Effectiveness and safety of opioid-free anaesthesia and analgesia in pain control and postoperative recovery of patients undergoing gynaecologic oncologic surgery: a retrospective cohort study

Effectiveness and safety of opioid-free anaesthesia and analgesia in pain control and postoperative recovery of patients undergoing gynaecologic oncologic surgery: a retrospective cohort study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effectiveness and safety of opioid-free anaesthesia and analgesia in pain control and postoperative recovery of patients undergoing gynaecologic oncologic surgery: a retrospective cohort study Jose Alexander Puentes Garcia, Daniel Rivera Tocancipa, Eugenio Medina, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5257068/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 14 Feb, 2025 Read the published version in BMC Anesthesiology → Version 1 posted 4 You are reading this latest preprint version Abstract Introduction: Opioids have been essential for the anesthesiologic management of patients undergoing surgical procedures such as gynecologic oncology. However, the use of opioids brings with it hemodynamic problems, which is why opioid-free anesthesia (OFA) and multimodal postoperative analgesia techniques that restrict the excessive use of opioids are necessary. Objective: To determine the effectiveness and safety of opioid-free anesthesia and analgesia in pain control and postoperative recovery of adult patients undergoing gynecologic oncology surgery. Methodology: A retrospective observational cohort study was conducted by reviewing the medical records of patients at the Neiva University Hospital. Female patients who underwent gynecologic oncology surgery at the Neiva University Hospital and who received OFA, or opioid-based anesthesia (OBA) were identified. Data on pain were collected using a visual analog pain scale (VAPS), along with hemodynamic variables and adverse events at 7 different times from admission to the operating room until discharge from the hospital. A bivariate analysis was performed for the type of anesthesia, comparing frequencies of VAPS and adverse events with chi2 and mean difference for hemodynamic variables with t student. A multivariate analysis was performed with multiple logistic regression to evaluate differences in frequency of pain by VAPS based on the anesthesia regimen and other clinical variables for statistical difference times. Results: Data were collected from 335 patients, of whom 196 (58.5%) received an OBA regimen and 139 (41.5%) an OFA regimen. A difference was identified for greater pain in OFA than in OBA (p<0.001) for the times before surgery, recovery discharge, and 24 hours after surgery. For heart rate, significant differences were only identified at admission to the operating room, 30 minutes of induction and admission to the recovery room. For respiratory rate, the differences were only significant at admission to the operating room, 30 minutes of induction. For mean arterial pressure, it was significant only in the recovery room and for oxygen saturation at admission to the operating room and discharge from recovery. As an adverse event, a higher frequency of requiring antiemetics was only identified in patients with AFO than with ABO on the fifth day of surgery. No significance was identified in multivariate analysis between OBA and OFA controlled for VAPS by other factors at 24 hours. Conclusions: Opioids for gynecologic oncologic surgery patients have a partial impact on pain control, with poor control upon discharge to recovery areas, at 24 and 48 hours, and no clinically relevant differences in hemodynamic variables or adverse events. Figures Figure 1 Figure 2 Figure 3 Figure 4 INTRODUCTION Balanced anesthesia involves the administration and combination of different pharmacological groups to achieve an optimal anesthetic state by achieving more adjusted doses, increasing the proportion of desired effects and reducing side effects ( 1 ). In turn, general anesthesia could be defined as the result of the pharmacological combination that seeks to achieve its fundamental pillars, the loss of consciousness or hypnosis, amnesia, and immobility during the surgical procedure, together with adequate control of postoperative pain avoiding hemodynamic alterations; all dependent on specific therapeutic agents and sensitive to the body's response according to the doses used ( 2 ). Multiple drugs meet the aforementioned objectives, opioids are considered the second most used drug after inhaled agents and propofol. Their preference lies in the controlling effect of the central nervous system's responses to nociception, maintaining stable hemodynamics, in addition to their effects on postoperative pain control, decreased anesthetic requirements and control of the sympathetic response ( 2 ). However, the administration of opioids in the perioperative period involves a risk due to the high incidence of minor adverse events in about 82% of cases and moderate events in 13.6%. Sedation, transient delirium, dizziness, nausea and vomiting, constipation, respiratory depression, and increased stay in the post-anesthesia care unit are frequent and unwanted side effects in early postoperative recovery techniques ( 3 ). In addition, drug dependence and chronic abuse of patients using opioids in the intra- and postoperative period affects developed countries to the point of constituting a “crisis”. For example, in the United States nearly 107000 overdose deaths were reported in 2021, of which 75% were related to an opioid ( 4 , 5 ). In Colombia, the Ministry of Justice reported 30 deaths associated with fentanyl use between 2013 and 2023, distributed in the cities of Medellín, Cartagena, Bogotá, Pereira and Villavicencio, without finding reports of deaths due to fentanyl abuse in the department of Huila ( 6 ). Thus, adverse events related to opioids, as well as the epidemic of excessive use of them, has motivated specialists to replace them and opt for the use of techniques based on complementary medications ( 7 ). Opioid-free anesthesia (OFA) has demonstrated a decrease in hypotensive events, lower consumption of rescue analgesics and ondansetron in laparoscopic abdominal surgery ( 8 ). In a meta-analysis evaluating 33 randomized controlled clinical trials, it was found that patients who received OFA had lower pain levels at 2 hours postoperatively, required lower doses of morphine at 2 and 24 hours after the surgical procedure, and additionally had a lower incidence of nausea, vomiting, sedation, and chills ( 9 ). Although current evidence focuses the benefits of OFA mainly on the prevention of postoperative adverse events, the benefit and safety of these regimens in particular surgical procedures such as gynecologic oncologic surgeries remains to be elucidated, where studies comparing the use of intra- or postoperative opioids versus opioid-free techniques are limited. New studies are required to support the generation of universal anesthetic management recommendations and protocols to impact postoperative patient outcomes, satisfaction, and quality of life. Therefore, in order to offer an effective alternative that reduces opioid consumption and its unwanted effects ( 10 – 13 ), opioid-free techniques have been developed at the Hernando Moncaleano Perdomo University Hospital in Neiva, which allowed us to raise the question: What is the effectiveness and safety of opioid-free anesthesia and analgesia in pain control and postoperative recovery of adult patients undergoing gynecologic-oncologic surgery? METHODOLOGY • Study design: This study answered the research question and objectives set out through a retrospective observational cohort analytical design. The approval by the medical ethics committee of the Moncaleano Perdomo University Hospital was submitted on December 14, 2023, which was approved by approval act No. 12 − 07. • Place and time: The population information was obtained from the medical records of adult patients undergoing gynecologic oncology surgery at the Hospital Universitario de Neiva between the period from January 2021 to December 2022. • Inclusion and Exclusion Criteria: All patients undergoing gynecologic oncology surgery at the Neiva University Hospital between the period from January 2021 to December 2022 were included. Patients who were administered during the intra- and postoperative period (no opioid drugs administered by any intravenous, oral, rectal, intrathecal or epidural route) were included as OFA. Those who were administered opioids that met the complete proposed variables were included as Opioid-based Anesthesia (OBA). Exclusion criterias where patients who had underreporting or missing data in their clinical histories for sample collection, cases of mortality or data that did not meet the objectives proposed in the research work were not taken into account. • Data collection Information was collected through Microsoft Excel®, which was completed solely by the principal researcher (JAPG) based on the information recorded in the institution's official legal document (medical records). Variables such as the age in years, BMI, history of heart disease, respiratory disease, anemia, kidney disease, liver disease, vascular disease, chronic pain, smoking, drug use, alcoholism, American Society of Anesthesiologist classification (ASA), clinical origin and premedication were collected for clinical descriptions. Other variables such as surgical approach, kind of anesthesia, kind of surgical wound, time of surgery, blood loss, medications for induction of anesthesia and medications for anesthesia maintenance were collected for surgery description. Postoperative pain management was collected as the need of epidural catheter, kind of analgesic used and number of analgesic rescues at post surgery immediate recuperation and post surgery late recuperation. Visual analogue pain scale (VAPS) and hemodynamics variables such as Heart rate (HR), Mean arterial pressure (MAP), Respiratory rate (RR), Blood Oxygen Saturation (SaO2), in 7 and 4 different times respectively were collected to evaluate efficacy. VAPS was classified as equal or below to 3 ( = 8). Postoperative complications variables such as vomiting, urinary retention, nausea, hypotension, respiratory depression and delirium were collected to evaluate safety in 4 different times. Variables for efficacy and safety were collected in 7 or 4 different times respectively which were pre surgery, post surgery immediate recuperation, post surgery late recuperation, 24 hour, 48 hours, 5 days and upon discharge from the hospital. • Statical Analysis Data was analyzed using the statistical software Rstudio® version 3.6.1. A descriptive analysis of the information was performed between anesthetic techniques, using means and standard deviations for continuous quantitative variables with normal distribution; medians with interquartile ranges for continuous quantitative variables with non-parametric distributions. Categorical variables were described in absolute and relative frequencies. The association between VAPS, hemodynamics variables and postoperative complications between anesthetic techniques, in the 7 or 4 times periods were explored by bivariate analysis. T-Student's tests for continuous variables or the Mann-Whitney test when they did not meet normality assumptions were used. Contingency tables were constructed for categorical variables and the Chi-square test or Fisher's exact test was calculated when they did not meet the Chi-square assumptions. Significance was established at p = 0.05. For the association analysis, multivariable logistic regression models were built, where the response variable was VAPS at times when significance was obtained and was different from admission to recovery. The explanatory variables were the sociodemographic and clinical/surgical practice data collected. The model was interpreted from the exponential coefficients obtained by the final model (Odds Ratio-OR) in which greater than 1 is better pain control (VAPS = 4). The variables were adjusted and the model that best explained the response variable with the lowest Akaike information criterion (AIC) was selected. RESULTS • Clinical characteristics of patients A total of 387 patients who underwent gynecologic oncologic surgery were collected, of which 335 patients were eligible for the present study and 52 patients were excluded because their medical history was incomplete or they had died during their hospital stay (Fig. 1 ). Of the patients who met the proposed criteria, 196 (58.5%) received OBA regimen and 139 (41.5%) received OFA regimen. Clinical characteristics of the included patients are described in Table 1 . Table 1 clinical characteristics by anesthesia regimen: OBA vs OFA Clinical features OBA OFA Total p Patients n (%) 196 (58.5%) 139(41.5%) 335(100) - Age Median-IQR 48.5 [40–60] 47 [36–61] 47[38–61] 0.43 Ψ IMC (Kg/m2) Median-IQR 25.9 [23.7–30.8] 26.4 [22.6–30.1] 26.0 [23.4–30.3] 0.43 Ψ Cardiovascular disease n (%) 14 (7.1%) 13 (9.4%) 27 (8.1%) 0.46 † Respiratory disease n (%) 11 (5.6%) 2 (1.4%) 13 (3.8%) 0,13 ‡ Anemia n (%) 9 (4.6%) 21 (15.1%) 30 (9.0%) 0,001* † Diabetes n (%) 8 (4.1%) 10 (7.2%) 18 (5.4%) 0.21 † Renal disease n (%) 2 (1.0%) 3 (2.2%) 5 (1.5%) 0.65 ‡ Hepatic disease (%) 5 (2.6%) 3 (2.2%) 8 (2.4%) 0.82 ‡ Chronic pain n (%) 20 (10.3%) 36 (25.9%) 56 (16.8) < 0.0001* † vulvar cancer n (%) 5 (2.6%) 2 (1.4%) 7 (2.1%) 0.38 ‡ Cervical cancer n (%) 31 (15.8%) 17 (12.2%) 48 (14.3%) Endometrial cancer n (%) 33 (16.8%) 30 (21.6%) 63 (18.8%) Ovarian cancer n (%) 98 (50%) 76 (54.7%) 174 (51.9%) Body of uterus cancer n (%) 12 (6.1%) 3 (2.2%) 15 (4.5%) Other gynecologic cancers n (%) 17 (8.7%) 11 (7.9%) 28 (8.4%) Smoking n (%) 8 (4.1%) 6 (4.3%) 14 (4.2%) 1.0 † History of IV analgesics n (%) 1 (0.5%) 0 (0%) 1 (0.3%) 0.39 ‡ Previous use of painkillers n (%) 100 (51%) 99 (71.2%) 199 (59.4%) < 0.0001* † ASA 1 n (%) 10 (5.1%) 0 (0%) 10 (3.0%) 0,002* ‡ ASA 2 n (%) 76 (38.8%) 78 (56.1%) 154 (46%) ASA 3 n (%) 109 (55.6%) 61 (43.9%) 170 (50.7%) ASA 4 n (%) 1 (0.5%) 0 (0%) 1 (0.3%) Outpatient origin n (%) 111 (56.6%) 53 (38.1%) 164 (49%) 0,001* ‡ Hospitalization origin n (%) 84 (42.9%) 83 (59.7%) 167 (49.8%) Urgency origin n (%) 1 (0.5%) 3 (2.2%) 4 (1.2%) Premedication (Acetaminophen (1 gram) + Pregabalin (150 mg) 153 (78.1%) 117 (84.2%) 270 (80.6%) 0,16† * Statistically significant (p < 0.05), † Calculated by χ2 test ‡ Calculated by Fisher's exact test Ψ Calculated by Mann-Whitney U test • Surgical characteristics of patients and Postoperative pain management There were no differences between groups (p = 0.8) in surgical technique which was laparotomy in 120 cases (66.1%) for OBA and 88 cases (63.3%) for OFA; laparoscopy in 71 cases (36.2%) for OBA and 49 cases (35.3%) for OFA and others in procedures such as vulvectomy or vaginal surgery in 5 cases (2.6%) for OBA and 2 cases (1.40%) for OFA. For the kind of anesthesia used, there were no statistically significant differences between the OBA and OFA groups (p = 0.13), being as a general technique for OBA: 186 (94.9%) and OFA: 134 (98.5%) for a total of 320 (96.4%), for regional anesthesia a total of 12 (3.6%) in OBA 10 (5.1%) and OFA 2 (1.5%) scheme. There were no differences between the groups in terms of surgical wound kind (p = 0.10). The time in minutes for the duration of surgery was not different between groups by anesthesia schemes (p = 0.08), with a median of 135 minutes [95–195] for OBA and a median of 148 [113–195] for OFA. The duration of anesthesia in minutes was significant (p = 0.02) for OBA: 180 [125–235] and for OFA 190 [150–245]. All surgical characteristics are described in Table 2 . Table 2 Surgical characteristics by anesthesia regimen: OBA vs OFA Surgical features OBA OFA Total p Laparoscopic approach n (%) 71 (36.2%) 49 (35.3%) 120 (35.8%) 0.8 ‡ Laparotomic approach n (%) 120 (61.2%) 88 (63.3%) 208 (62.1%) Other surgical approach n (%) 5 (2.6%) 2 (1.4%) 7 (2.1%) General anesthesia n (%) 186 (94.9%) 134 (98.5%) 320 (96.4%) 0.13 * ‡ Regional anesthesia n (%) 10 (5.1%) 2 (1.5%) 12 (3.6%) Contaminated surgical wound n (%) 2 (1.0%) 0 (0%) 2 (0.6%) 0.10 ‡ Clean contaminated surgical wound n (%) 144 (73.5%) 96 (69.1%) 240 (71.6%) Clean surgical wound n (%) 50 (25.5%) 43 (30.9%) 93 (27.8%) Surgical time (min) Median-IQR 135.5 [95–195] 148 [112–195)] 141 [105–195] 0.12 Ψ Anesthesia time (min) Median-IQR 180 [125–235] 190 [150–245] 185 [135–240] 0.02* Ψ Blood loss (ml) Median-IQR 300 [200–600] 350 [200–400] 350 [200–600] 0.62 Ψ Anesthesia induction Bupivacaine 0.5% Median-IQR 15 [0] - 15 [0] - Lidocaine (mg) Median-IQR 80 [60–80] 80 [60–80] 80 [60–80] 0.76 Ψ propofol (mg) Median-IQR 100 [80–100] 100 [80–100] 100 [80–100] 0.34 Ψ Ketamine (mg) Median-IQR 20 [15–30] 20 [15–25] 20 [15–25] 0.16 Ψ Fentanyl (mg) Median-IQR 200 [150–200] - 200 [150–200] - Rocuronium (mg) Median-IQR 50 [45–70] 50 [50–70] 50 [50–70] < 0.0001* Ψ Anesthesia maintenance Sevoflurane (MAC) Median-IQR 0.6 [0.5-0. 7] 0.6 [0.5-1] 0.6 [0.5–0.8] 0.58 Ψ Dexmedetomidine (mcg/kg/hour) Median-IQR 0.5 [0.4–0.7] 0.4 [0.3–0.55] 0.4 [0.3–0.55] 0.16Ψ Ketamine (mg/kg/hour) Median-IQR 0.3 [0] 0.2 [0.15–0.36] 0.2 [0.15–0.36] 0.44 Ψ Lidocaine (mg/kg/hour) Median-IQR 1 [1–2] 1 [0] 1 [0] < 0,0001* Ψ Fentanyl (mcg/kg/hour) Median-IQR 2 [2–3] - 2 [2–3] - Remifentanil (mcg/kg/min) Median-IQR 0.2 [0] - 0.2 [0] - * Statistically significant (p < 0.05) † Calculated by χ2 test ‡ Calculated by Fisher's exact test Ψ Calculated by Mann-Whitney U test It was found that at post surgery immediate recuperation there are statically significant diferences in the use of epidural catheter and the need of analgesic rescue (p = < 0.001), in both cases greater for OFA than OBA. At post surgery late recuperation, a great use of bupivacaine Infusion for OFA was identified (p = 0.0006) but not for dipyrone (p = 0.8). All postoperative pain management are summarized in Table 3 . Table 3 Postoperative pain management by anesthesia regimen: OBA vs OFA Analgesic features OBA OFA Total p Post surgery immediate recuperation Epidural Catheter n (%) 152 (77.6%) 137 (98.6%) 289 (86.2%) < 0.001* † none analgesic rescue n (%) 193 (98.5%) 116 (83.5%) 309 (92.2%) < 0.001* † one analgesic rescue n (%) 3 (1.5%) 15 (10.8%) 18 (5.4%) Two analgesic rescue n (%) 0 (0%) 6 (4.3%) 6 (1.8%) three analgesic rescue n (%) 0 (0%) 2 (1.4%) 2 (0.6) Epidural Morphine (mg) Median-IQR 2 [0] - 2 [0] - Ketamine infusion (mg/kg/hour) Median-IQR - 2 [0] 2 [0] - Post surgery late recuperation Bupivacaine Infusion (ml/hour) Median-IQR 4 [4–6] 6 [0] 6 [0] 0.0006* Ψ Dipyrone (gr) Median-IQR 2 [1–2] 2 [0] 2 [0] 0.8 Ψ Morphine (mg) Median-IQR 2 [0] 2 [2–3] 2 [2–3] 0.54 Ψ Ketamine infusion (mg/kg/hour) Median-IQR - 0.2 [0] 0.2 [0] - * Statistically significant (p < 0.05) † Calculated by χ2 test ‡ Calculated by Fisher's exact test Ψ Calculated by Mann-Whitney U test • VASP by anesthesia regimen and time Regarding the pain assessment, the VASP pre surgery was found to have significant differences between the groups (p = 0.001), VAS 7 for a total of 10 (7.2%) for OFA. In the post surgery immediate recuperation time, differences were detected between groups in the VAPS (p = 0.42). For the OBA group in the rating 7 were 6 patients (3.1%), while for the OFA group in the rating 7 were 7 (5.1%) patients. For post surgery late recuperation time there were differences between groups (p 0.05). All those analyses are illustrated in Fig. 2 . • Hemodynamic variables and Postoperative complications by anesthesia regimen and time For MAP it was found to have a close similarity in general. For the hemodynamic variables pre surgery there were significant differences for HR, RR and SaO2 (p < 0.001). For 30 minutes after anesthetic induction, only HR and RR were statically significant (p 0.10). At surgery immediate recuperation time, only Sa02 presented statically significant differences (p = 0.002), Finally, at surgery late recuperation time, HR and MAP were statically significant (p > 0.03). All analysys are illustrated in Fig. 3 . Except for antiemetic requirement, all postoperative complications present percentages below 10% between anesthesia regimen in all 4 times evaluated and no patient present delirium at any time. In many cases, due to the absence of any complication it was nos possible to evaluate possible differences. Only antiemetic requirement at 5 days post surgery evidenced significantly higher prevalence for OFA (p = 0.001), and hypotension with greater prevalence for OBA at 24 hour post surgery (p = 0.02). All results for post operative complications are presented in Fig. 4 . • Multivariable VAPS model Due to only observing statistical significance at 24 hours post surgery after post surgery late recuperation, no other time was evaluated in a logistic multivariate model for VAPS and anesthetic regime. Table 4 shows that hospitalized patients had an OR 2.55 (95% CI 1.13–5.76) times the chance of VAPS < = 3 at 24 hours post surgery compared to patients admitted as outpatients. In contrast, patients with a pre-surgery VAS score of 4–7 had 0.1 (95% CI 0.02–0.6) times less pain control compared to those with a score ≤ 3. Patients with 3 opioid rescues in the recovery room had an OR of 27.03 (95% CI 1.05–695.48) times better pain management at 24 hours postoperatively than those who were not given these drugs as rescue therapy. Similarly, patients with 2 opioid rescues had an OR of 21.6 (95% CI 2.22–209.74) times better pain management at 24 hours postoperatively than those who were not given these drugs as rescue therapy. MAP and RR were other variables with OR of 0.95 (95% CI 0.92–0.98) and OR of 1.36 (1.05–1.78) respectively. No statistically significant OR was observed for anesthesia regimen or any other variable included in the multivariable model which can be found in Table 4 . Table 4 Adjusted multivariable regression model for pain control at 24 hours after surgery (n = 297) Variables OR IC 95% p Constant 13.87 0.0001–75746171 0.74 anesthesia regimen 1.17 0.54–2.5 0.69 Epidural Catheter 0.47 0.13–1.67 0.24 Precedence 0.44 0.20–0.95 0.036 * Surgery time (min) 0.98 0.96–0.99 0.004 * Anesthesia time (min) 1.02 1.002–1.03 0.021 * Previous use of analgesic 0.43 0.19–0.95 0.04 * Hypotension at 24 hours post surgery 0.1 0.01–1.07 0.06 Mean arterial pressure at 24 hours post surgery 0.95 0.92–0.98 0.01 * Respiratory Rate at 24 hours post surgery 1.36 1.05–1.78 0.02 * SaO2 at 24 hours post surgery 0.94 0.82–1.07 0.357 Scope of care Ambulatory 1 - - Hospitalization 2.55 1.13–5.76 0.024 * Urgency 1.64 0.05–51.9 0.778 Pre surgery VAPS = 8 1 - - Number of analgesic rescue at post surgery immediate recuperation time 0 1 - - 1 2.66 0.66–10.64 0.167 2 21.6 2.22–209.74 0.008 * 3 27.07 1.05–695.48 0.046 * Number of analgesic rescue at 24 hours post surgery 0 1 - - 1 0.05 0.004–0.62 0.019 * 2 1 - - 3 1 - - Kind of gynecological cancer Vulvar 1 - - Cervical 1.06 0.01–194.75 0.98 Endometrial 1.37 0.01–266.97 0.907 Ovarian 2.84 0.02–542.84 0.696 Body of uterus 4.7 0.02–1149.38 0.582 Others 2.89 0.01–608.4 0.697 ASA 1 - - - 2 1.02 0.49–2.11 0.962 3 1 - - 4 1 - - Surgical Approach Laparotomy 1 - - Laparoscopic 1.24 0.58–2.68 0.577 other 7.94 0.04–1533.52 0.441 DISCUSSION Since the introduction of intravenous synthetic opioids around the 1960s, the paradigm of balanced anesthesia with opioids has been established ( 14 ). The OFA technique is a multimodal approach that avoids the use of systemic opioids by any route of administration. Instead, drugs with diverse mechanisms of action are used that act synergistically or additively to provide analgesia at different levels of the nociceptive process. Although current evidence on this technique is limited, since approximately 2005 both benefits and disadvantages have been documented in its application, especially in obese patients undergoing bariatric surgery and plastic surgery ( 15 ). Its main advantage lies in the reduction of common adverse events associated with opioids, such as nausea, vomiting, respiratory depression, constipation, tolerance, secondary hyperalgesia, immunomodulation mediated by µ receptors, neurotoxicity, neuronal hypermetabolism and even dependence ( 16 – 18 ). Currently, there is no specific protocol for the perioperative management of cancer patients, although the available evidence suggests that this technique may be beneficial in pathologies such as breast and colorectal cancer. In gynecologic oncologic surgery, the evidence is scarce, and some data suggest its application in laparoscopic gynecologic surgery. Although current oncologic treatments have improved survival, multiple side effects have been documented that affect the quality of life of patients, the prevalence of which varies according to the type of pharmacological treatment ( 19 – 21 ). There are controversies regarding pain management in cancer patients using opioid-free techniques. Some studies question its efficacy, suggesting that it does not provide additional benefits ( 22 ). Although no specific studies have been conducted in gynecologic oncologic surgery with opioid-free anesthesia, Lian Chen et al. evaluated the OFA technique versus OBA in patients undergoing laparoscopic gynecologic surgery under an ERAS protocol. They found that, although OFA was not inferior to the traditional technique in terms of reducing pain measured with VAPS, it cannot be considered an inferior technique ( 23 ). In our study, it was observed that, in a bivariate analysis, the opioid-free technique showed a 4.3% decrease in the pre-procedure VAPS compared to admission to recovery rooms, although pain increased significantly (p < 0.001) upon leaving the recovery room. At 24 hours, pain intensity decreased, but 11.9% of patients still reported poor pain control. At 48 hours, severe and moderate pain was evident in some patients undergoing the opioid-free technique. On