Opioid Free Anesthesia (OFA) by tushar chokshi

1. Opioid Free Anesthesia
(OFA)
Opioid Free -Total Intra Venous Anesthesia
(OF-TIVA)
Dr. Tushar Chokshi
Anesthesiologist
VADODARA

2. Disclosure Statement
• I have no financial relationships with any
commercial interest related to the content of
this presentation
• I will discuss many medications with my
experience and recent developments in OFA
• OFA is only one technique for providing
anesthesia
• It is a scientifically-based, systematic treatment
of the surgical patient in para operative period

3. Lecture Outline
• Introduction
• History
• Definition
• Why and How OFA / Opioid Epidemic
• Opioid Risk/Use/Abuse/Side Effects/Complications
• Opioid epidemic in Anaesthesia
• OFA Goals
• OFA – Benefits
• Methods of OFA
• OFA Indications and Contraindications
• Multimodal and Intravenous drugs for OFA and their details
• Standard OFA Induction and Maintenance
• My experience & techniques of OFA and OF-TIVA with economics
• Conclusion
• Take Home message
• My Verdict
• Cartoons
• Thanks
• Join ISOFA (Indian Society for Opioid Free Anesthesia) FB group

4. INTRODUCTION
The practice of
anesthesia requires a
full spectrum of drugs
from which an
anesthetic plan can
be implemented to
achieve a desired
level of surgical
anesthesia, analgesia,
amnesia and muscle
relaxation
Opioid Free
Anesthesia (OFA) is a
technique where no
intra-operative
systemic, neuraxial,
or intracavitary opioid
is administered
during the anesthetic
period
OFA is possible
- An alternative to opioid
Anesthesia
- Provides benefits to
selective group of patients
- Facilitates postoperative
analgesia with less opioids
- Enhances recovery after
surgery (ERAS)
The epidemic of
opioid abuse is
increasing, and the
number of deaths
secondary to opioid
overdose is also
increasing
for patient safety,
anesthetists have
begun to develop
protocols centered on
minimizing or even
avoiding opioids for
their patients
altogether

5. HISTORY
• The use of natural opiates, such as
opium, is more than millennial
• the history of synthetic opioids
begins after 1950, with the
development of the so-called
'modern' anaesthetic techniques.
• In 1962, in Belgium, the use of
fentanyl, the first synthetic opioid
for use in anaesthesia, is described
• Subsequently, the use of opioids at
high doses during surgery became
common
• However, over the last twenty years,
many studies have questioned this
practice, highlighting the many
unknowns as the side effects of
these molecules
• The so-called opioid-free
anaesthesia (OFA) techniques were
developed in parallel with a better
understanding of perioperative pain
The following questions are addressed
• Why is the human body producing
endogenous opioid ?
• Is the concept of pain valid during
general anesthesia ?
• What are the effects of
intraoperative opioid on
postoperative pain ?
• Is anesthesia without opioid actually
possible ?
So, Opioid-free
anesthesia (OFA) has
emerged as a new
technique and branch
of anesthesia

6. DEFINITION of OFA
It is a technique in anesthesia portfolio with
simple cocktail of drugs without opioids
In other words
It is Multimodal Anesthesia and Analgesia

7. Why and How
OFA
Developed

8. Opioid Epidemic
• Devastating consequences of the opioid epidemic, included increases in
opioid misuse and related overdoses, as well as the rising incidence of
newborns experiencing withdrawal syndrome due to opioid use and
misuse during pregnancy
• Opioid overdoses accounted every year more than 1 lac deaths and
estimated 40% of opioid overdose deaths involved a prescription opioid
• In the late 1990s, pharmaceutical companies reassured the medical
community that patients would not become addicted to opioid pain
relievers and healthcare providers began to prescribe them at greater
rates
• Increased prescription of opioid medications led to widespread misuse
of both prescription and non-prescription opioids before it became clear
that these medications could indeed be highly addictive
• Since the 1990s, high-income countries have seen an exponential
increase in opioid use, misuse, and overdose. This “opioid crisis”, or
“opioid epidemic”, began in the USA, spread to Europe, and is now
extending to Asia

10. This rise in opioid overdose deaths can
be outlined in three distinct waves
• The first wave began with increased prescribing of opioid in
the 1990s, with overdose deaths involving prescription
opioid (natural and semi-synthetic opioid) increasing since at
least 1999
• The second wave began in 2010, with rapid increases in
overdose deaths involving heroin
• The third wave began in 2013, with significant increases in
overdose deaths involving synthetic opioid, particularly
those involving illicitly manufactured fentanyl

