TOPLINE

Opioid-free anesthesia (OFA) with propofol-based total intravenous anesthesia (TIVA) or sevoflurane inhalation produced comparable rates of postoperative nausea and vomiting (PONV), pain scores, and opioid use in patients undergoing laparoscopic sleeve gastrectomy. However, prolonged emergence (extubation time exceeding 10 minutes) occurred more frequently with TIVA than with sevoflurane.

METHODOLOGY

• OFA agents such as lidocaine, ketamine, dexmedetomidine, and magnesium are used to reduce postoperative opioid requirements, nausea, vomiting, and hyperalgesia in bariatric surgery; propofol-based TIVA has been linked to lower nausea in some prior studies, and sevoflurane-based inhalational anesthesia is less irritating to the airway and has a smaller environmental impact than desflurane.
• Researchers conducted a trial at a tertiary university hospital in Poland to compare the two OFA techniques in 256 patients (mean age, 41.3 years; 75.4% women) with severe obesity undergoing elective laparoscopic sleeve gastrectomy.
• Patients were randomly assigned to receive OFA with either propofol-based TIVA (n = 133) or sevoflurane inhalation (n = 123); both groups received the same nonopioid adjuncts (lidocaine, ketamine, and dexmedetomidine) and standardized antiemetic prophylaxis.
• All surgical procedures were performed laparoscopically by the same bariatric surgery team using a standard five-port technique, with the patient in a steep reverse Trendelenburg position.
• The primary outcome was the incidence of PONV within 24 hours postoperatively; secondary outcomes included pain scores (up to 24 hours), 24-hour opioid consumption, hemodynamic stability, and emergence characteristics.

TAKEAWAY

• The primary endpoint of PONV within 24 hours did not differ between the two groups, occurring in 65.0% vs 64.7% of patients in the sevoflurane group vs the TIVA group (P = 1.000).
• Postoperative nausea rates were 65.0% vs 63.2% in the sevoflurane group vs the TIVA group (P = .855), and postoperative vomiting occurred in 25.2% and 26.3%, respectively (P = .952).
• Median 24-hour total opioid consumption was low and comparable between the two groups, postoperative pain scores at all timepoints were comparable, and hemodynamic parameters also remained comparable and stable in both groups.
• Prolonged emergence (extubation time > 10 minutes) was significantly more frequent in the TIVA group than in the sevoflurane group (22.6% vs 12.2%; P = .044).

IN PRACTICE

“The propofol-based and sevoflurane-based OFA techniques performed similarly in terms of patient recovery and comfort, which is a clinically relevant observation for practitioners. We suggest that anesthesiologists can tailor the maintenance anesthetic to the patient’s or surgeon’s needs (eg, using TIVA to reduce environmental pollution or volatile anesthesia for familiarity and cost considerations) without an apparent compromise in patient outcomes, as long as a comprehensive opioid-sparing strategy is in place,” the authors of the study wrote.

“The high incidence of PONV in both groups serves as a reminder that certain challenges, namely PONV in this high-risk population, persist despite eliminating intraoperative opioids and must be addressed with aggressive prophylaxis and novel strategies,” they added.

SOURCE

The study was led by Pawel Maciejewski, MD, Department of Intensive Interdisciplinary Care, Jagiellonian University, Kraków, Poland. It was published online on July 20 in Obesity Surgery.

LIMITATIONS

This trial was conducted at a single high-volume bariatric center with experienced teams, so the results may not apply to smaller hospitals or places using different recovery practices. The anesthetist could not be blinded to the assigned drug. The study expected a large reduction in PONV with propofol but did not find one; because it was powered to detect a big effect, a smaller benefit could have been missed.

DISCLOSURES

The authors declared no conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.