the fifth day, moderate pain control improved, with 7.2% of patients and finally, at hospital discharge, patients were pain-free or reported mild pain. It is important to highlight certain variables related to the pain score. History of chronic pain was statistically significant in patients undergoing opioid-free techniques, with 25.9% (36 subjects) versus 10.3% (20 subjects) in those treated with opioids. In addition, prior medication use significantly influenced the statistical analysis, with 71.2% of patients exposed to opioid-free techniques. Among patients receiving opioid-free anesthesia, 98.6% used a neuraxial technique as a cost-saving measure. Postoperatively, patients with the OFA technique were observed to require more opioid rescues: 10.8% needed at least one rescue dose in the recovery room, 15.4% at 24 hours, and 3.7% at 48 hours. Although the opioid-free technique can offer partial pain control, its efficacy depends on several factors previously mentioned. These findings are consistent with existing literature and suggest that opioid-free analgesia may be indicated in certain groups of patients. The OFA technique has been shown to allow a more satisfactory postoperative recovery. In a systematic review by Salomé et al., which included randomized controlled clinical trials comparing OFA with OBA, a reduction in the incidence of postoperative nausea and vomiting was observed, with high certainty in the evidence ( 24 ). The same authors found no significant differences in the incidence of intraoperative tachycardia, bradycardia, hypertension and hypotension ( 24 ), different from those reported in the present study. Feenstra et al. confirmed that, although there were no differences in postoperative pain scores, the quality of recovery was better in the OFA group. Additional benefits of OFA have been reported, such as the reduction in the incidence of postoperative pain ( 25 ). On the other hand, Beloeil et al. conducted a multicenter randomized clinical trial to evaluate the outcomes in the first 48 postoperative hours with a regimen of OFA with dexmedetomidine versus OBA with remifentanil. The results obtained showed the appearance of the composite primary outcome (postoperative hypoxemia, postoperative ileus and postoperative cognitive dysfunction) for the dexmedetomidine group in 122 of 156 (78%) patients and in 105 of 156 (67%) patients in the remifentanil group, concluding that there is a greater risk of adverse effects when exposed to an OFA regimen with dexmedetomidine versus the opioid-based regimen with remifentanil ( 26 ). Regarding complications and safety, our study confirms some problems related to hemodynamic compromise and anesthetic complications. Hypotension was identified as a main complication; Although not statistically significant, 64.8% of patients exposed to opioid-free anesthesia required vasopressor support during their stay in recovery rooms. Bradycardia was also observed with a lower mean in the OFA group, and being different from OBA when leaving the recovery rooms. In addition, antiemetics were noted to be required, which were administered prophylactically in both OBA and OFA patients. However, it was not possible to achieve adequate convergence in the regression models for the main outcomes related to complications (respiratory depression, urinary retention, hypotension, nausea/vomiting and delirium) at the evaluated times (admission to recovery room, 24 hours, 48 ​​hours and fifth day) due to the low frequency of these events. Finally, opting for opioid-free anesthesia presents several challenges. One of the main ones is the appearance of unforeseen adverse effects that can arise from the analgesics used and from the possible interactions between anesthetics. Furthermore, the lack of studies conducted in more homogeneous populations, especially in oncological subgroups, and the lack of research with high methodological quality that evaluates chronic pain after opioid-free anesthesia and the quality of recovery are important limitations. CONCLUSION The OFA technique for gynecologic oncologic surgery patients has a partial impact on pain control, with poor control upon discharge to recovery areas, at 24 and 48 hours; ultimately requiring rescues from potent opioids or exposure to them, therefore it is a partially effective technique in terms of pain control for this group of patients. Regarding complications, hemodynamic compromise such as hypotension and bradycardia presented in this type of patients must be evaluated given their clinical condition and some of them under comorbid conditions, in addition to the evaluation of length of stay in recovery rooms and hospital stays to provide patient-focused care with application to ERAS® protocols. These outcomes are confirmed in other populations that undergo OFA. More studies are required with adequate methodologies and statistical weight that allow reaching a definitive conclusion. Declarations ● Ethics approval and consent to participate. The approval by the medical ethics committee of the Hernando Moncaleano Perdomo University Hospital de Neiva was submitted on December 14, 2023, which was approved by approval act No. 12-07. Our study consists of reviewing medical records for data collection and statistical analysis. The institutional ethics committee did not consider the need for new consent for the data used from these patients, and consent for medical record management that is requested from all those who enter the institution is sufficient. Therefore, an informed consent waiver was used, and the data used in this study were anonymized before use. ● Consent for publication Does not apply. ● Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. ● Conflict of Interests The author(s) declare that they do not have conflicting interests. Additionally, the author(s) received no financial support for the research, authorship, and/or publication of this manuscript. ● Funding The author(s) received no financial support for the research, authorship, and/or publication of this article. ● Author´s contributions Design: JAPG, DRP, EM Performed the literature review: JAPG, DRP, EM Acquisition of data: JAPG Interpretation of data: JAPG, FLCH Wrote the manuscript: JAPG, FLCH ● Acknowledgments We don't have acknowledgements. References Brown EN, Pavone KJ, Naranjo M. Multimodal General Anesthesia: Theory and Practice. Anesth Analg. 2018;127(5):1246-58. Tung A. New anesthesia techniques. Thorac Surg Clin. 2005;15(1):27-38. Swegle JM, Logemann C. Management of common opioid-induced adverse effects. Am Fam Physician. 2006;74(8):1347-54. Benyamin R, Trescot AM, Datta S, Buenaventura R, Adlaka R, Sehgal N, et al. Opioid complications and side effects. Pain Physician. 2008;11(2 Suppl):S105-20. Bakan M, Umutoglu T, Topuz U, Uysal H, Bayram M, Kadioglu H, et al. Opioid- free total intravenous anesthesia with propofol, dexmedetomidine and lidocaine infusions for laparoscopic cholecystectomy: a prospective, randomized, double- blinded study. Braz J Anesthesiol. 2015;65(3):191-9. https://www.minjusticia.gov.co/programasco/ODC/Documents/SAT/Alertas/2019%2008%20Alerta%20Opioides.pdf Egan TD. Are opioids indispensable for general anaesthesia? Br J Anaesth. 2019;122(6):e127-e35. Bakan M, Umutoglu T, Topuz U, Uysal H, Bayram M, Kadioglu H, et al. Opioid- free total intravenous anesthesia with propofol, dexmedetomidine and lidocaine infusions for laparoscopic cholecystectomy: a prospective, randomized, double- blinded study. Braz J Anesthesiol. 2015;65(3):191-9. Salome A, Harkouk H, Fletcher D, Martinez V. Opioid-Free Anesthesia Benefit- Risk Balance: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Clin Med. 2021;10(10). Rawal N. Current issues in postoperative pain management. Eur J Anaesthesiol. 2016;33(3):160-71. Cali Cassi L, Biffoli F, Francesconi D, Petrella G, Buonomo O. Anesthesia and analgesia in breast surgery: the benefits of peripheral nerve block. Eur Rev Med Pharmacol Sci. 2017;21(6):1341-5. Wheatley RG, Schug SA, Watson D. Safety and efficacy of postoperative epidural analgesia. Br J Anaesth. 2001;87(1):47-61. Dieu A, Huynen P, Lavand'homme P, Beloeil H, Freys SM, Pogatzki-Zahn EM, et al. Pain management after open liver resection: Procedure-Specific Postoperative Pain Management (PROSPECT) recommendations. Reg Anesth Pain Med. 2021;46(5):433-45. Bugada, Dario, et al. “Opioid-Free Anesthesia and Postoperative Outcomes in Cancer Surgery: A Systematic Review.” Cancers , vol. 15, no. 1, 22 Dec. 2022, p. 64, https://doi.org/10.3390/cancers15010064. Accessed 18 Aug. 2024. Friedberg BL. Propofol-ketamine technique: dissociative anesthesia for office surgery (a 5-year review of 1264 cases). Aesthetic Plast Surg 1999; 23:70–75. 2 Mulier JP, Wouters R, Dillemans B, De Kock M. A randomized controlled, double-blind trial evaluating the effect of opioid-free versus opioid general anaesthesia on postoperative pain and discomfort measured by the QoR-40. J Clin Anesth Pain Med 2018; 2:15. Sacerdote P, Franchi S, Panerai AE. Non-Analgesic Effects of Opioids: Mechanisms and Potential Clinical Relevance of Opioid-Induced Immunodepression. Curr Pharm Des. 2012;18:6034–42. Andrew Kofke W, Attaallah AF, Kuwabara H, Garman RH, Sinz EH, Barbaccia J, et al. The Neuropathologic Effects in Rats and Neurometabolic Effects in Humans of Large-Dose Remifentanil [Internet]. Available from: http://journals.lww.com/anesthesia-analgesia Watts N, Amann M, Ayeb-Karlsson S, Belesova K, Bouley T, Boykoff M, et al. The Lancet Countdown on health and climate change: from 25 years of inaction to a global transformation for public health. Vol. 391, The Lancet. Lancet Publishing Group; 2018. p. 581–630. Ray-Coquard I, Morice P, Lorusso D, Prat J, Oaknin A, Pautier P, et al. Non-epithelial ovarian cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of Oncology. 2018 Oct 1;29:iv1–18. Oaknin A, Bosse TJ, Creutzberg CL, Giornelli G, Harter P, Joly F, et al. Endometrial cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up ☆. Annals of Oncology. 2022 Sep 1;33(9):860–77. Shalowitz DI, Epstein AJ, Buckingham L, Ko EM, Giuntoli RL. Survival implications of time to surgical treatment of endometrial cancers. Am J Obstet Gynecol. 2017 Mar 1;216(3):268.e1-268.e18. Shanthanna H, Ladha KS, Kehlet H, Joshi GP. Administración perioperatoria de opioides. Anestesiología. 2021; 134 (4):645–659. Doi: 10.1097/ALN.0000000000003572. Chen, Liang, et al. “Application of Opioid-Free General Anesthesia for Gynecological Laparoscopic Surgery under ERAS Protocol: A Non-Inferiority Randomized Controlled Trial.” BMC Anesthesiology , vol. 23, no. 1, 27 Jan. 2023, https://doi.org/10.1186/s12871-023-01994-5. Accessed 19 Aug. 2024. Salomé A, Harkouk H, Fletcher D, Martinez V. Opioid-free anesthesia benefit–risk balance: a systematic review and meta-analysis of randomized controlled trials. Vol. Journal of Clinical Medicine. MDPI; 2021 Feenstra ML, Jansen S, Eshuis WJ, van Berge Henegouwen MI, Hollmann MW, Hermanides J. Opioid-free anesthesia: A systematic review and meta-analysis. Vol. 90, Journal of Clinical Anesthesia. Elsevier Inc.; 2023. Beloeil H, Garot M, Lebuffe G, Gerbaud A, Bila J, Cuvillon P, et al. Balanced Opioidfree Anesthesia with Dexmedetomidine versus Balanced Anesthesia with Remifentanil for Major or Intermediate Noncardiac Surgery: The Postoperative and Opioid-free Anesthesia (POFA) Randomized Clinical Trial. Anesthesiology. 2021 Apr 1;134(4):541–51. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 14 Feb, 2025 Read the published version in BMC Anesthesiology → Version 1 posted Editorial decision: Revision requested 16 Oct, 2024 Editor assigned by journal 16 Oct, 2024 Submission checks completed at journal 15 Oct, 2024 First submitted to journal 13 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5257068","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":366704109,"identity":"67a4f6b1-1e91-4660-a3f8-215e3664df55","order_by":0,"name":"Jose Alexander Puentes Garcia","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/0lEQVRIiWNgGAWjYBAC9gbmBhDNCCSZH36oADKZISI4AWMDI1wLm7HEGZAWRuK1MEjwtsHZeLS0H2x8zFNzR7Zf+uwBA8l5tdH87UAtPyq24dbSk9hsOOPYM+OZfXkJDwq3Hc+dcRhoc8+Z23gcltgm8YHtcOKGMzwGBpLbjuU2ALUwM7bh0dL/sP1Hwr/DifuBWiR45xzLnU9Ii+CMxDaGj21AW3hAWhpqcjcQ0iIt8bBZcmbfYeMZZ/jSjCWOHcjdCNRyEJ9f+PiTD37m+XZYtr+H9/DDDzV1ufPOHz744EcFbi1IgAdEHAYzDxCjHqaljkjFo2AUjIJRMJIAAFISYlG0H8SLAAAAAElFTkSuQmCC","orcid":"","institution":"Hospital Universitario de Neiva","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Jose","middleName":"Alexander Puentes","lastName":"Garcia","suffix":""},{"id":366704110,"identity":"30a021d5-63c3-4c6a-b7cd-04ee178db5c2","order_by":1,"name":"Daniel Rivera Tocancipa","email":"","orcid":"","institution":"Hospital Universitario de 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06:30:03","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":198659,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePain control over time\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-5257068/v1/d496791e7da4e22a6988d7d6.png"},{"id":71727299,"identity":"aa621415-496c-45cb-929a-d8b42233062f","added_by":"auto","created_at":"2024-12-18 06:22:03","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":158845,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAnesthesia regimen and hemodynamic variables\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-5257068/v1/3fbacd35926112308194f0ee.png"},{"id":71726476,"identity":"c861fc44-617a-4f02-95a3-81e27d3c6d59","added_by":"auto","created_at":"2024-12-18 06:14:03","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":192518,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAnesthesia regimen and Postoperative complications.