Opioid Based Anesthesia

Thoracolumbar fixation is a major spine surgery; it is performed to stabilize the spine after trauma, deformity or advanced degenerative disease. The primary surgical goals are to restore spinal alignment and achieve solid arthrodesis (fusion). From a surgical view, success is often measured by radiographic outcomes, hardware integrity and fusion rates. As anesthesiologists, we must recognize that technical success does not the same as optimal patient recovery. This is why the concept of Quality of Recovery (QoR) becomes very important. QoR is a patient-centered outcome that covers more than the absence of surgical complications. It includes rapid return of physical function, pain control, psychological well-being, emotional stability and Patient satisfaction. Therefore, our focus in the perioperative care shifts the focus from "did the surgery succeed?" to "how we can help the patient to recover physically, mentally, and functionally?" This approach is measured using patient-reported outcomes such as the QoR-15 or QoR-40 questionnaires. Dexmedetomidine (Precedex) has become one of the most valuable medications in modern anesthesia, especially for surgeries associated with significant pain. As a highly selective α2-adrenergic agonist, dexmedetomidine provides a unique combination of analgesia, anxiolysis, and cooperative sedation without causing respiratory depression; it is helpful during painful procedures such as spine surgery. When infused intraoperative; Precedex reduces central sensitization and diminishes the stress response to surgical stimuli, resulting in improved intraoperative hemodynamic stability, lower postoperative pain scores, reduced opioid requirements, and a smooth and calm recovery from anesthesia. Intraoperative intravenous lidocaine infusion has become an important tool for improving postoperative pain control; especially in major surgeries. Although lidocaine is commonly known as a local anesthetic, when given systemically during surgery it works in several meaningful ways: it calms the central nervous system, reduces the body's inflammatory response to tissue trauma, and decreases pain sensitivity that often appears after anesthesia wears off. Because of these combined effects, patients who receive IV lidocaine typically experience lower postoperative pain scores and need less opioid medications; therefore, avoid many opioid-related side effects such as nausea, sedation and constipation. Lidocaine infusion not only reduces early postoperative pain but also help for faster recovery, earlier mobilization, and improved overall patient satisfaction. Magnesium sulfate has become an increasingly valuable tool for anesthesiologists caring for patients undergoing long and painful surgical procedures. During major surgeries, the body's stress response can increase pain and make anesthetic management more challenging. Magnesium works by blocking NMDA receptors, which are the key player in central sensitization and postoperative hyperalgesia. This means patients wake up with less pain, lower opioid requirements, and often more stable intraoperative vital signs. Many doctors preferred to use magnesium sulphate because it is inexpensive, widely available, and easy to administer as a slow infusion.

The introduction of synthetic opioids in 1960 to general anesthesia together with sedative hypnotics and muscle relaxants allowed the appearance of the concept of multimodal balanced anesthesia. Although they help in achieving hemodynamic stability during anesthesia of open heart surgeries, their administration consequences are neither scarce nor benign to the patient. Perioperative opioids are associated with increased incidence of respiratory depression, prolonged mechanical ventilation, nausea and vomiting, prolonged sedation, Postoperative ileus (POI), urine retention, Postoperative cognitive dysfunction (POCD), immune depression and hyperalgesia (Beloeil et al., 2018). Coronary artery bypass graft surgery with cardiopulmonary bypass (CPB) is particularly vulnerable to the above-mentioned complications. Indeed, some of the side effects of this surgery overlap with the adverse effects of opioids. Postoperative pulmonary complications are observed in up to 50% of patients (Fisscher et al., 2022) and POCD or delirium in 4-54% according to studies (Bhushan et al., 2021). Whereas major gastrointestinal complications are estimated to occur in around 3% of patients, essentially acute pancreatitis, postoperative ileus (Marsoner et al., 2019). Opioid-free anesthesia (OFA) strategies have emerged to avoid intraoperative opioid use. It is based on the fact that a sympathetic reaction evidenced by hemodynamic changes in an anesthetised patient does not systematically reflect pain. In addition, a sleeping patient will not recall pain, while hormonal stress and sympathetic and inflammatory reactions can be controlled by therapeutic classes