引言：阿片类药物是大肠外科手术中和术后疼痛治疗的“黄金标准”。它们可以抑制细胞和体液免疫，并被认为可以促进癌细胞增殖和转移。通过使用非阿片类药物，即多模态镇痛，可以实现充分的疼痛管理，这些药物可以在小剂量下一起使用，并可以在手术期间和手术后减少阿片类药物的需要。无阿片类药物麻醉（OFA）是多模式镇痛的一部分，在围手术期不使用阿片类药物。 材料和方法：在这项前瞻性随机临床研究中，招募了60名计划进行开放性大肠手术的患者。他们年龄在45至70岁之间，属于美国麻醉师协会分类1、2和3，并分成三组。第一组患者或阿片类药物麻醉组（OBAG）在麻醉诱导期间接受以下治疗：利多卡因1mg/kg、芬太尼100µgr、丙泊酚2mg/kg和罗库溴铵0.6mg/kg。在手术过程中，他们间歇性静脉注射50-100µgr芬太尼和硬膜外导管中的0.25%布比卡因2-3 ml，每30-45分钟一次。第二组患者或低阿片类药物麻醉组（LOAG）在麻醉诱导期间接受以下治疗：利多卡因1mg/kg、芬太尼100 µgr、丙泊酚2mg/kg和罗库溴铵0.6mg/kg。在手术前，向硬膜外导管中注射50 µgr的芬太尼和5毫升的0.25％布比卡因，手术结束时接受相同剂量的药物。第三组或无阿片类药物麻醉组（OFAG）在进行全身麻醉诱导之前接受以下治疗：地塞米松0.1mg/kg和对乙酰氨基酚1克。全身麻醉诱导采用利多卡因1mg/kg、丙泊酚2mg/kg、氯胺酮0.5mg/kg和罗库溴铵0.6mg/kg。插管后，静脉持续输注利多卡因2mg/kg/h、氯胺酮0.2mg/kg/h和镁15mg/kg/h，并间断地给予硬膜外导管中的0.25％布比卡因2-3毫升，每30-45分钟一次。主要目标是在所有三组中测量术后72小时后患者的疼痛程度（手术后2、6、12、24、36、48和72小时）。次要目标是测量所有三组在术后期间通过硬脊膜外导管给予的吗啡总量。其他次要目标是：比较第一组和第二组在手术期间静脉注射的芬太尼总量，确定是否需要在术后期间使用救援镇痛剂，测量术后恶心呕吐的发生情况，并测量所有三组在手术期间给予的布比卡因总量。结果：组间视觉模拟评分（VAS）得分比较表明，OBAG和LOA组的患者在手术后2、12、24和48小时仍然有较高的VAS分数，而OFA组的患者得分最低。术后6小时，LOA组患者的VAS得分显著高于OBAG和OFA组的患者。术后36小时，OBAG组的患者VAS得分显著高于LOA和OFA组的患者。在最后一次随访点72小时后，OBAG和LOA组的患者VAS得分显著高于OFA组的患者。所有OBA和LOA组的患者，以及OFA组的仅有9名患者在术后期间通过硬脊膜外导管接受了吗啡。阿片类药物组患者在手术期间需要较高剂量的芬太尼。OBAG组中有55％的患者在术后期间处方了其他镇痛药物，LOAG组中有50％，OFA组中有35％。OBAG组有60％的患者和LOAG组有40％的患者出现了术后恶心呕吐症状。OFA组中没有患者出现术后恶心呕吐症状。在手术期间给予的布比卡因总量最多的是OBAG组（26.37 ± 2.6 mg），LOAG组为25.0 ± 0，而在OFG组中最少（24.50 ± 4.3）。 结论：相较于OBAG和LOAG组的患者，OFA组的患者在开放性结直肠手术后的前72小时内疼痛得分最低，通过硬膜外导管在术后期间需要的阿片类药物剂量最少，需要其他救援镇痛剂的几率较低，在术后期间没有恶心呕吐的发生情况，并在术中需要硬膜外导管中的布比卡因的剂量最少。 ©2023 Marija Toleska等，Sciendo出版。

Introduction: Opioids are the "gold standard" for pain treatment during and after colorectal surgery. They can inhibit cellular and humoral immunity and it is assumed that can promote cancer cell proliferation and metastatic spread. Adequate pain management can be achieved not only with opioids, but also with non-opioid drugs, which can be used together in small doses, i.e., multimodal analgesia, and can lower the need for opioids during and after surgery. Opioid free anesthesia (OFA) is part of multimodal analgesia, where opioids are not used in the intraoperative period. Materials and methods: In this prospective and randomized clinical study 60 patients scheduled for open colorectal surgery were enrolled. They were between the ages of 45 and 70 with the American Association of Anesthesiologists (ASA) classifications 1, 2 and 3, divided in three groups. The first group of patients, or Opioid-based anesthesia group (OBAG), received the following for induction to anesthesia: lidocaine at 1 mg/kg, fentanyl 100 at µgr, propofol at 2mg/kg and rocuronium bromide at 0.6 mg/kg. They intermittently received 50-100 µgr fentanyl intravenously and 0.25 % bupivacaine 2-3 ml every 30-45 minutes, given in the epidural catheter during surgery. The second group of patients, or Low opioid anesthesia group (LOAG), received the following for induction to anesthesia: lidocaine at 1 mg/kg, fentanyl at 100 µgr, propofol at 2mg/kg and rocuronium bromide at 0.6 mg/kg. Prior to surgery, 50 µgr of fentanyl with 5 ml 0.25% bupivacaine was given into the epidural catheter, and the same dose was received at