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-5257068/v1/8bdcf919eaf577bc1dd107a6.png"},{"id":76487470,"identity":"6f8706c7-a414-413e-a49a-57e5c0dd8bb8","added_by":"auto","created_at":"2025-02-17 16:07:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1554006,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5257068/v1/04522be9-6469-483d-8abf-134e024dba68.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effectiveness and safety of opioid-free anaesthesia and analgesia in pain control and postoperative recovery of patients undergoing gynaecologic oncologic surgery: a retrospective cohort study","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eBalanced anesthesia involves the administration and combination of different pharmacological groups to achieve an optimal anesthetic state by achieving more adjusted doses, increasing the proportion of desired effects and reducing side effects (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). In turn, general anesthesia could be defined as the result of the pharmacological combination that seeks to achieve its fundamental pillars, the loss of consciousness or hypnosis, amnesia, and immobility during the surgical procedure, together with adequate control of postoperative pain avoiding hemodynamic alterations; all dependent on specific therapeutic agents and sensitive to the body's response according to the doses used (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMultiple drugs meet the aforementioned objectives, opioids are considered the second most used drug after inhaled agents and propofol. Their preference lies in the controlling effect of the central nervous system's responses to nociception, maintaining stable hemodynamics, in addition to their effects on postoperative pain control, decreased anesthetic requirements and control of the sympathetic response (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). However, the administration of opioids in the perioperative period involves a risk due to the high incidence of minor adverse events in about 82% of cases and moderate events in 13.6%. Sedation, transient delirium, dizziness, nausea and vomiting, constipation, respiratory depression, and increased stay in the post-anesthesia care unit are frequent and unwanted side effects in early postoperative recovery techniques (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn addition, drug dependence and chronic abuse of patients using opioids in the intra- and postoperative period affects developed countries to the point of constituting a \u0026ldquo;crisis\u0026rdquo;. For example, in the United States nearly 107000 overdose deaths were reported in 2021, of which 75% were related to an opioid (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). In Colombia, the Ministry of Justice reported 30 deaths associated with fentanyl use between 2013 and 2023, distributed in the cities of Medell\u0026iacute;n, Cartagena, Bogot\u0026aacute;, Pereira and Villavicencio, without finding reports of deaths due to fentanyl abuse in the department of Huila (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThus, adverse events related to opioids, as well as the epidemic of excessive use of them, has motivated specialists to replace them and opt for the use of techniques based on complementary medications (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Opioid-free anesthesia (OFA) has demonstrated a decrease in hypotensive events, lower consumption of rescue analgesics and ondansetron in laparoscopic abdominal surgery (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). In a meta-analysis evaluating 33 randomized controlled clinical trials, it was found that patients who received OFA had lower pain levels at 2 hours postoperatively, required lower doses of morphine at 2 and 24 hours after the surgical procedure, and additionally had a lower incidence of nausea, vomiting, sedation, and chills (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough current evidence focuses the benefits of OFA mainly on the prevention of postoperative adverse events, the benefit and safety of these regimens in particular surgical procedures such as gynecologic oncologic surgeries remains to be elucidated, where studies comparing the use of intra- or postoperative opioids versus opioid-free techniques are limited. New studies are required to support the generation of universal anesthetic management recommendations and protocols to impact postoperative patient outcomes, satisfaction, and quality of life.\u003c/p\u003e \u003cp\u003eTherefore, in order to offer an effective alternative that reduces opioid consumption and its unwanted effects (\u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), opioid-free techniques have been developed at the Hernando Moncaleano Perdomo University Hospital in Neiva, which allowed us to raise the question: What is the effectiveness and safety of opioid-free anesthesia and analgesia in pain control and postoperative recovery of adult patients undergoing gynecologic-oncologic surgery?\u003c/p\u003e"},{"header":"METHODOLOGY","content":"\u003cp\u003e\u0026bull; Study design:\u003c/p\u003e \u003cp\u003eThis study answered the research question and objectives set out through a retrospective observational cohort analytical design. The approval by the medical ethics committee of the Moncaleano Perdomo University Hospital was submitted on December 14, 2023, which was approved by approval act No. 12\u0026thinsp;\u0026minus;\u0026thinsp;07.\u003c/p\u003e \u003cp\u003e\u0026bull; Place and time:\u003c/p\u003e \u003cp\u003eThe population information was obtained from the medical records of adult patients undergoing gynecologic oncology surgery at the Hospital Universitario de Neiva between the period from January 2021 to December 2022.\u003c/p\u003e \u003cp\u003e\u0026bull; Inclusion and Exclusion Criteria:\u003c/p\u003e \u003cp\u003eAll patients undergoing gynecologic oncology surgery at the Neiva University Hospital between the period from January 2021 to December 2022 were included. Patients who were administered during the intra- and postoperative period (no opioid drugs administered by any intravenous, oral, rectal, intrathecal or epidural route) were included as OFA. Those who were administered opioids that met the complete proposed variables were included as Opioid-based Anesthesia (OBA). Exclusion criterias where patients who had underreporting or missing data in their clinical histories for sample collection, cases of mortality or data that did not meet the objectives proposed in the research work were not taken into account.\u003c/p\u003e \u003cp\u003e\u0026bull; Data collection\u003c/p\u003e \u003cp\u003eInformation was collected through Microsoft Excel\u0026reg;, which was completed solely by the principal researcher (JAPG) based on the information recorded in the institution's official legal document (medical records). Variables such as the age in years, BMI, history of heart disease, respiratory disease, anemia, kidney disease, liver disease, vascular disease, chronic pain, smoking, drug use, alcoholism, American Society of Anesthesiologist classification (ASA), clinical origin and premedication were collected for clinical descriptions. Other variables such as surgical approach, kind of anesthesia, kind of surgical wound, time of surgery, blood loss, medications for induction of anesthesia and medications for anesthesia maintenance were collected for surgery description. Postoperative pain management was collected as the need of epidural catheter, kind of analgesic used and number of analgesic rescues at post surgery immediate recuperation and post surgery late recuperation.\u003c/p\u003e \u003cp\u003eVisual analogue pain scale (VAPS) and hemodynamics variables such as Heart rate (HR), Mean arterial pressure (MAP), Respiratory rate (RR), Blood Oxygen Saturation (SaO2), in 7 and 4 different times respectively were collected to evaluate efficacy. VAPS was classified as equal or below to 3 (\u0026thinsp;\u0026lt;\u0026thinsp;=\u0026thinsp;3), between 4 and 7 (\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) and greater or equal to 8 (\u0026thinsp;\u0026gt;\u0026thinsp;=\u0026thinsp;8). Postoperative complications variables such as vomiting, urinary retention, nausea, hypotension, respiratory depression and delirium were collected to evaluate safety in 4 different times. Variables for efficacy and safety were collected in 7 or 4 different times respectively which were pre surgery, post surgery immediate recuperation, post surgery late recuperation, 24 hour, 48 hours, 5 days and upon discharge from the hospital.\u003c/p\u003e \u003cp\u003e\u0026bull; Statical Analysis\u003c/p\u003e \u003cp\u003eData was analyzed using the statistical software Rstudio\u0026reg; version 3.6.1. A descriptive analysis of the information was performed between anesthetic techniques, using means and standard deviations for continuous quantitative variables with normal distribution; medians with interquartile ranges for continuous quantitative variables with non-parametric distributions. Categorical variables were described in absolute and relative frequencies. The association between VAPS, hemodynamics variables and postoperative complications between anesthetic techniques, in the 7 or 4 times periods were explored by bivariate analysis. T-Student's tests for continuous variables or the Mann-Whitney test when they did not meet normality assumptions were used. Contingency tables were constructed for categorical variables and the Chi-square test or Fisher's exact test was calculated when they did not meet the Chi-square assumptions. Significance was established at p\u0026thinsp;=\u0026thinsp;0.05.\u003c/p\u003e \u003cp\u003eFor the association analysis, multivariable logistic regression models were built, where the response variable was VAPS at times when significance was obtained and was different from admission to recovery. The explanatory variables were the sociodemographic and clinical/surgical practice data collected. The model was interpreted from the exponential coefficients obtained by the final model (Odds Ratio-OR) in which greater than 1 is better pain control (VAPS\u0026thinsp;\u0026lt;\u0026thinsp;=\u0026thinsp;3) and lower than 1 in worst pain control (VAPS\u0026thinsp;\u0026gt;\u0026thinsp;=\u0026thinsp;4). The variables were adjusted and the model that best explained the response variable with the lowest Akaike information criterion (AIC) was selected.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u0026bull; Clinical characteristics of patients\u003c/p\u003e \u003cp\u003eA total of 387 patients who underwent gynecologic oncologic surgery were collected, of which 335 patients were eligible for the present study and 52 patients were excluded because their medical history was incomplete or they had died during their hospital stay (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Of the patients who met the proposed criteria, 196 (58.5%) received OBA regimen and 139 (41.5%) received OFA regimen. Clinical characteristics of the included patients are described in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eclinical characteristics by anesthesia regimen: OBA vs OFA\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical features\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOBA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOFA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatients n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e196 (58.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e139(41.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e335(100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge Median-IQR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48.5 [40\u0026ndash;60]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47 [36\u0026ndash;61]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47[38\u0026ndash;61]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.43 Ψ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIMC (Kg/m2) Median-IQR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.9 [23.7\u0026ndash;30.8]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.4 [22.6\u0026ndash;30.1]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.0 [23.4\u0026ndash;30.3]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.43 Ψ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiovascular disease n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (7.