11. MORPHINE DERIVATIVES
During the 20th century, the following morphine
derivatives were developed
1916: Oxycodone (Germany)
1924: Hydromorphone (Germany)
1932: Pethidine (1st synthetic – Germany)
1937: Methadone (Germany)
1960: Piritramide (Janssen - Belgium)
1963: Pentazocin (USA)
1963: Tramadol (Germany)
1965: Buprenorphine (USA)
1971: Butorphanol (USA)
1979: Nalbuphin (USA)
Others are
Fentanyl
Alfentanil
Remifentanyl
Sufentanyl
Etorphin
Carfentanyl

12. OPIOID RISK
• Respiratory depression
• Need for post-op ventilation with ventilator associated pneumonia
• Addiction
• Nausea & Vomiting
• Gastrointestinal dysfunction, ileus
• Pruritus
• Urinary retention
• Opioids and cancer
Dozens of publications are available concerning opioid use in anesthesia,
cancer growth, recurrence, and metastasis
• Opioid-induced hyperalgesia (most common even in single dose)
• Misuse, Abuse and Overuse
Hyperalgesia means abnormally heightened sensitivity to pain

15. Opioid Induced Hyperalgesia (OIH)
• State of nociceptive sensitization caused by
exposure to opioids
• Patient becomes more sensitive to certain
painful stimuli
• Patients have a prolonged period of
hypersensitivity to pain
• Ketamine reduces opioid induced hyperalgesia
• May occur after single dose of an opioid
– Remifentanil > Fentanyl > Morphine

16. OPOID BENEFITS
• First
Haemodynemic stability
• Second
Analgesia and Little Sedation

17. Opioid Epidemic in Anesthesia
Opioid analgesic overdose leading to opioid toxicity
has three features in anesthesia
• First, opioid analgesic overdose can have life-threatening toxic
effects in multiple organ systems
• Second, normal pharmacokinetic properties are often disrupted
during an overdose and can prolong intoxication dramatically
• Third, the duration of action varies among opioid formulations,
and failure to recognize such variations can lead to
inappropriate treatment decisions, sometimes with lethal
results.

18. Why Opioids used in Anesthesia?
• Opioids were primarily used initially because of
their safe intraoperative profile
– Minimal cardiac depression
• Blunting of pain transmission
• Provide the basis of postoperative pain control

19. Why To Avoid Opioids
• Negative side effect profile
– Respiratory depression, N/V, pruritus, urinary retention
• Opioids suppress the immune response
– Suppression of Natural Killer cells
• Cause cognitive/sleep dysfunction
• Increased risk for addiction postoperatively
• Increased risk of chronic pain with opioid
administration

20. So
What is the alternative to opioids ?
Replacing opioids with other analgesics will not
only reduce the development of opioid
addiction but will also lead to better
perioperative outcomes and enhanced patient
recovery (ERAS)

21. Opioid free anesthesia, a new paradigm

22. So first concept of
OFA
came in 1990

23. Goals of OFA
In
Nine words only

24. Barry Friedberg, USA
(Inventor of Ketofol)
Father of OFA
(BIS)
(Ketamine)
(OPIOID)
No much anesthesia
No less anesthesia
Only Brain FOG
Main aim in OFA is
anesthetized brain should
not come to know
about the pain during
skin incision
Goals of OFA
In
Nine words only

26. OFA completes Anesthesia Circle

27. OFA BENEFITS
Stable hemodynamics intraoperatively
No respiratory depression
No addiction except for ketamine
Less need for post op ventilation
No nausea and vomiting
No gastrointestinal dysfunction and ileus
No pruritus
No urinary retention
Prevention of chronic pain

28. Advantages of OFA

29. 17 Benefits of OFA
OFA

30. Non Opioid Drugs

31. Methods Of OFA
• Management of peripheral sensitization
• Management of central sensitization
• Prevention of OIH
• Weight based dosing on drugs(IBW)

32. Management Of Peripheral Sensitization
• Local Anesthetics
– Peripheral nerve blocks
– Lidocaine infusion
• Steroids
– Dexamethasone
• NSAIDS
– Diclofenac sodium
– Paracetamol