the end of surgery. The third group, or Opioid free anesthesia group (OFAG), received the following before the induction to general anesthesia: dexamethasone at 0.1 mg/kg and 1 gr of paracetamol. Induction to general anesthesia was with lidocaine at 1 mg/kg, propofol at 2mg/kg, ketamine at 0.5 mg/kg and rocuronium bromide at 0.6 mg/kg. After intubation, intravenous continuous infusion with lidocaine was at 2 mg/kg/h, ketamine 0.2 mg/kg/h and magnesium 15 mg/kg/h loaded on and intermittently 0.25 % bupivacaine 2-3 ml every 30-45 minutes given in the epidural catheter during surgery. The primary goal was to measure the patients' pain after the first 72 postoperative hours in all three groups (2, 6, 12, 24, 36, 48 and 72 hours after surgery). The secondary goal was to measure the total amount of morphine given in the epidural catheter in the postoperative period in all three groups. Other secondary goals were: to compare the total amount of fentanyl given intravenously during surgery in the first and second groups, determine if there was a need to use rescue analgesia in the postoperative period, measure the occurrence of PONV, and to measure the total amount of bupivacaine given in the epidural catheter during operation in all three groups. Results: Visual Analogue Scale (VAS) score comparisons between groups showed patients from the OBA and LOA groups had significantly higher VAS scores, compared to the patients from the OFA group 2, 12, 24 and 48 hours after operation. After 6 hours postoperatively, patients from the LOA group had significantly higher VAS scores, compared to patients from the OBA and OFA groups. After 36 hours postoperatively, patients from the OBA group had significantly higher VAS scores compared to patients from the LOA and OFA groups. At the last follow-up point, 72 hours after the intervention, the patients from the OBA and LOA groups had significantly higher VAS scores compared to the patients from the OFA group. All patients from the OBA and LOA groups, and only 9 from the OFA group received morphine in the postoperative period via epidural catheter. Patients from the Opioid group received significantly higher amounts of fentanyl during surgery. Additional administration of another analgesic drug in the postoperative period was prescribed in 55% of patients in the OBAG, in 50% in the LOAG and in 35% of the OFA group. PONV was registered in 60% of patients from the OBAG and in 40% of patients from the LOAG. In the OFA group did not register PONV in any of the patients. The biggest amount of bupivacaine given during surgery was in the OBAG (26.37 ± 2.6 mg), in LOAG was 25.0 ± 0 and the less in OFAG group (24.50 ± 4.3). Conclusion: Patients from OFA group, compared with patients from OBAG and LOAG, have the lowest pain score in first 72 hours after open colorectal surgery, received fewer opioids via an epidural catheter in the postoperative period, had less need for rescue analgesia, no occurrence of PONV, and less need for bupivacaine via an epidural catheter in the intraoperative period.© 2023 Marija Toleska et al., published by Sciendo.