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (9.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27 (8.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.46 \u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRespiratory disease n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (5.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (3.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,13 \u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnemia n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (4.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (15.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30 (9.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,001* \u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (4.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (7.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 (5.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.21 \u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRenal disease n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (2.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (1.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.65 \u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHepatic disease (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (2.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (2.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (2.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.82 \u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic pain n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (10.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36 (25.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56 (16.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001* \u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003evulvar cancer n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (2.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (2.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e0.38 \u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCervical cancer n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (15.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (12.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e48 (14.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEndometrial cancer n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (16.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (21.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e63 (18.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOvarian cancer n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e98 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76 (54.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e174 (51.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody of uterus cancer n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (6.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (2.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (4.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther gynecologic cancers n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (8.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (7.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28 (8.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (4.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (4.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (4.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.0 \u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory of IV analgesics n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (0.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.39 \u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious use of painkillers n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100 (51%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e99 (71.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e199 (59.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001* \u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA 1 n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (5.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (3.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0,002* \u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA 2 n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76 (38.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78 (56.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e154 (46%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA 3 n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e109 (55.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61 (43.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e170 (50.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA 4 n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (0.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutpatient origin n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e111 (56.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53 (38.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e164 (49%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0,001* \u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospitalization origin n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84 (42.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83 (59.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e167 (49.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrgency origin n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (2.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (1.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePremedication\u003c/p\u003e \u003cp\u003e(Acetaminophen (1 gram)\u003c/p\u003e \u003cp\u003e+ Pregabalin (150 mg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e153 (78.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e117 (84.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e270 (80.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,16\u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e* Statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05),\u003c/p\u003e \u003cp\u003e\u0026dagger; Calculated by χ2 test\u003c/p\u003e \u003cp\u003e\u0026Dagger; Calculated by Fisher's exact test\u003c/p\u003e \u003cp\u003eΨ Calculated by Mann-Whitney U test\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u0026bull; Surgical characteristics of patients and Postoperative pain management\u003c/p\u003e \u003cp\u003eThere were no differences between groups (p\u0026thinsp;=\u0026thinsp;0.8) in surgical technique which was laparotomy in 120 cases (66.1%) for OBA and 88 cases (63.3%) for OFA; laparoscopy in 71 cases (36.2%) for OBA and 49 cases (35.3%) for OFA and others in procedures such as vulvectomy or vaginal surgery in 5 cases (2.6%) for OBA and 2 cases (1.40%) for OFA. For the kind of anesthesia used, there were no statistically significant differences between the OBA and OFA groups (p\u0026thinsp;=\u0026thinsp;0.13), being as a general technique for OBA: 186 (94.9%) and OFA: 134 (98.5%) for a total of 320 (96.4%), for regional anesthesia a total of 12 (3.6%) in OBA 10 (5.1%) and OFA 2 (1.5%) scheme. There were no differences between the groups in terms of surgical wound kind (p\u0026thinsp;=\u0026thinsp;0.10). The time in minutes for the duration of surgery was not different between groups by anesthesia schemes (p\u0026thinsp;=\u0026thinsp;0.08), with a median of 135 minutes [95\u0026ndash;195] for OBA and a median of 148 [113\u0026ndash;195] for OFA. The duration of anesthesia in minutes was significant (p\u0026thinsp;=\u0026thinsp;0.02) for OBA: 180 [125\u0026ndash;235] and for OFA 190 [150\u0026ndash;245]. All surgical characteristics are described in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSurgical characteristics by anesthesia regimen: OBA vs OFA\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical features\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOBA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOFA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaparoscopic approach n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71 (36.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49 (35.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e120 (35.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.8 \u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaparotomic approach n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e120 (61.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88 (63.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e208 (62.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther surgical approach n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (2.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (2.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral anesthesia n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e186 (94.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e134 (98.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e320 (96.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.13 * \u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegional anesthesia n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (5.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (3.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContaminated surgical wound n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (0.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.10 \u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClean contaminated surgical wound\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e144 (73.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96 (69.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e240 (71.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClean surgical wound n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 (25.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43 (30.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e93 (27.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical time (min) Median-IQR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e135.5 [95\u0026ndash;195]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e148 [112\u0026ndash;195)]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e141 [105\u0026ndash;195]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.12 Ψ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnesthesia time (min) Median-IQR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e180 [125\u0026ndash;235]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e190 [150\u0026ndash;245]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e185 [135\u0026ndash;240]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.02* Ψ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood loss (ml) Median-IQR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e300 [200\u0026ndash;600]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e350 [200\u0026ndash;400]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e350 [200\u0026ndash;600]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.62 Ψ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eAnesthesia induction\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBupivacaine 0.5% Median-IQR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 [0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 [0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLidocaine (mg) Median-IQR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80 [60\u0026ndash;80]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80 [60\u0026ndash;80]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e80 [60\u0026ndash;80]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.76 Ψ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epropofol (mg) Median-IQR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100 [80\u0026ndash;100]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100 [80\u0026ndash;100]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100 [80\u0026ndash;100]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.34 Ψ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKetamine (mg) Median-IQR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 [15\u0026ndash;30]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 [15\u0026ndash;25]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20 [15\u0026ndash;25]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.16 Ψ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFentanyl (mg) Median-IQR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e200 [150\u0026ndash;200]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e200 [150\u0026ndash;200]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRocuronium (mg) Median-IQR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 [45\u0026ndash;70]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50 [50\u0026ndash;70]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50 [50\u0026ndash;70]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001* Ψ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eAnesthesia maintenance\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevoflurane (MAC) Median-IQR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.6 [0.5-0. 