Letter to the Director
Allergy to opioids and lung resection surgery. Use of dexmedetomidine and ketamine as part of a multimodal approach
Alergia a opioides y cirugía de resección pulmonar. Uso de dexmedetomidina y ketamina como parte de un abordaje multimodal
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Use of dexmedetomidine and ketamine as part of a multimodal approach" "tieneTextoCompleto" => true "saludo" => "To the Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "172" "paginaFinal" => "173" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "S. Pérez, A. Parera, J.C. Trujillo, C. Unzueta Merino" "autores" => array:4 [ 0 => array:4 [ "nombre" => "S." "apellidos" => "Pérez" "email" => array:1 [ 0 => "sperezga@santpau.cat" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "A." "apellidos" => "Parera" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "J.C." "apellidos" => "Trujillo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "C." "apellidos" => "Unzueta Merino" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Anestesiología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Cirugía Torácica, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Alergia a opioides y cirugía de resección pulmonar. Uso de dexmedetomidina y ketamina como parte de un abordaje multimodal" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Opioids continue to be the mainstay of perioperative pain management and, in general, of most hospitalised patients.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A number of multimodal pain management strategies have been developed in recent years, perhaps partly motivated by the opioid crisis affecting public health in certain countries. The development and dissemination of these opioid-free or opioid-sparing anaesthesia strategies and the development of new locoregional techniques and therapeutic adjuvants have paved the way to good pain management in complex surgical procedures.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The main aims of these opioid-free approaches are to achieve optimal analgesia while maintaining haemodynamic stability. This is achieved, in part, by suppressing the sympathetic response produced by nociceptive stimuli. Clinicians usually use a combinations of drugs that act at various levels of the pain pathway. Combining drugs allows clinicians to administer smaller doses of the drugs involved compared to the dose normally required in monotherapy, thereby reducing the risk of undesired effects.</p><p id="par0020" class="elsevierStylePara elsevierViewall">It is also curious to note that despite the widespread use of opioids, allergic reactions reliably attributed to their use are practically anecdotal, and according to the literature account for around 1% of anaphylactic reactions within the perioperative period.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">We report a case in which a multimodal, opioid-free approach was taken due to our patient's documented opioid allergy.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The patient was a 75-year-old woman scheduled for lung resection surgery for a recently diagnosed adenocarcinoma. During the preoperative consultation the patient described an incident in which she required life support manoeuvres after intravenous morphine administration. She also explained that she had recently had to stop using transdermal fentanyl due to an allergic skin reaction. Between these events, she underwent a multitude of surgical interventions without presenting complications. The consulting physician referred the patient for an allergy workup. Patch tests were positive for morphine and fentanyl, so the allergist recommended avoiding all opioid derivatives. This recommendation prompted us to search for an alternative approach, and we finally decided on a combination of dexmedetomidine, ketamine and paravertebral nerve block.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Dexmedetomidine, a highly selective α2 blocker that also has nociceptive activity, appears to reduce opioid requirements in abdominal surgery and attenuate the sympathetic response. It also appears to have a certain effect on hypoxic vasoconstriction by reducing intrapulmonary shunt and therefore improving oxygenation, which is particularly useful in thoracic surgery.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Administration of 0.6<span class="elsevierStyleHsp" style=""></span>μg<span class="elsevierStyleHsp" style=""></span>kg<span class="elsevierStyleSup">−1</span><span class="elsevierStyleHsp" style=""></span>min<span class="elsevierStyleSup">−1</span> dexmedetomidine was started in the preoperative room and then down-dosed to 0.4<span class="elsevierStyleHsp" style=""></span>μg<span class="elsevierStyleHsp" style=""></span>kg<span class="elsevierStyleSup">−1</span><span class="elsevierStyleHsp" style=""></span>min<span class="elsevierStyleSup">−1</span> during surgery. We also administered 0.5<span class="elsevierStyleHsp" style=""></span>mg/kg ketamine after induction, and maintained perfusion of 0.35<span class="elsevierStyleHsp" style=""></span>mg<span class="elsevierStyleHsp" style=""></span>kg<span class="elsevierStyleSup">−1</span><span class="elsevierStyleHsp" style=""></span>h<span class="elsevierStyleSup">−1</span> during surgery. As an NMDA agonist that acts on opioid receptors, ketamine has been shown to decrease postoperative opioid consumption; however, this effect is not reflected in a corresponding decrease in pain scale scores.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> We performed ultrasound-guided paravertebral block for locoregional anaesthesia, not only because it is the technique of choice in our hospital for these procedures, but also because current evidence suggests that it is equivalent to thoracic epidural and has a better safety profile. It can also be safely performed in an anaesthetised patient.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> We used an ultrasound-guided parasagittal approach and administered an initial 10<span class="elsevierStyleHsp" style=""></span>ml bolus of 0.375% ropivacaine which we repeated on an hourly basis during the intraoperative period. Postoperative analgesia was delivered via a patient-controlled analgesia pump set to administer an hourly dose of 7<span class="elsevierStyleHsp" style=""></span>ml 0.375% ropivacaine.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Anaesthesia was maintained with sevoflurane with an expired concentration of between 1.2–1.4%, and the patient also received conventional analgesia with NSAIDs and paracetamol.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The procedure, which ultimately consisted of upper right lobectomy under video-assisted thoracoscopic surgery, was uneventful. The patient remained haemodynamically stable with a heart rate of around 60<span class="elsevierStyleHsp" style=""></span>bpm and mean blood pressure of 70<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg. She was extubated in the operating room after withdrawing ketamine infusion, and then transferred to the postanaesthesia care unit where she remained for 24<span class="elsevierStyleHsp" style=""></span>h with conventional analgesia and paravertebral infusion. She rated her pain as 0 on a numeric rating scale (NRS). Thoracic drainage was continued for 48<span class="elsevierStyleHsp" style=""></span>h. The NRS score never exceeded 4, and the patient was discharged from hospital 72<span class="elsevierStyleHsp" style=""></span>h later.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The current trend towards minimally invasive surgery and the increasing implementation of fast-track protocols has prompted clinicians to search for opioid-sparing or opioid-free strategies, and to include these approaches in routine clinical practice. Reducing opioid use will in turn reduce the incidence of common adverse effects, such as nausea and vomiting which, though not particularly serious, are unpleasant for patients. Although we are aware of the limitations of a single case report, we believe that the multimodal approach described here provided adequate pain management, since the NRS score remained below 4 throughout the patient's hospital stay and she recovered without complications. Thoracic surgery could be a good setting for implementing opioid-sparing or opioid-free approaches, given the evidence that over-use of opioids is associated with a higher incidence of respiratory complications.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Pérez S, Parera A, Trujillo JC, Unzueta Merino C. Alergia a opioides y cirugía de resección pulmonar. Uso de dexmedetomidina y ketamina como parte de un abordaje multimodal. Rev Esp Anestesiol Reanim. 2021;68:172–173.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Multimodal general anesthesia: theory and practice" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "E.N. Brown" 1 => "M. 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