Experience of using multimodal opioid-saving anesthesia in children: single-center prospective randomized study

BACKGROUND: In the protocols of rapid recovery after surgery, it is recommended to avoid long-term administration and/ or high doses of opioids in order to reduce the severity of their adverse reactions in the postoperative period. In this regard, opioid-sparing anesthesia (OSA) may become a promising approach to the treatment of cancer patients.

AIM: To evaluate the effectiveness of multimodal OSA in the scheme “dexmedetomidine + ketamine (in subanesthetic doses) + lidocaine (intravenous infusion)” in pediatric oncosurgery.

MATERIALS AND METHODS: A single-center prospective randomized study involved 40 children aged 12 to 18 years. Patients were divided into 2 groups depending on the method of anesthesia: in group I (n =20), combined endotracheal anesthesia with opioids was performed, in group II (n =20) — multimodal OCA based on intravenous infusion of lidocaine, dexmedetomidine and subanesthetic doses of ketamine. The patients underwent extended operations in the head and neck area in the volume of thyroidectomy with fascial-sheath lymph dissection and excision of the central tissue of the neck from 2 sides.

RESULTS: With stable intraoperative hemodynamic parameters, the median total intraoperative need for analgesics in group II was: for lidocaine — 351 (289.6; 418.5) mg (which is 1.75 mg/kg per hour), for dexmedetomidine — 88.2 (38.5; 119.7) µ g, for ketamine — 21.6 (17.4; 27.3) mg. In group I, the median total intraoperative need for fentanyl was 273.7 (406; 240.9) µ g. In addition, in group I, the median amount required for postoperative analgesia of the synthetic opioid analgesic tramadol was 419 (365.6; 479) mg (which is 7.8 mg/kg; p =0.01). In group II, the median amount of lidocaine required for postoperative analgesia (1 mg/kg per hour) turned out to be 1377.3 (735.7; 1894) mg, while additional tramadol administration at a dose of 57.3 (28.5; 107.7) mg was required in only 7 (35%) patients.

CONCLUSION: Multimodal OSA based on dexmedetomidine, lidocaine, ketamine and sevoflurane is an effective and safe method of anesthesia in children from 12 to 18 years old, which is not inferior to opioid analgesics in the treatment of perioperative pain during surgical interventions on the thyroid and parathyroid glands in cancer patients, and also reduces the number of adverse reactions characteristic of opioids.