7]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.6 [0.5-1]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.6 [0.5\u0026ndash;0.8]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.58 Ψ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDexmedetomidine (mcg/kg/hour) Median-IQR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.5 [0.4\u0026ndash;0.7]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.4 [0.3\u0026ndash;0.55]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.4 [0.3\u0026ndash;0.55]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.16Ψ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKetamine (mg/kg/hour) Median-IQR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.3 [0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.2 [0.15\u0026ndash;0.36]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.2 [0.15\u0026ndash;0.36]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.44 Ψ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLidocaine (mg/kg/hour) Median-IQR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 [1\u0026ndash;2]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 [0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 [0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0,0001* Ψ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFentanyl (mcg/kg/hour) Median-IQR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 [2\u0026ndash;3]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 [2\u0026ndash;3]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRemifentanil (mcg/kg/min) Median-IQR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.2 [0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.2 [0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e* Statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05)\u003c/p\u003e \u003cp\u003e\u0026dagger; Calculated by χ2 test\u003c/p\u003e \u003cp\u003e\u0026Dagger; Calculated by Fisher's exact test\u003c/p\u003e \u003cp\u003eΨ Calculated by Mann-Whitney U test\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIt was found that at post surgery immediate recuperation there are statically significant diferences in the use of epidural catheter and the need of analgesic rescue (p\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.001), in both cases greater for OFA than OBA. At post surgery late recuperation, a great use of bupivacaine Infusion for OFA was identified (p\u0026thinsp;=\u0026thinsp;0.0006) but not for dipyrone (p\u0026thinsp;=\u0026thinsp;0.8). All postoperative pain management are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePostoperative pain management by anesthesia regimen: OBA vs OFA\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnalgesic features\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOBA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOFA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003ePost surgery immediate recuperation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEpidural Catheter n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e152 (77.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e137 (98.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e289 (86.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001* \u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003enone analgesic rescue n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e193 (98.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e116 (83.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e309 (92.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001* \u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eone analgesic rescue n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (10.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 (5.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTwo analgesic rescue n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (4.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (1.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ethree analgesic rescue n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (0.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEpidural Morphine (mg) Median-IQR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 [0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 [0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKetamine infusion (mg/kg/hour) Median-IQR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 [0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 [0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003ePost surgery late recuperation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBupivacaine Infusion (ml/hour) Median-IQR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 [4\u0026ndash;6]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 [0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 [0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.0006* Ψ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDipyrone (gr) Median-IQR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 [1\u0026ndash;2]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 [0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 [0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.8 Ψ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMorphine (mg) Median-IQR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 [0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 [2\u0026ndash;3]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 [2\u0026ndash;3]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.54 Ψ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKetamine infusion (mg/kg/hour) Median-IQR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.2 [0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.2 [0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e* Statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05)\u003c/p\u003e \u003cp\u003e\u0026dagger; Calculated by χ2 test\u003c/p\u003e \u003cp\u003e\u0026Dagger; Calculated by Fisher's exact test\u003c/p\u003e \u003cp\u003eΨ Calculated by Mann-Whitney U test\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u0026bull; VASP by anesthesia regimen and time\u003c/p\u003e \u003cp\u003eRegarding the pain assessment, the VASP pre surgery was found to have significant differences between the groups (p\u0026thinsp;=\u0026thinsp;0.001), VAS\u0026thinsp;\u0026lt;\u0026thinsp;=\u0026thinsp;3 pre surgery was 280 patients (84.4%) for all patients, 176 (90.2%) for OBA and 106 (76.3%) for OFA. VASP 4\u0026ndash;7 for OBA was 19 (9.7%) and OFA 23 (16.5%) for a total of 42 patients (12.6%) and VAS\u0026thinsp;\u0026gt;\u0026thinsp;7 for a total of 10 (7.2%) for OFA. In the post surgery immediate recuperation time, differences were detected between groups in the VAPS (p\u0026thinsp;=\u0026thinsp;0.42). For the OBA group in the rating\u0026thinsp;\u0026lt;\u0026thinsp;=\u0026thinsp;3 there were 179 patients (91.8%), between 4\u0026ndash;7 were 10 patients (5.1%) and \u0026gt;\u0026thinsp;7 were 6 patients (3.1%), while for the OFA group in the rating\u0026thinsp;\u0026lt;\u0026thinsp;=\u0026thinsp;3 there were 119 patients (87.5%), between 4\u0026ndash;7 were 10 patients (7.4%) and \u0026gt;\u0026thinsp;7 were 7 (5.1%) patients. For post surgery late recuperation time there were differences between groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), but at 24 hours there were differences in pain assessment between groups (p\u0026thinsp;=\u0026thinsp;0.02). No differences were observed at 48 hours, 5 days and upon discharge from the hospital (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). All those analyses are illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e\u0026bull; Hemodynamic variables and Postoperative complications by anesthesia regimen and time\u003c/p\u003e \u003cp\u003eFor MAP it was found to have a close similarity in general. For the hemodynamic variables pre surgery there were significant differences for HR, RR and SaO2 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). For 30 minutes after anesthetic induction, only HR and RR were statically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), but not for the rest of the hemodynamic variables (p\u0026thinsp;\u0026gt;\u0026thinsp;0.10). At surgery immediate recuperation time, only Sa02 presented statically significant differences (p\u0026thinsp;=\u0026thinsp;0.002), Finally, at surgery late recuperation time, HR and MAP were statically significant (p\u0026thinsp;\u0026gt;\u0026thinsp;0.03). All analysys are illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eExcept for antiemetic requirement, all postoperative complications present percentages below 10% between anesthesia regimen in all 4 times evaluated and no patient present delirium at any time. In many cases, due to the absence of any complication it was nos possible to evaluate possible differences. Only antiemetic requirement at 5 days post surgery evidenced significantly higher prevalence for OFA (p\u0026thinsp;=\u0026thinsp;0.001), and hypotension with greater prevalence for OBA at 24 hour post surgery (p\u0026thinsp;=\u0026thinsp;0.02). All results for post operative complications are presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e\u0026bull; Multivariable VAPS model\u003c/p\u003e \u003cp\u003eDue to only observing statistical significance at 24 hours post surgery after post surgery late recuperation, no other time was evaluated in a logistic multivariate model for VAPS and anesthetic regime. Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows that hospitalized patients had an OR 2.55 (95% CI 1.13\u0026ndash;5.76) times the chance of VAPS\u0026thinsp;\u0026lt;\u0026thinsp;=\u0026thinsp;3 at 24 hours post surgery compared to patients admitted as outpatients. In contrast, patients with a pre-surgery VAS score of 4\u0026ndash;7 had 0.1 (95% CI 0.02\u0026ndash;0.6) times less pain control compared to those with a score\u0026thinsp;\u0026le;\u0026thinsp;3. Patients with 3 opioid rescues in the recovery room had an OR of 27.03 (95% CI 1.05\u0026ndash;695.48) times better pain management at 24 hours postoperatively than those who were not given these drugs as rescue therapy. Similarly, patients with 2 opioid rescues had an OR of 21.6 (95% CI 2.22\u0026ndash;209.74) times better pain management at 24 hours postoperatively than those who were not given these drugs as rescue therapy. MAP and RR were other variables with OR of 0.95 (95% CI 0.92\u0026ndash;0.98) and OR of 1.36 (1.05\u0026ndash;1.78) respectively. No statistically significant OR was observed for anesthesia regimen or any other variable included in the multivariable model which can be found in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAdjusted multivariable regression model for pain control at 24 hours after surgery (n\u0026thinsp;=\u0026thinsp;297)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIC 95%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConstant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.0001\u0026ndash;75746171\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.74\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eanesthesia regimen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.54\u0026ndash;2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEpidural Catheter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.13\u0026ndash;1.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrecedence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.20\u0026ndash;0.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.036 *\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgery time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.96\u0026ndash;0.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.004 *\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnesthesia time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.002\u0026ndash;1.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.021 *\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious use of analgesic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.19\u0026ndash;0.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.04 *\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypotension at 24 hours post surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.01\u0026ndash;1.