Journal of Clinical Anesthesia 52 (2019) 65–66
Contents lists available at ScienceDirect
Journal of Clinical Anesthesia
journal homepage: www.elsevier.com/locate/jclinane
Correspondence
Opioid-free total intravenous anesthesia with ketamine as part of an enhanced recovery protocol for
bariatric surgery patients with sleep disordered breathing☆
A R T I C LE I N FO
Keywords:
Bariatric surgery
ERAS
Sleep disordered breathing
Ketamine
Bariatric surgical patients with sleep disordered breathing (SDB) pre-
sent a unique challenge for the anesthesiologist. The incidence of obesity
and SDB is growing at a rapid pace, with obstructive sleep apnea (OSA)
reportedly present in 71% of patients being evaluated for bariatric surgery
[1]. Obesity is the most common and well-recognized risk factor for OSA
and places patients at higher risk for postoperative critical events, in-
cluding death [2]. Although the benefits of various multimodal analgesic
techniques for post-operative pain management continue to be scrutinized
in the literature, the effects of eliminating intraoperative narcotics during
bariatric surgery have not been widely studied. Opioid free anesthesia may
prevent development of acute opioid tolerance and facilitate postoperative
pain management with less narcotics and their associated side effects.
Written consent was obtained for this report.
A 40 year-old morbidly obese (BMI 50.1 kg·m−2) female with history
of severe OSA non-compliant with home CPAP presented for laparo-
scopic vertical sleeve gastrectomy. To avoid the side-effects of narcotic
anesthesia and potential postoperative respiratory adverse events, we
employed an opioid-free total intravenous anesthetic with propofol and
ketamine.
After the patient was brought to the operating room, standard ASA
and bispectral index monitors were applied. General anesthesia was
induced utilizing a rapid sequence technique with intravenous propofol
200 mg and succinylcholine 140 mg. Intraoperative management fol-
lowed the bariatric enhanced recovery protocol at our institution. Post-
induction, the patient received dexamethasone 8 mg, and ofirmev
1000 mg. The port sites were injected with liposomal bupivicaine 20 cc
by the surgeon. Anesthesia was maintained with a propofol infusion
titrated to keep the BIS value 40–60. An initial bolus of ketamine
5 mg·kg−1 was followed by a continuous infusion at 5 μg·kg−1 min−1.
Intermittent boluses of rocuronium were administered to keep the train-
of-four count 0–1 as assessed by ulnar nerve stimulation. The surgery
proceeded uneventfully and during emergence the patient received
4 mg ondansetron and 30 mg ketorolac. Residual neuromuscular
blockade was reversed with sugammadex 500 mg. The patient rapidly
met all extubation criteria and was transported to the post-anesthesia
☆
Disclosures: None.
https://doi.org/10.1016/j.jclinane.2018.09.014
Received 24 July 2018; Received in revised form 23 August 2018; Accepted 8 September 2018
0952-8180/ © 2018 Elsevier Inc. All rights reserved.
T
care unit awake and alert on 2 l of oxygen via nasal cannula. The
oxygen saturation remained at or above 94% throughout her PACU
stay. Her pain was well managed with ofirmev and ketorolac and no
opioids were administered. She reached an Aldrete score of 10 within
45 min and was ambulating unassisted in 90 min. There were no epi-
sodes of hypoxia (SpO2 < 93%), airway obstruction, or apnea in the
PACU. She was discharged from the hospital the following morning.
Ketamine, a phencyclidine, produces intense analgesia through
NMDA receptor antagonism and inhibition of μ-, δ-, and κ-opioid re-
ceptors. It preserves respiration and airway patency and may decrease
the incidence of postoperative nausea and vomiting through its opioid-
sparing effect. Recent literature highlights renewed interest in ketamine
for acute pain management, particularly in patients at risk for adverse
events related to opioid administration [3]. Ketamine has been shown
to decrease postoperative pain scores and opioid consumption in bar-
iatric surgery patients when given preoperatively [4]. Similarly, its
inclusion as a component of an opioid free anesthetic technique re-
sulted in comparable analgesia and less sedation when compared to an
opioid group [5].
The principles of enhanced recovery have challenged anesthesiolo-
gists to develop evidence-based strategies for safe, effective pain control
without side effects that prolong recovery and return to preoperative
functional status. Anesthetic techniques that promote rapid sustained
awakening, early ambulation and control of postoperative pain without
sedation, respiratory depression, or nausea and vomiting are needed.
This case illustrates that ketamine with propofol can achieve these
objectives in selected patients, and should be considered when an-
esthetizing morbidly obese patients with SDB.
References
[1] WC Frey, Pilcher J. Obstructive sleep-related breathing disorders in patients eval-
uated for bariatric surgery. Obes Surg 2003 Oct;13(5):676–83.
[2] Subramani Y, Nagappa M, Wong J, Patra J, Chung F. Death or near-death in patients
with obstructive sleep apnoea: a compendium of case reports of critical complica-
tions. Br J Anaesth 2017 Nov;119(5):885–99.
Correspondence Journal of Clinical Anesthesia 52 (2019) 65–66

[3] Potter DE, Choudhury M. Ketamine: repurposing and redefining a multifaceted drug.
Drug Discov Today 2014 Dec;19(12):1848–54.
[4] Zeballos JL, Lirk P, Rathmell JP. Low-dose ketamine for acute pain management: a
timely nudge toward multimodal analgesia. Reg Anesth Pain Med 2018
Jul;43(5):453.
[5] Sollazzi L, Modesti C, Vitale F, et al. Preinductive use of clonidine and ketamine
improves recovery and reduces postoperative pain after bariatric surgery. Surg Obes
Relat Dis 2009 Jan;5(1):67–71.
⁎
Judith Aronsohn, MD , Gabriel Orner, DO, Greg Palleschi, MD,
Madina Gerasimov, MD
Zucker School of Medicine at Hofstra/Northwell, North Shore University
Hospital, 300 Community Dr., Manhasset, NY 11030, USA
E-mail addresses: jaronsohn@northwell.edu (J. Aronsohn),
gpalleschi@northwell.edu (G. Palleschi),
mgerasimov@northwell.edu (M. Gerasimov)

⁎
Corresponding author at: Long Island Jewish Medical Center, Department of Anesthesiology, 270-05 76th Ave. Research building Rm. B341, New Hyde Park, NY
11040, USA.

66