CC BY
6MEDICAL SCIENCES
MULTIMODAL ANESTHESIA IN BARIATRIC SURGERY AND COGNITIVE CHARACTERISTICS
Arabidze K., Gogokhia I., Lebanidze N.
DavitAgmashenebeli University, Tbilisi Iv. Javakhishvili University DOI: 10.5281/zenodo.7479735
ABSTRACT
Multimodal anesthesia facilitates early postoperative activation, which is very important for morbidly obese patients.
The aim of our study is to study cognitive characteristics during multimodal anesthesia used in bari-atric surgery.
Material and methods:
203 patients aged 20-70, including 103 women, who underwent bariatric surgery were under our observation; 113 (55.67%) of them are women and 90 (44.33%) are men.
Standard anesthesia with opioids was administered to 49 (24.14%) patients - group I, multimodal + partial use of opioids - group II: 76 (37.44%), multimodal anesthesia - 78 (38.42%) - group III. Results
In the second phase of postanesthetic care, there is a decrease in neurological disorders in all three groups, cognitive function disorders are no longer observed in the third group, and in the second group it is significantly less compared to the first group - 10.53% and 26.53%, respectively (p<0.0001).
Conclusion: multimodal anesthesia improves cognitive and neurologic outcomes compared with opioid general anesthesia in bariatric surgery.
Keywords: multimodal anesthesia, bariatric surgery, neurological characteristics.
Bariatric surgery is the most effective treatment for morbid obesity, resulting in sustained weight loss and significant impact on obesity-related co-morbidities. Between 2003 and 2011, the number of surgeries performed worldwide increased from 146,000 to 340,000.
Obesity is currently a worldwide problem. Changes caused by obesity significantly increase the risk of fatal complications in the perioperative period. An increase in the volume of adipose tissue has a heterogeneous effect on the pharmacokinetics of intravenous drugs, and the effect of inhalation anesthetics becomes more unpredictable.
Structural changes in the upper airway, in extreme cases manifested as obstructive sleep apnea syndrome (OSAS), dramatically reduce visualization during direct laryngoscopy. The rate of difficult intubation in patients with a body mass index (BMI) > 40 is 13-24%. In some cases, tracheal intubation is also used, which, in turn, replaces the traditional plan of induction of an-esthesiaFrequent accompanying heart pathology, tendency to early expiratory closure of airways and increased intra-abdominal pressure dictate the need for a differentiated approach to ventilation strategy for this category of patients.
Patients with comorbid obesity show increased sensitivity to opioid-induced sedation and respiratory depression. Various multimodal anesthetic techniques are used to reduce perioperative opioid load in bariatric surgeryMultimodal anesthesia facilitates early postoperative activation, which is very important for morbidly obese patients.
The aim of our study is to study cognitive characteristics during multimodal anesthesia used in bari-atric surgery.
Material and methods:
203 patients aged 20-70, including 103 women, who underwent bariatric surgery were under our observation; 113 (55.67%) of them are women and 90 (44.33%) are men.
Standard anesthesia with opioids was administered to 49 (24.14%) patients - group I, with partial use of multimodal + opioids - group II: 76 (37.44%), multimodal anesthesia without opioids - 78 (38.42%) -group III.
1 group
Propofol - potentiator of GABA A receptors Fentanyl - opioid (narcotic analgesic) Sevoflurane - inhalation drug Morphine - opioid (narcotic analgesic) Promedol - opioid (narcotic analgesic)
2 group
Propofol - potentiator of GABA A receptors Fentanyl - opioid (narcotic analgesic) Sevoflurane - inhalation drug Dexmedotomidine is a selective agonist of alpha 2 receptors
Locoregional analgesia (lidocaine, naropin, bupi-vacaine - sodium channel blockers)
3 group
Propofol - potentiator of GABA A receptors Sevoflurane - inhalation drug Dexmedotomidine is a selective agonist of alpha 2 receptors
Locoregional analgesia (lidocaine, naropin, bupi-vacaine - sodium channel blockers)
Patients' cognitive status was evaluated by means of two scales
Confusion assessment method for intensive care unit (CAM-ICU) - Assessment of clouding of consciousness in the intensive care unit
Richmond Agitation-Sedation Scale RASS -Richmond Agitation Sedation Scale
Table 1.
Neurological characteristics and sensitivity after surgery in phase 1
Factors 1 group (with opioids) n=49 2Group (multimodal + partial use of opioids) n=76 3groups (multimodal) n=78 F P
Neurological features vomiting 17 34.69 7 9.21 0 0.00 21.22 0.0000
shaking 35 71.43 20 26.32 6 7.69 40.94 0.0000
Agitation 8 16.33 3 3.95 0 0.00 8.65 0.0002
itching 28 57.14 18 23.68 10 12.82 17.70 0.0000
Violation of reflexes 7 14.29 3 3.95 0 0.00 7.05 0.0011
Intentional visibility 24 48.98 55 72.37 77 98.72 27.05 0.0000
gaze fixation 25 51.02 21 27.63 1 1.28 27.05 0.0000
sensitivity tingling 40 81.63 62 81.58 76 97.44 5.81 0.0035
temperature 30 61.22 52 68.42 75 96.15 14.99 0.0000
Movement in the joint passive 27 55.10 62 81.58 78 100.00 25.79 0.0000
controlled 24 48.98 41 53.95 75 96.15 27.75 0.0000
because it is more convenient to use abbreviated testsStatistical processing was performed using SPSS 23. We determined the difference between groups by means of UNIVARIATE ANOVA, Fisher's F test.