33. Management Of Central Sensitization
• Propofol and Etomidate
• Substance P inhibition
– Clonidine (a2-adrenoreceptor agonist)
– Dexmedetomidine (Strong a2-adrenoreceptor agonist)
• Glutamate antagonist
– Ketamine (NMDA antagonist)
– N2O (NMDA antagonist)
– Magnesium (NMDA antagonist)
– Gabapentinoids (Pregabalin)

34. OFA Indications

35. OFA Contraindications
• Absolute
- Allergy to any adjuvant drugs
• Relative
- Disorders of autonomic failure
- Cerebrovascular disease
- Critical coronary stenosis or acute coronary ischemia
- Heart block / extreme bradycardia
- Non-stabilized hypovolemic shock or polytrauma patients
- Acute bleeding with significant blood loss
- Elderly patients on beta-blockers
- ASA - 4 patients

37. Multimodel drugs in OFA
with their advantages
• Majority of drugs used for OFA including Benzodiazepines,
Propofol, Ketamine, Etomidate, Dexmedetomidine, muscle
relaxants, and other adjuvants are easily available in almost
all the Operation theatres and outside OT
• All these drugs can be given to any subset of population in
any surgical procedure without opioids

38. All
Benzodiazepines
Dexmedetomidine
Dexamethasone Magnesium Sulphate
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OFA
DRUGS
IN
TOOLBOX
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39. Universal Weapon
For
Anesthesiologist
Anti-Emetic and Anti-Nauseatic
Anti-Inflammatory
Analgesic Effect
Anti Shivering
Increase Quality of Recovery
No effect on sepsis and sugar in single dose

41. Best Companion of Anesthesiologist
Lidocaine
Analgesic & Anti Hyperalgesic
Anti Inflammatory
Reduced opioid analgesic consumption
Anti Arrhythmic
Improvements in patient’s outcomes
Decrease Aerosol and Droplets during Extubation

42. (Opioid sparing adjunct) (Gives central analgesia)

43. Ketamine
NMDA antagonist
- Key role and main drug in OFA
- Best analgesic, amnesic and opioid sparing effect
- Dose less than 0.5 mg/kg reduces postoperative analgesic needs and especially seen in
opioid-tolerant patients
- It has anti-hyperalgesic and anti-tolerance effects.
Most popular drug for anesthesiologist across globe since 50 years
Brahmashtra for anesthesiologist in pain relief

44. Dexmedetomidine
• Dexmedetomidine has hypnotic,
sedative, and analgesic
properties and is estimated to be
7-10 times more potent than
clonidine
• Most ideal anesthetic agent with
all the properties of anesthesia
• Has got opioid sparing effect
• Dexket/Ketodex combination is
becoming very popular in
Pediatric OFA
• Patients sedated, but, arousable,
alert and respond without
uncomfortable
• They may quickly return to
sedation again
• Conscious Sedation as natural
sleep
• This drug is becoming widely
popular in all part of world in all
anesthesia techniques
An alpha-2 agonist

45. Clonidine
An alpha-2 agonist
• Analgesic properties are due
to both peripheral and
central a2-
adrenoreceptor agonism
• Avoid in patients with:
– Bradyarrthymias
– severe AS
– Coronary artery
• Strong considerations
– Renal patients require
less dose
• Long half life up to 18 hours
with both PO and IV dose
• PO dose:
– 3-5mcg/kg (IBW) given
1-2 hours preop
• Bioavailbility is 75-
95%
• IV dose:
– Give 1.5mcg/kg (IBW) on
induction
• Total dose 3mcg/kg,
should not exceed
• Dose may be given
over 30 minutes
before preop

46. Paracetamol
• Preemptive analgesic
• Has got opioid sparing effect
• Loading dose is 30 mg/kg and
maximum not to exceed 2 gm
• Very innocent drug in OFA
and can be repeated at every
six hours interval in dose of
1000 mg
• Excellent adjuvant in pediatric
OFA
Diclofenac Sodium
• Powerful NSAID in OFA with
analgesia and anti-
inflammatory action
• Best is given in single dose of
1.5 mg/Kg IV slowly and
maximum is 150 mg
• Always give before surgical
incision to inhibit
prostaglandin receptors
• Use aqueous solution only
• Avoid in renal, hepatic,
pulmonary and heart failure
patients

