Opioid-free anaesthesia with loco-regional block enhances safety and recovery in patients with obesity undergoing non-bariatric surgery: A randomised controlled trial

INTRODUCTION: Opioid-free anaesthesia (OFA), when incorporated into enhanced recovery after surgery (ERAS) pathways, may improve peri-operative safety and recovery in patients with obesity. We evaluated the efficacy and safety of a multimodal OFA regimen incorporating loco-regional anaesthesia in this population undergoing general anaesthesia. PATIENTS AND METHODS: In this prospective randomised study with participant and outcome-assessor blinding, 380 adults (body mass index >35 kg/m 2 ) undergoing elective laparoscopic cholecystectomy were randomised to receive OFA or non-OFA (N-OFA). The OFA group received dexmedetomidine (0.3-0.5 μg/kg/h), low-dose ketamine (0.2 mg/kg) and an ultrasound-guided subcostal transversus abdominis plane block with 30 ml of 0.25% bupivacaine. The N-OFA group received fentanyl (1-2 μg/kg ideal body weight). All patients received total intravenous anaesthesia. The primary outcome was time to discharge readiness (DR). Secondary outcomes included pain scores, opioid requirement, quality of recovery-40 (QoR-40) and airway-related adverse events (ARAEs). RESULTS: Baseline characteristics were comparable, and pain scores were significantly lower in the OFA group at 3 and 24 h ( P < 0.001). At 24 h, 61.1% of patients in the OFA group reported no pain compared with 42.6% in the N-OFA group. Rescue opioid requirement was markedly reduced (2.1% vs. 95.5%, P < 0.001). Time to DR was shorter (9.7 ± 1.6 h vs. 11.6 ± 2.7 h, P < 0.001), and QoR-40 scores were higher in the OFA group. ARAEs were not statistically significant. CONCLUSION: OFA using loco-regional block, dexmedetomidine and ketamine improves recovery, reduces opioid use and accelerates DR in patients with obesity undergoing laparoscopic surgery.