Results:
Neurological characteristics and sensitivity after surgery in PACU phase 1 are shown in Table
As can be seen from the table, the frequency of vomiting, agitation and impaired reflexes was significantly higher in the 1st group than in the 2nd group and was not observed at all in the 3rd group. Compared with the second and third pairs, the first group had significantly higher tremors, itching, and gaze fixation, and
Sensitivity to tingling and temperature, as well as controlled movement in the joint was significantly higher in the third group, while the difference in the first and second groups was not reliable. Cognitive characteristics in phase 1 of postanesthetic care are shown in Figure 1
significantly less intentional gaze.
Cognitive characteristics in the first phase
100 90 80 70 60 50 40 30 20 10 0
bo3^ßg3o
3™BG0BÔ^5GO5
3mBÔ5dÔo
Il
53,06
44,9
44,9
44,9
11
63,16
42,11
34,21
32,89
111
100
100
97,44
100
Diagram 1
In phase 1 of post-anesthetic care during multimodal anesthesia, a better state of post-surgery cognitive characteristics was noted, namely 100% results of gaze tasks, orientation in time and space, non-verbal contact and 97.44% results of attention concentration,
which is reliably higher than the results of the other two groups.
Evaluation of neurological and cognitive characteristics in the second phase of postanesthetic care (intensive care unit) is given in Table 2
Table 2.
Evaluation of neurological and cognitive characteristics in the second phase of postanesthetic care
Factors 1 group (with opioids) n=49 2 groups (multimodal + partial use of opi-oids) n=76 3 groups (opioid-free multimodal) n=78 F p
Dizziness 12 24.49 4 5.26 0 0.00 14.69 0.0000
vomiting 11 22.45 5 6.58 0 0.00 11.64 0.0000
shaking 21 42.86 11 14.47 1 1.28 23.40 0.0000
agitation 2 4.08 0 0.00 0 0.00 3.23 0.0417
itching 8 16.33 6 7.89 1 1.28 5.18 0.0064
Violation of cognitive functions 13 26.53 8 10.53 0 0.00 12.68 0.0000
In the second phase of postanesthetic care, all three groups have decreased neurological disorders, the second and third groups have no agitation, the third group - vomiting and dizziness. The frequency of tremors and dizziness is significantly higher in the first group and significantly lower in the third group. Disruption of cognitive functions is no longer observed in the third group, and in the second group it is reliably less compared to the first group.
Review
The goal of postoperative pain management in obese patients is to provide comfort, early mobilization, and improve respiratory function without inadequate sedation and respiratory distress.
The use of short-acting agents and minimization of opioids in a broader ERAS regimen appears to reduce costs, complication rates, and PACU length of stay.
In a population at high risk for perioperative complications from ASA, multimodal analgesia was associated with incremental reductions in opioid use and complications.
Recent guidelines recommend a multimodal approach with baseline risk reduction using antiemetics, taking into account the patient's risk factors. According to our study, the frequency of vomiting and agitation was significantly higher in group 1 than in group 2, and it was not observed at all in the opioid-free multimodal anesthesia group According to Brown, (2018), inhibiting nociceptive transmission has the important additional benefit of reducing arousal, which significantly reduces the hypnotic doses required to maintain depth of anesthesia. Thus, reducing the use of hypnotics may facilitate faster recovery and reduce the contribution of general anesthesia to postoperative cognitive dysfunction Similarly, muscle relaxants reduce arousal by reducing proprioceptive feedback. According to his strategy, there is no need to eliminate opioid use. Instead, other drugs are used in combination with opioids to achieve antinociceptive control during surgery and pain control in the postoperative period. According to our study, cognitive performance in mixed anesthesia is better than in opioids alone, but significantly worse than in multimodal anesthesia. There is evidence in the
literature that non-opioid postoperative pain management techniques, limiting narcotics and avoiding morphine, reduce the risk of postoperative cognitive dys-functionOur study showed that both cognitive and neurological characteristics are reliably better with multimodal anesthesia. Conclusion:
In bariatric surgery, recovery of cognitive function upon awakening after opioid-free multimodal anesthesia compared with general anesthesia using opioids
Passive movement in the joints is when there is movement (we move the joint), but the patient cannot do it himself, i.e. Movement function is not fully restored. But if it has an active one along with the passive one, then the movement is completely restored and cognitive as well. i.e. Passive alone is bad, passive and active together are very good.