47. In short
Dexamethasone given before induction to general anaesthesia in dose 0.1 mg/kg has
antiemetic effect and can reduce opioid consumption in the first 24 h
Paracetamol has analgesic and antipyretic effect and given preemptively has shown to
be effective in the postoperative treatment of pain with less opioid consumption in the
first 24 h after surgery and less nausea and vomiting and Together with the NSAID is
the first analgesic of choice for treatment of acute pain
Analgesic doses of lignocaine needed in the perioperative period are 1–2 mg/kg as a
bolus dose, continuing with intravenous continuous infusion from 1–2 mg/kg/h, which
are clinically effective
Ketamine and magnesium sulphate are both N-methyl D-aspartate (NMDA)
antagonists. Ketamine is most effective given as a bolus dose 0.5 mg/kg during
induction to general anaesthesia and to be continued in the peri- and postoperative
period in dose 0.25 mg/kg up to 48 h in major abdominal operations, with reduction on
postoperative opioid consumption
Magnesium sulphate given as a continuous i.v. infusion potentiates analgesia after
surgery and reduces the need for opioids in the postoperative period.

48. Some OFA RISK with these drugs
# Bradycardia with dexmedetomidine
# Hepatic damage with paracetamol
# Bleeding, renal impairment and bronchospasm
with diclofenac
# Hallucinations, tachycardia and addiction with
ketamine
# Tinnitus, seizures and cardiac arrest with
lidocaine
# Sedation with dex
# Hypotension with magnesium

51. Standard OFA Induction
10 minutes prior to induction
Sympathetic Block
Dexmedetomindine 0.3 mcg/kg IBW (20-
30 mcg)
1 minute prior to induction
Hypnotic and rapid stress block –
Lidocaine 1.5 mg /kg ( 100 mg)
Induction
Hypnotic and stress block
Propofol 2.5 mg/kg IBM (200mg)
Rapid preload reduction
Magnesium Sulfate 40 mg / kg IBW (2.5 g)
Anti-inflammatory agents before surgery
Dexamethasone 8-10 mg
Diclofenac 75 – 150 mg
Paracetamol – 1 gm
NMDA Antagonist
Ketamine 50-100 mg (bolus / slow infusion /
end of surgery)
On standby
Beta-Blocker – Esmolol / Metoprolol
Calcium channel blocker – Nicardipine 1–5 mg
Ephedrine 3–9 mg / Mephentermine 15-30 mg
Phenylephrine 10 – 30 mcg
Anticholinergic, Antiemetic and Antacid as per choice of anesthetist
Neuromuscular Blocking drugs if needed for anesthesia or surgery

52. Standard OFA Maintenance
Sympathetic Block
Dexmedetomidine 0.5 – 1 mcg/kg/h
Clonidine 150 mcg
Local Anesthetics
Lidocaine 1 – 2 mg / kg /h
Magnesium Sulfate :
2.5 – 10 mg / kg IBW/ h
Inhalation Agent (If required)
Sevoflurane / Desflurane
0.6 – 0.8 MAC with BIS around 40%
Propofol infusion
higher dose than TIVA required
NMDA block
Ketamine 0.1-0.2 mg/kg/hr
IV Paracetamol: 1000 mg
Post Operative (not more than 24 hrs)
Lidocaine 1-2 mg/kg/hr
Ketamine 0.1-0.2 mg/kg/hr
Block Anesthesia
Local Infiltration

53. I
use
OF – TIVA
Opioid Free -TIVA

54. Best Premedication in OF TIVA
DML mixture in 10 ml syringe
• D – Dexamethasone 8 mg (2ml) -- D
• M – Magnesium Sulphate 1 gm (2ml) -- M
• L – Lidocaine 1.5 mg/kg (3 to 6 ml) -- L
Given slowly at least for 2-5 minutes
Opioid free drugs for Anesthesiologists

55. KPD TIVA (Ketamine, Propofol and Dex)
Mixture in 1:1:1 Dose for TIVA
Combination of all these drugs permit lower dose
of each individual agent for TIVA and reducing
their adverse hemodynamic and respiratory
effects which is very safe and important for
patient and anesthesiologist
The advantage is low dose of each agent as compared to full
dose
Excellent analgesia and anesthesia
 dose of individual
agents
 airway complications
Stable haemodynamics Rapid recovery

56. KPD
• In my 80 % practice I use this mixture In all
OF -TIVA cases
• For maintenance intraop I use Dex infusion or
Propofol infusion depends upon surgery, surgical
time and vital parameters
• I put 100 mcg Dex in RL 500 ml during intraop
• Maximum user of Dex
• Started practice of Opioid Free Multi Model
Analgesia and Anesthesia with Ketamine,
Propofol, Dex (KPD) help of other adjuvants in
OF - TIVA
56TMC

