Combined Opioid Free and Loco-Regional Anesthesia Enhances the Quality of Recovery in Sleeve Gastrectomy Done Under ERAS Protocol: A Randomized Controlled Trial

Background: There is still debate as to whether opioid-free anaesthsia (OFA) may offer additional benefit over multimodal analgesia to better achieve the goals of ERAS(Enhanced recovery after surgery) in bariatric surgery. Patients and method: Patients in the OFA group (n=51) were pre-medicated with IV dexmedetomidine 0.1 µg.kg -1 then induced with propofol (2 mg. kg -1 ) -ketamine (0.5 mg. kg -1 ) mixture and maintained on dexmedetomidine 0.5µg. kg -1 .h -1 , ketamine 0.5 mg.kg -1 .h -1 , and lidocaine 1 mg. kg -1 .h -1 . Patients in the MMA(Multimodal analgesia) group (n= 52) were induced using IV propofol 2 mg. kg -1, and fentanyl 1 µg. kg -1 . Cisatracurium (0.15 mg.kg -1 ) was given to all patients for muscle relaxation. Ultrasound-guided bilateral oblique subcostal transverse abdominis plane (OSTAP) block was performed in all patients. The postoperative quality of recovery at 6 and 24 hours was measured as a primary outcome. Postoperative pain control; subsequent opioid consumption; time to ambulate; time to tolerate oral fluid; and time to readiness for discharge were measured as secondary outcomes Results: The total QoR-40 (quality of recovery-40) scores at 6 hours were significantly higher in the OFA group (184.84 versus 180.69 in the MMA group with an estimated difference in mean of -4.15, 95% CI, -5.78 to -2.5, and P ˂0.001. The OFA group tolerated oral fluid intake earlier (194.94, 95% CI, 162.59 to 227.30) versus (273, 95% CI, 223.65 to 322.27) for the MMA group (p value=0.009). Readiness for discharge was significantly quicker in the OFA group (447.49, 95% CI, 409.69 to 485.29 versus 544.56, 95% CI, 503.08 to 586.04 in the MMA group, P-value =0.001). The post-anesthesia care unit (PACU) (0 Hour) and the floor 2 and 6-hour numerical rating scales (NRS) for pain were significantly higher in the MMA group. The OFA group needed less opioid rescue analgesia in the PACU and at 24-hours (P value= 0.003 and 0.014; respectively). Conclusion: Combined Opioid free and loco-regional anesthesia provides better early recovery with reduced postoperative pain intensity, and opioid consumption when compared to multimodal analgesia; and is better suited to achieve the goals of ERAS protocol. Clinical trial number: registration number NCT04285255.