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean arterial pressure at 24 hours post surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.92\u0026ndash;0.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.01 *\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRespiratory Rate at 24 hours post surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.05\u0026ndash;1.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.02 *\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSaO2 at 24 hours post surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.82\u0026ndash;1.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.357\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eScope of care\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmbulatory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospitalization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.13\u0026ndash;5.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.024 *\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrgency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.05\u0026ndash;51.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.778\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003ePre surgery VAPS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;= 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u0026ndash;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.02\u0026ndash;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.011 *\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;= 8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eNumber of analgesic rescue at post surgery immediate recuperation time\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.66\u0026ndash;10.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.167\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.22\u0026ndash;209.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.008 *\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.05\u0026ndash;695.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.046 *\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eNumber of analgesic rescue at 24 hours post surgery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.004\u0026ndash;0.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.019 *\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eKind of gynecological cancer\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVulvar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCervical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.01\u0026ndash;194.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.98\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEndometrial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.01\u0026ndash;266.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.907\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOvarian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.02\u0026ndash;542.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.696\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody of uterus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.02\u0026ndash;1149.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.582\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.01\u0026ndash;608.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.697\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eASA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.49\u0026ndash;2.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.962\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eSurgical Approach\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaparotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaparoscopic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.58\u0026ndash;2.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.577\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eother\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.04\u0026ndash;1533.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.441\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eSince the introduction of intravenous synthetic opioids around the 1960s, the paradigm of balanced anesthesia with opioids has been established (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The OFA technique is a multimodal approach that avoids the use of systemic opioids by any route of administration. Instead, drugs with diverse mechanisms of action are used that act synergistically or additively to provide analgesia at different levels of the nociceptive process. Although current evidence on this technique is limited, since approximately 2005 both benefits and disadvantages have been documented in its application, especially in obese patients undergoing bariatric surgery and plastic surgery (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Its main advantage lies in the reduction of common adverse events associated with opioids, such as nausea, vomiting, respiratory depression, constipation, tolerance, secondary hyperalgesia, immunomodulation mediated by \u0026micro; receptors, neurotoxicity, neuronal hypermetabolism and even dependence (\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Currently, there is no specific protocol for the perioperative management of cancer patients, although the available evidence suggests that this technique may be beneficial in pathologies such as breast and colorectal cancer. In gynecologic oncologic surgery, the evidence is scarce, and some data suggest its application in laparoscopic gynecologic surgery. Although current oncologic treatments have improved survival, multiple side effects have been documented that affect the quality of life of patients, the prevalence of which varies according to the type of pharmacological treatment (\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThere are controversies regarding pain management in cancer patients using opioid-free techniques. Some studies question its efficacy, suggesting that it does not provide additional benefits (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Although no specific studies have been conducted in gynecologic oncologic surgery with opioid-free anesthesia, Lian Chen et al. evaluated the OFA technique versus OBA in patients undergoing laparoscopic gynecologic surgery under an ERAS protocol. They found that, although OFA was not inferior to the traditional technique in terms of reducing pain measured with VAPS, it cannot be considered an inferior technique (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn our study, it was observed that, in a bivariate analysis, the opioid-free technique showed a 4.3% decrease in the pre-procedure VAPS compared to admission to recovery rooms, although pain increased significantly (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) upon leaving the recovery room. At 24 hours, pain intensity decreased, but 11.9% of patients still reported poor pain control. At 48 hours, severe and moderate pain was evident in some patients undergoing the opioid-free technique. On the fifth day, moderate pain control improved, with 7.2% of patients and finally, at hospital discharge, patients were pain-free or reported mild pain.\u003c/p\u003e \u003cp\u003eIt is important to highlight certain variables related to the pain score. History of chronic pain was statistically significant in patients undergoing opioid-free techniques, with 25.9% (36 subjects) versus 10.3% (20 subjects) in those treated with opioids. In addition, prior medication use significantly influenced the statistical analysis, with 71.2% of patients exposed to opioid-free techniques. Among patients receiving opioid-free anesthesia, 98.6% used a neuraxial technique as a cost-saving measure. Postoperatively, patients with the OFA technique were observed to require more opioid rescues: 10.8% needed at least one rescue dose in the recovery room, 15.4% at 24 hours, and 3.7% at 48 hours. Although the opioid-free technique can offer partial pain control, its efficacy depends on several factors previously mentioned. These findings are consistent with existing literature and suggest that opioid-free analgesia may be indicated in certain groups of patients.\u003c/p\u003e \u003cp\u003eThe OFA technique has been shown to allow a more satisfactory postoperative recovery. In a systematic review by Salom\u0026eacute; et al., which included randomized controlled clinical trials comparing OFA with OBA, a reduction in the incidence of postoperative nausea and vomiting was observed, with high certainty in the evidence (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). The same authors found no significant differences in the incidence of intraoperative tachycardia, bradycardia, hypertension and hypotension (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), different from those reported in the present study. Feenstra et al. confirmed that, although there were no differences in postoperative pain scores, the quality of recovery was better in the OFA group. Additional benefits of OFA have been reported, such as the reduction in the incidence of postoperative pain (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOn the other hand, Beloeil et al. conducted a multicenter randomized clinical trial to evaluate the outcomes in the first 48 postoperative hours with a regimen of OFA with dexmedetomidine versus OBA with remifentanil. The results obtained showed the appearance of the composite primary outcome (postoperative hypoxemia, postoperative ileus and postoperative cognitive dysfunction) for the dexmedetomidine group in 122 of 156 (78%) patients and in 105 of 156 (67%) patients in the remifentanil group, concluding that there is a greater risk of adverse effects when exposed to an OFA regimen with dexmedetomidine versus the opioid-based regimen with remifentanil (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRegarding complications and safety, our study confirms some problems related to hemodynamic compromise and anesthetic complications. Hypotension was identified as a main complication; Although not statistically significant, 64.8% of patients exposed to opioid-free anesthesia required vasopressor support during their stay in recovery rooms. Bradycardia was also observed with a lower mean in the OFA group, and being different from OBA when leaving the recovery rooms. In addition, antiemetics were noted to be required, which were administered prophylactically in both OBA and OFA patients. However, it was not possible to achieve adequate convergence in the regression models for the main outcomes related to complications (respiratory depression, urinary retention, hypotension, nausea/vomiting and delirium) at the evaluated times (admission to recovery room, 24 hours, 48 ​​hours and fifth day) due to the low frequency of these events.\u003c/p\u003e \u003cp\u003eFinally, opting for opioid-free anesthesia presents several challenges. One of the main ones is the appearance of unforeseen adverse effects that can arise from the analgesics used and from the possible interactions between anesthetics. Furthermore, the lack of studies conducted in more homogeneous populations, especially in oncological subgroups, and the lack of research with high methodological quality that evaluates chronic pain after opioid-free anesthesia and the quality of recovery are important limitations.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe OFA technique for gynecologic oncologic surgery patients has a partial impact on pain control, with poor control upon discharge to recovery areas, at 24 and 48 hours; ultimately requiring rescues from potent opioids or exposure to them, therefore it is a partially effective technique in terms of pain control for this group of patients. Regarding complications, hemodynamic compromise such as hypotension and bradycardia presented in this type of patients must be evaluated given their clinical condition and some of them under comorbid conditions, in addition to the evaluation of length of stay in recovery rooms and hospital stays to provide patient-focused care with application to ERAS\u0026reg; protocols. These outcomes are confirmed in other populations that undergo OFA. More studies are required with adequate methodologies and statistical weight that allow reaching a definitive conclusion.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cstrong\u003e●\u003c/strong\u003e Ethics approval and consent to participate.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe approval by the medical ethics committee of the Hernando Moncaleano Perdomo University Hospital de Neiva was submitted on December 14, 2023, which was approved by approval act No. 12-07.\u003c/p\u003e\n\u003cp\u003eOur study consists of reviewing medical records for data collection and statistical analysis. The institutional ethics committee did not consider the need for new consent for the data used from these patients, and consent for medical record management that is requested from all those who enter the institution is sufficient. Therefore, an informed consent waiver was used, and the data used in this study were anonymized before use.