PACU (Post Anesthesia Care Unit) first phase of awakening. We divided it into three parts
Phase I PACU 1 Movement, sensation, and cognition are restored upon awakening
I Phase PACU 2 Movement, sensation, and cognitive recovery 30 min after awakening
Phase I PACU 3 Movement, sensation, and cognitive recovery 2 hours after awakening
PACU (Post Anesthesia Care Unit) intensive observation phase. It also divides us into three parts indicating the duration of P/O observation
II Phase PACU 1 indicates the duration of p/o observation up to 24 hours
II Phase PACU 2 indicates the duration of p/o observation is 24 hours
II Phase PACU 3 indicates the duration of p/o observation is more than 24 hours
The best case is when we have I Phase PACU 1-1 The worst case is when we have I Phase PACU 3-1 When we have I Phase PACU 1 - 1, at this time, from the anesthesiological point of view, the patient does not need intensive therapy, but due to possible surgical complications, observation is still continued.
References
1. Miranda F, Arevalo-Rodriguez I, Díaz G, Gonzalez F, Plana MN, Zamora J, Quinn TJ, Seron P. Confusion Assessment Method for the intensive care unit (CAM-ICU) for the diagnosis of delirium in adults in critical care settings. Cochrane Database Syst Rev. 2018 Sep 10;2018(9):CD013126.
2. Miranda F, Arevalo-Rodriguez I, Díaz G, Gonzalez F, Plana MN, Zamora J, Quinn TJ, Seron P. Confusion Assessment Method for the intensive care unit (CAM-ICU) for the diagnosis of delirium in adults in critical care settings. Cochrane Database Syst Rev. 2018 Sep 10;2018(9):CD013126.
3. Epshtein SL, Azarova TM, Storozhev VY, Vdo-vin VV, Sablin IA, Romanov BV, Martynov AN. General anesthesia without opioids in surgery for morbid obesity. What for and how? Regional anesthesia and acute pain management. 2016 Mar 15;10(1):47-54.
4. Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obesity surgery. 2013 Apr; 23(4):427-36.
5. Гарбузов ЕЮ, Овсянников ГА, Щербак СГ. Особенности анестезии в бариатрической хирургии. Вестник интенсивной терапии имени АИ Салтанова. 2018(2):31-5.
6. Vorotyntsev S, Grytcenko S, Grynovska M. Multimodal anesthesia/analgesia model in obese patients undergoing open abdominal surgery. GSL Journal of Anesthesiology. Open Access 2017; 1:101.
7. Epshtein SL, Azarova TM, Storozhev VY, Vdo-vin VV, Sablin IA, Romanov BV, Martynov AN. General anesthesia without opioids in surgery for morbid obesity. What for and how? Regional anesthesia and acute pain management. 2016 Mar 15;10(1):47-54.
8. Miranda F, Arevalo-Rodriguez I, Díaz G, Gonzalez F, Plana MN, Zamora J, Quinn TJ, Seron P. Confusion Assessment Method for the intensive care unit (CAM-ICU) for the diagnosis of delirium in adults in critical care settings. Cochrane Database Syst Rev. 2018 Sep 10;2018(9):CD013126.
9. Miranda F, Arevalo-Rodriguez I, Díaz G, Gonzalez F, Plana MN, Zamora J, Quinn TJ, Seron P. Confusion Assessment Method for the intensive care unit (CAM-ICU) for the diagnosis of delirium in adults in critical care settings. Cochrane Database Syst Rev. 2018 Sep 10;2018(9):CD013126.
10. Schug SA, Raymann A. Postoperative pain management of the obese patient. Best Practice & Research Clinical Anesthesiology. 2011 Mar 1;25(1):73-81.
11. Gustafsson UO, Scott MJ, Schwenk W, et al. Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clin Nutr. 2012;31(6):783-800.
12. Cozowicz, C., Poeran, J., Zubizarreta, N., Liu, J., Weinstein, S. M., Pichler, L., Mazumdar, M., & Memtsoudis, S. G. (). Non-opioid analgesic modes of pain management are associated with reduced postoperative complications and resource utilisation: a retrospective study of obstructive sleep apnoea patients undergoing elective joint arthroplasty. British journal of anaesthesia, 2019; 122(1): 131-140
13. Arabidze K, Gogokhia I, Lebanidze N. Postoperative pain management using multimodal analgesia. Scientific journal „Spectri". 2022 Jun 15;1.
14. Gan TJ, Diemunsch P, Habib AS, et al. Consensus guidelines for the management of postoperative nausea and vomiting [published correction appears in Anesth Analg. 2014 Mar;118(3):689] [published correction appears in Anesth Analg. 2015 Feb;120(2):494]. Anesth Analg. 2014;118(1):85-113.
15. Brown EN, Pavone KJ, Naranjo M. Multimodal General Anesthesia: Theory and Practice. Anesth Analg. 2018 Nov;127(5):1246-1258.
16. Zywiel MG, Prabhu A, Perruccio AV, Gandhi R. The influence of anesthesia and pain management on cognitive dysfunction after joint arthroplasty: a systematic review. Clin Orthop Relat Res. 2014;472(5):1453-1466.
