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Opioid-free anesthesia (OFA) represents an innovative approach that prioritizes patient safety, reduces the risks associated with opioid use, and seeks to enhance recovery. Few descriptions regarding the practical and implementation aspects exist. This review serves as a practical guide on OFA teaching and application. We briefly discuss the historical use of opioids in anesthesia, side effects and their consequences. We discuss pedagogical avenues and challenges, as well as implementation of OFA in less experienced settings. Opioid use in anesthesia originally coexisted with OFA. During the last decades, the advent of multimodal analgesia has resulted in decreased opioid dosages both before and after surgery. Recently, OFA increased in popularity, supported by meta-analyses, due to reduced nausea and vomiting, with a potential, even if limited, impact on pain. OFA, as part of rational prescribing, may contribute to a more patient-centered approach. Different strategies for OFA implementation coexist. Educational aspects, leadership, guidelines, local guidance, and training are all important. We propose a framework for OFA implementation with concrete options, including patient preparation, choice of OFA pharmacological agents (according to type of surgery and patient), and postoperative care. Whilst opioids still have an important place in pain management, they have brought harms that we cannot ignore. Evidence for using opioid-sparing and OFA techniques continues to emerge and there is a need to personalize more approaches. In this review, we provide evidence-based, relatively simple methods that can be used in implementing and delivering OFA.

Background: Continuous wound infusion (CWI) is effective for post-operative pain management, but the effect of prolonged infusions and the use of steroids in the infused mixture have never been addressed. We investigate the effect of prolonged CWI with ropivacaine 0.2% (R) over seven days and methylprednisolone (Mp) 1 mg/kg infused in the wound in the first 24 hours., Methods: This is a randomized, double blind, phase III trial (RCT) in major abdominal surgery with laparotomy. After a 24-hours pre-peritoneal CWI of R-Mp, patients were randomized to receive either R-Mp or placebo for the next 24 hours. Then, patient-controlled CWI with only ropivacaine 0.2% or placebo (according to the randomization group) was planned between 48 hours and seven days after surgery. Morphine equivalents at seven days were analyzed, together with any catheter- or drug-related side effect and PPSP at 3 months., Results: We enrolled 120 patients (63 in the CWI group, 57 in the placebo group). Prolonged CWI did not reduce opioid consumption in the first seven postoperative days (P=0.08). CWI was associated with reduced consumption of non-opioid analgesics (P=0.03). Most of the patients continued to require bolus in the surgical wound beyond 48 hours. PPSP prevalence was not different between groups., Conclusions: Prolonged infusion with R-Mp is safe and effective but did not reduce opioid consumption in the seven days after surgery or PPSP prevalence.

The introduction of synthetic opioids in clinical practice played a major role in the history of anesthesiology. For years, anesthesiologists have been thinking that opioids are needed for intraoperative anesthesia. However, we now know that opioids (especially synthetic short-acting molecules) are definitely not ideal analgesics and may even be counterproductive, increasing postoperative pain. As well, opioids have revealed important drawbacks associated to poor perioperative outcomes. As a matter of fact, efforts in postoperative pain management in the last 30 years were driven by the idea of reducing/eliminating opioids from the postoperative period. However, a modern concept of anesthesia should eliminate opioids already intra-operatively towards a balanced, opioid-free approach (opioid-free anesthesia - OFA). In OFA drugs and techniques historically proven for their efficacy are combined in rational and defined protocols. They include ketamine, alpha-2 agonists, lidocaine, magnesium, anti-inflammatory drugs and regional anesthesia. Promising results have been obtained on perioperative outcome. For sure, analgesia is not reduced with OFA, but it is effective and with less opioid-related side effects. These benefits may be of particular importance in some high-risk patients, like OSAS, obese and chronic opioid-users/abusers. OFA may also increase patient-reported outcomes; despite it is difficult to specifically rule out the effect of intraoperative opioids. Finally, few data are available on long-term outcomes (persistent pain and opioid abuse, cancer outcome). New studies and data are required to elaborate the optimal approach for each patient/surgery, but interest and publication are increasing and may open the road to the wider adoption of OFA.

Routine use of regional anesthesia for patients having surgery is supported by general safety and proven effectiveness as a targeted modality in the prevention and treatment of acute pain. Recently, perioperative physicians have become much more interested in improving long-term outcomes after surgery rather than focusing on the well-established short-term benefits of regional anesthesia. This interest has raised important questions regarding the potential influence of regional anesthesia on morbidity and mortality, persistent pain and cancer prognosis. Tissue injury is responsible for the inflammatory reaction and physiologic stress response observed during the perioperative period and can influence a patient's recovery trajectory. Regional anesthesia can modulate the inflammatory response through the direct anti-inflammatory effect of local anesthetics, blocking neural afferents, and blunting sympathetic activation. Moreover, continuous techniques (e.g., epidural and perineural catheters) that provide longer duration and titratable pain relief in the perioperative period may be protective against the development of persistent post-surgical pain by providing effective acute pain management and decreasing exposure to opioids. To maximize the potential for long-term outcome benefits to surgical patients, continuous regional anesthesia techniques are preferred over single injection techniques. Although the data are not yet definitive, some studies have demonstrated better functional recovery after joint replacement and lower rates of cancer recurrence in patients treated with continuous regional anesthesia. Future research studies in regional anesthesia will have to focus on these long-term patient-centered outcomes and may need to incorporate novel study designs and analyses of big data.

Opioids are the most frequently administered analgesics in the perioperative period. The analgesic potency of opioids is without question. While the opioid- free or opioid-less perioperative care concept is not a reality in most surgical centers of the United States and other developed countries, there is a significant number of healthcare problems (i.e. adverse events, opioid-induced hyperalgesia and opioid diversion) related to the indiscriminate use of opioids that warrants the implementation of multimodal analgesia strategies. Although it has been suggested an association between the use of opioids and cancer progression, there is a need of well-designed studies to confirm that association.

Background: Regional anesthesia (RA) is associated with many advantages, but side effects also occur. Several registries were developed to investigate such complications in many countries, which produced conflicting results. In consideration of the ongoing evolution and improvements in RA, and its widespread diffusion in Italy in the last decade (with increasing experience by anesthesiologists), a reappraisal of the incidence and the characteristics of major complications are useful to improve patient's safety., Methods: A web-based prospective registry was developed in Italy with: 1) quarterly report of total anesthetic acts and RA procedures performed; and 2) voluntary registration of complications on dedicated forms. We evaluated incidence of complications, describing their characteristics and outcomes., Results: Participants (N.=17 hospitals) registered 117,182 procedures, including 63,692 with RA (54.3%, both as primary anesthetic technique and for postoperative analgesia). A total of 34,147 neuraxial blocks (4954 epidurals/CSE, 29,193 subarachnoid blocks) and 29,545 peripheral (single shot and continuous) blocks were registered. Total incidence of complication was 4.6/10.000; incidence was 4.1/10,000 for central blocks and 5.1/10,000 for peripheral blocks, long-term neurologic deficit (at 6 months) was observed after an epidural abscess, while other complications did not lead to any long-term adverse outcomes. No hemorrhagic events or other infections have occurred. Incidence of major complications was 0.07/1000, while minor complications presented in 0.38/1000 cases., Conclusions: We confirmed RA as generally safe, but monitoring and diagnosis, together with further research efforts, are needed to improve patients' care and clarify potential risk factors.