drug combinations and doses in
2g 8-hourly which maintained resting and dynamic pain scores at relatively small trials with low statistical power, and heterogeneity
0 to 1/10 and 2 to 3/10 respectively, and she did not require opioids in outcome measures. Future prospective studies may be necessary
at any time until her discharge from the hospital. On the 13th day, to establish optimal routes of drugs administration and determine
she was reassessed when she reported mild pain (VAS 2/10) and the utility and safety of OFA for moderate to severe postsurgical
was satisfied with the result of the surgery. pain [2,4]. We believe that the success of MA must be associated
with good monitoring of the patient and the adjustment and balance
Discussion of drugs used in the perioperative period to maintain the patient's
Increasing evidence indicates that pain is insufficiently treated hemodynamic stabilization.
following surgical procedures and spine surgery has been
associated with higher levels of pain compared to other surgical References
procedures [1]. Multimodal analgesia is most likely an important 1. Christelis N, Simpson B, Russo M, et al. Persistent Spinal Pain
strategy in reducing postoperative pain by combining panoply of Syndrome: A Proposal for Failed Back Surgery Syndrome and
drugs with several levels of action in the CNS, as it develops a ICD-11. Pain Medicine. 2021; 22: 807-818.
state of modulation of nociceptive processing in the dorsal horn. 2. Basto T, Machado HS. Effect of Opioid-Free Anaesthesia on
In addition to that, the avoidance of opioid-induced hyperalgesia Perioperative Period: A Review. Int J Anesthetic Anesthesiol.
may significantly reduce the need for postoperative opioid 2020; 7: 104.
analgesia [4]. Our protocol with complete omission of opioids in 3. Mobbs RJ, Phan K, Malham G, et al. Lumbar interbody fusion:
the perioperative anesthesia may have been a determinant factor techniques, indications and comparison of interbody fusion
in the patient’s rapid recovery in the PACU. Furthermore, it options including PLIF, TLIF, MI-TLIF, OLIF/ATP, LLIF and
fulfilled the criteria of the ERAS protocol for an opiate-free post- ALIF. J Spine Surg. 2015; 1: 2-18.
operative recovery [5]. Equipment monitoring was used to titrate
4. Bugada D, Lorini LF, Lavand homme P. Opioid free anesthesia:
administration of anesthetic medication, to detect physiologic
evidence for short and long-term outcome. Minerva Anestesiol.
perturbations, and allow intervention before the patient suffers
2021; 87: 230-237.
harm. In addition to conventional monitoring, we added new
monitoring possibilities (ANI/ICG) with the objective of better 5. Soffin EM, Wetmore DS, Beckman JD, et al. Opioid-free
control of pain (ANI) and guarantee patient security during the anesthesia within an enhanced recovery after surgery pathway
change to the prone position (ICG). We were still able to stabilize for minimally invasive lumbar spine surgery: a retrospective
the patient’s nociception-antinociception balance and maintained matched cohort study. Neurosurg Focus. 2019; 46: 8.
the ANI between 50 and 70 until the end of surgery without any 6. Logier R, De jonckheere J, Delecroix M, et al. Heart rate
intraoperative hemodynamic instability. We can highlight the variability analysis for arterial hypertension etiological
following drugs that produced perioperative analgesic stability and diagnosis during surgical procedures under tourniquet. Conf
potentiated post-operative analgesia: Lidocaine, Ketamine, and Proc IEEE Eng Med Biol Soc. 2011; 2011: 3776-3779.
Anesth Pain Res, 2022 Volume 6 | Issue 1 | 3 of 4
7. Saugel B, Cecconi M, Wagner JY, et al. Noninvasive 8. Beloeil H, Garot M, Lebuffe G, et al. SFAR Research Network.
continuous cardiac output monitoring in perioperative Balanced Opioid-free Anesthesia with Dexmedetomidine versus
and intensive care medicine. Br J Anaesth. 2015; 114: Balanced Anesthesia with Remifentanil for Major or Intermediate
562-575. Noncardiac Surgery. Anesthesiology. 2021; 134: 541-551.

© 2022 Marco D, et al. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License

Anesth Pain Res, 2022 Volume 6 | Issue 1 | 4 of 4