57. OFA

58. For Postoperative Pain Relief
• Local Infiltration or respective Nerve Blocks
• Ketamine and Lidocaine drip for 24 hours
after major surgery
• Ketamine 0.2 mg/kg/hr
• Lidocaine 1 mg/kg/hr
• Paracetamol 1000 mg every 12 hrs
• Diclofenac Sodium 1 mg/kg every 12 hrs
• No Opioid at all

59. Name of Drug Form Strength Cost (Rs.) Remark
Glycopyrrolate 1 ml ampoule 0.2 mg 25 2 ampoule
Ondensetron 2 ml ampoule 4 mg 10 1 ampoule
Dexamethasone 2 ml amp/bulb 8 mg 10 1 amp/bulb
MgSO4 2 ml ampoule 1 gm 10 1 amp
Paracetamol 3 ml ampoule 450 mg 20 2 ampoule
Diclofenac Aqua 1 ml ampoule 75 mg 25 1 ampoule
Lidocaine IV 30 ml bulb 21.3 mg/ml
Total 640 mg
50 1 bulb
Etamsylate 2 ml ampoule 125 mg 25 1 ampoule
Propofol 20 ml bulb 200 mg 300 2 bulb
Suxamethonium 10 ml bulb 500 mg 50 2 ml
Ketamine 10 ml bulb 500 mg 100 3 - 4 ml
Dexmedetomidine 1 ml amp 100 mcg 350 1 ml
Esmolol 10 ml bulb 100 mg 250 3 – 4 ml
Atracurium / Neostigmine 5 ml / 5 ml amp 50 mg / 2.5 mg 250 + 25 5 ml – 5 ml
Total 15
drugs in
my OFA
Toolbox
This is
example
of routine
case lasting
for 90-120
minutes
e.g.
Lap. Chole.
or
Lap. TLH
or
Mastoid.
Total cost
is only
1500 Rs.
for my
OF TIVA
No Volatile
agent is
used

60. Surgical Procedures under OFA
• From OT to Outside OT
• From Pediatric to Geriatric patients
• From any Surgical to Medical Specialty

62. Tips To Starting OFA
• Do not administer Opioids
• Communicate in Doubt
• Educate Yourself
• Keep Update with Latest

63. CONCLUSION
• Do we really need opioids in anesthesia?
• Opioid crisis/epidemic became a hard reality since 1990,
so the concept of opioid-reduced, and eventually opioid-
free anesthesia started
• Opioid Free anesthesia is the future of anesthesia
• It is slowly but surely being considered the best way to
give GA.
• There are very few contraindications for opioid free
anesthesia
• Multimodal anesthesia and analgesia with no opioid use
is becoming popular method in OFA and OF-TIVA
• Replacing opioids with other analgesics will not only
reduce the development of opioid addiction but will also
lead to better perioperative outcomes and enhanced
patient recovery

64. Take Home Message
• Opioids can be replaced by multi drugs to avoid complications of opioids
• Postoperative pain management without opioids are viable truth
• Ketamine is the main key role in OFA (Preempt Ketamine)
• Don’t give Ketamine before propofol or Dexmedetomidine
• Don’t exceed Ketamine more than 200 mg intraop in OFA
• No bolus Propofol more than 2 mg/kg in OFA
• Ketamine laryngospasm is not common, but whatever we see is light anesthesia
induction causing laryngospasm and treatment is IV lidocaine 2 mg/kg
• NMDA receptors are antagonized with Ketamine / MgSO4 / Dexmedetomidine
in OFA
• You don’t have to be worry, if your OFA is perfect than better outcome without
pain and PONV (ERAS)
• To reduce intraop blood pressure use Esmolol, with its multiple effect in OFA
• Dexamethasone, MgSO4 and Lidocaine are three main friends in OFA
• NSAIDs and Paracetamol are best adjuvant in OFA for postop pain relief

65. OFA will be a game changer in high risk patients,
especially Geriatric and COPD patients
Let's begin
Opioid sparing or opioid free anesthesia with
technique of Multimodal Anesthesia and Analgesia
By reducing opioid-related adverse effects, OFA aims to
enhance optimal perioperative analgesia through
reducing pain scores and enabling earlier mobilization
with enhanced rehabilitation, faster discharge and
improved patient satisfaction

68. Thank You
Join
Face book Group of
“Indian Society for Opioid Free Anesthesia”
(I SOFA)
chokshitushar@hotmail.com
https://sites.google.com/site/tusharchokshisite