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e●\u003c/strong\u003e\u0026nbsp; \u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDoes not apply.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e●\u003c/strong\u003e\u0026nbsp; \u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e●\u003c/strong\u003e\u0026nbsp; \u003cstrong\u003eConflict of Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author(s) declare that they do not have conflicting interests. Additionally, the author(s) received no financial support for the research, authorship, and/or publication of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e●\u003c/strong\u003e\u0026nbsp; \u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author(s) received no financial support for the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e●\u003c/strong\u003e\u0026nbsp; \u003cstrong\u003eAuthor\u0026acute;s contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDesign: JAPG, DRP, EM\u003c/p\u003e\n\u003cp\u003ePerformed the literature review: JAPG, DRP, EM\u003c/p\u003e\n\u003cp\u003eAcquisition of data: JAPG\u003c/p\u003e\n\u003cp\u003eInterpretation of data: JAPG, FLCH\u003c/p\u003e\n\u003cp\u003eWrote the manuscript: JAPG, FLCH\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e●\u003c/strong\u003e\u0026nbsp; \u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe don\u0026apos;t have acknowledgements.\u003c/p\u003e"},{"header":"References","content":"\u003col start=\"1\" type=\"1\"\u003e\n\u003cli\u003eBrown EN, Pavone KJ, Naranjo M. Multimodal General Anesthesia: Theory and Practice. Anesth Analg. 2018;127(5):1246-58. \u003c/li\u003e\n\u003cli\u003eTung A. New anesthesia techniques. Thorac Surg Clin. 2005;15(1):27-38. \u003c/li\u003e\n\u003cli\u003eSwegle JM, Logemann C. Management of common opioid-induced adverse effects. Am Fam Physician. 2006;74(8):1347-54. \u003c/li\u003e\n\u003cli\u003eBenyamin R, Trescot AM, Datta S, Buenaventura R, Adlaka R, Sehgal N, et al. Opioid complications and side effects. Pain Physician. 2008;11(2 Suppl):S105-20. \u003c/li\u003e\n\u003cli\u003eBakan M, Umutoglu T, Topuz U, Uysal H, Bayram M, Kadioglu H, et al. Opioid- free total intravenous anesthesia with propofol, dexmedetomidine and lidocaine infusions for laparoscopic cholecystectomy: a prospective, randomized, double- blinded study. Braz J Anesthesiol. 2015;65(3):191-9. \u003c/li\u003e\n\u003cli\u003ehttps://www.minjusticia.gov.co/programasco/ODC/Documents/SAT/Alertas/2019%2008%20Alerta%20Opioides.pdf\u003c/li\u003e\n\u003cli\u003eEgan TD. Are opioids indispensable for general anaesthesia? Br J Anaesth. 2019;122(6):e127-e35. \u003c/li\u003e\n\u003cli\u003eBakan M, Umutoglu T, Topuz U, Uysal H, Bayram M, Kadioglu H, et al. Opioid- free total intravenous anesthesia with propofol, dexmedetomidine and lidocaine infusions for laparoscopic cholecystectomy: a prospective, randomized, double- blinded study. Braz J Anesthesiol. 2015;65(3):191-9.\u003c/li\u003e\n\u003cli\u003eSalome A, Harkouk H, Fletcher D, Martinez V. Opioid-Free Anesthesia Benefit- Risk Balance: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Clin Med. 2021;10(10). \u003c/li\u003e\n\u003cli\u003eRawal N. Current issues in postoperative pain management. Eur J Anaesthesiol. 2016;33(3):160-71. \u003c/li\u003e\n\u003cli\u003eCali Cassi L, Biffoli F, Francesconi D, Petrella G, Buonomo O. Anesthesia and analgesia in breast surgery: the benefits of peripheral nerve block. Eur Rev Med Pharmacol Sci. 2017;21(6):1341-5. \u003c/li\u003e\n\u003cli\u003eWheatley RG, Schug SA, Watson D. Safety and efficacy of postoperative epidural analgesia. Br J Anaesth. 2001;87(1):47-61. \u003c/li\u003e\n\u003cli\u003eDieu A, Huynen P, Lavand\u0026apos;homme P, Beloeil H, Freys SM, Pogatzki-Zahn EM, et al. Pain management after open liver resection: Procedure-Specific Postoperative Pain Management (PROSPECT) recommendations. Reg Anesth Pain Med. 2021;46(5):433-45. \u003c/li\u003e\n\u003cli\u003eBugada, Dario, et al. \u0026ldquo;Opioid-Free Anesthesia and Postoperative Outcomes in Cancer Surgery: A Systematic Review.\u0026rdquo; \u003cem\u003eCancers\u003c/em\u003e, vol. 15, no. 1, 22 Dec. 2022, p. 64, https://doi.org/10.3390/cancers15010064. Accessed 18 Aug. 2024.\u003c/li\u003e\n\u003cli\u003eFriedberg BL. Propofol-ketamine technique: dissociative anesthesia for office surgery (a 5-year review of 1264 cases). Aesthetic Plast Surg 1999; 23:70\u0026ndash;75. 2 Mulier JP, Wouters R, Dillemans B, De Kock M. A randomized controlled, double-blind trial evaluating the effect of opioid-free versus opioid general anaesthesia on postoperative pain and discomfort measured by the QoR-40. J Clin Anesth Pain Med 2018; 2:15.\u003c/li\u003e\n\u003cli\u003eSacerdote P, Franchi S, Panerai AE. Non-Analgesic Effects of Opioids: Mechanisms and Potential Clinical Relevance of Opioid-Induced Immunodepression. Curr Pharm Des. 2012;18:6034\u0026ndash;42.\u003c/li\u003e\n\u003cli\u003eAndrew Kofke W, Attaallah AF, Kuwabara H, Garman RH, Sinz EH, Barbaccia J, et al. The Neuropathologic Effects in Rats and Neurometabolic Effects in Humans of Large-Dose Remifentanil [Internet]. Available from: http://journals.lww.com/anesthesia-analgesia\u003c/li\u003e\n\u003cli\u003eWatts N, Amann M, Ayeb-Karlsson S, Belesova K, Bouley T, Boykoff M, et al. The Lancet Countdown on health and climate change: from 25 years of inaction to a global transformation for public health. Vol. 391, The Lancet. Lancet Publishing Group; 2018. p. 581\u0026ndash;630.\u003c/li\u003e\n\u003cli\u003eRay-Coquard I, Morice P, Lorusso D, Prat J, Oaknin A, Pautier P, et al. Non-epithelial ovarian cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of Oncology. 2018 Oct 1;29:iv1\u0026ndash;18.\u003c/li\u003e\n\u003cli\u003eOaknin A, Bosse TJ, Creutzberg CL, Giornelli G, Harter P, Joly F, et al. Endometrial cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up ☆. Annals of Oncology. 2022 Sep 1;33(9):860\u0026ndash;77.\u003c/li\u003e\n\u003cli\u003eShalowitz DI, Epstein AJ, Buckingham L, Ko EM, Giuntoli RL. Survival implications of time to surgical treatment of endometrial cancers. Am J Obstet Gynecol. 2017 Mar 1;216(3):268.e1-268.e18.\u003c/li\u003e\n\u003cli\u003eShanthanna H, Ladha KS, Kehlet H, Joshi GP. Administraci\u0026oacute;n perioperatoria de opioides. \u003cem\u003eAnestesiolog\u0026iacute;a.\u003c/em\u003e 2021; 134 (4):645\u0026ndash;659. Doi: 10.1097/ALN.0000000000003572. \u003c/li\u003e\n\u003cli\u003eChen, Liang, et al. \u0026ldquo;Application of Opioid-Free General Anesthesia for Gynecological Laparoscopic Surgery under ERAS Protocol: A Non-Inferiority Randomized Controlled Trial.\u0026rdquo; \u003cem\u003eBMC Anesthesiology\u003c/em\u003e, vol. 23, no. 1, 27 Jan. 2023, https://doi.org/10.1186/s12871-023-01994-5. Accessed 19 Aug. 2024.\u003c/li\u003e\n\u003cli\u003eSalom\u0026eacute; A, Harkouk H, Fletcher D, Martinez V. Opioid-free anesthesia benefit\u0026ndash;risk balance: a systematic review and meta-analysis of randomized controlled trials. Vol. Journal of Clinical Medicine. MDPI; 2021\u003c/li\u003e\n\u003cli\u003eFeenstra ML, Jansen S, Eshuis WJ, van Berge Henegouwen MI, Hollmann MW, Hermanides J. Opioid-free anesthesia: A systematic review and meta-analysis. Vol. 90, Journal of Clinical Anesthesia. Elsevier Inc.; 2023.\u003c/li\u003e\n\u003cli\u003eBeloeil H, Garot M, Lebuffe G, Gerbaud A, Bila J, Cuvillon P, et al. Balanced Opioidfree Anesthesia with Dexmedetomidine versus Balanced Anesthesia with Remifentanil for Major or Intermediate Noncardiac Surgery: The Postoperative and Opioid-free Anesthesia (POFA) Randomized Clinical Trial. Anesthesiology. 2021 Apr 1;134(4):541\u0026ndash;51.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-anesthesiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bane","sideBox":"Learn more about [BMC Anesthesiology](http://bmcanesthesiol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bane","title":"BMC Anesthesiology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-5257068/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5257068/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction:\u003c/strong\u003e Opioids have been essential for the anesthesiologic management of patients undergoing surgical procedures such as gynecologic oncology. However, the use of opioids brings with it hemodynamic problems, which is why opioid-free anesthesia (OFA) and multimodal postoperative analgesia techniques that restrict the excessive use of opioids are necessary.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e To determine the effectiveness and safety of opioid-free anesthesia and analgesia in pain control and postoperative recovery of adult patients undergoing gynecologic oncology surgery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethodology: \u003c/strong\u003eA retrospective observational cohort study was conducted by reviewing the medical records of patients at the Neiva University Hospital. Female patients who underwent gynecologic oncology surgery at the Neiva University Hospital and who received OFA, or opioid-based anesthesia (OBA) were identified. Data on pain were collected using a visual analog pain scale (VAPS), along with hemodynamic variables and adverse events at 7 different times from admission to the operating room until discharge from the hospital. A bivariate analysis was performed for the type of anesthesia, comparing frequencies of VAPS and adverse events with chi2 and mean difference for hemodynamic variables with t student. A multivariate analysis was performed with multiple logistic regression to evaluate differences in frequency of pain by VAPS based on the anesthesia regimen and other clinical variables for statistical difference times.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eData were collected from 335 patients, of whom 196 (58.5%) received an OBA regimen and 139 (41.5%) an OFA regimen. A difference was identified for greater pain in OFA than in OBA (p\u0026lt;0.001) for the times before surgery, recovery discharge, and 24 hours after surgery. For heart rate, significant differences were only identified at admission to the operating room, 30 minutes of induction and admission to the recovery room. For respiratory rate, the differences were only significant at admission to the operating room, 30 minutes of induction. For mean arterial pressure, it was significant only in the recovery room and for oxygen saturation at admission to the operating room and discharge from recovery. As an adverse event, a higher frequency of requiring antiemetics was only identified in patients with AFO than with ABO on the fifth day of surgery. No significance was identified in multivariate analysis between OBA and OFA controlled for VAPS by other factors at 24 hours.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Opioids for gynecologic oncologic surgery patients have a partial impact on pain control, with poor control upon discharge to recovery areas, at 24 and 48 hours, and no clinically relevant differences in hemodynamic variables or adverse events.\u003c/p\u003e","manuscriptTitle":"Effectiveness and safety of opioid-free anaesthesia and analgesia in pain control and postoperative recovery of patients undergoing gynaecologic oncologic surgery: a retrospective cohort study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-18 06:13:58","doi":"10.21203/rs.3.rs-5257068/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-16T09:52:59+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-16T07:36:25+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-15T07:09:45+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Anesthesiology","date":"2024-10-13T23:32:01+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-anesthesiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bane","sideBox":"Learn more about [BMC Anesthesiology](http://bmcanesthesiol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bane","title":"BMC Anesthesiology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8cb01b06-98e5-4cf8-96a0-29a5d217a06b","owner":[],"postedDate":"December 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-02-17T16:00:25+00:00","versionOfRecord":{"articleIdentity":"rs-5257068","link":"https://doi.org/10.1186/s12871-024-02867-1","journal":{"identity":"bmc-anesthesiology","isVorOnly":false,"title":"BMC Anesthesiology"},"publishedOn":"2025-02-14 15:57:17","publishedOnDateReadable":"February 14th, 2025"},"versionCreatedAt":"2024-12-18 06:13:58","video":"","vorDoi":"10.1186/s12871-024-02867-1","vorDoiUrl":"https://doi.org/10.1186/s12871-024-02867-1","workflowStages":[]},"version":"v1","identity":"rs-5257068","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5257068","identity":"rs-5257068","version":["v1"]},"buildId":"CiT4i_kKBbxQbnFL0ufpk","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}