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Background and Aims Opioids are widely utilized agents for pain control, both intraoperatively and postoperatively. However, due to the abundance of adverse effects associated with their use such as nausea, vomiting, respiratory depression, ileus, delayed gastric emptying and pruritus, the use of opioid-sparing and opioid-free techniques have gained growing interest as part of a multimodal analgesic approach. In this context and in the era of an ever- increasing opioid epidemic, regional anesthesia and analgesia techniques are an interesting supplementary alternative aiming at minimizing opioid use.

Methods In this report, we present the use of an opioid-free general anesthesia modality in conjunction with a thoracic epidural technique in an elderly patient with comorbidities who underwent pancreatoduodenectomy. The anesthetic technique was based on the Mulier protocol. In specific, 0.1 mcg/kg dexmedetomidine, 0.1 mg/kg ketamine and 1 mg/kg lidocaine were administered as a bolus, followed by a continuous infusion of a mixture of dexmedetomidine 0.1 mcg/kg/h, ketamine 0.1 mg/kg/h and lidocaine 1 mg/kg/h throughout the operation. Before skin incision, an additional bolus of ketamine 0.5 mg/kg was administered, followed by 40 mg/kg of magnesium and 8 mg of dexamethasone. The anesthetic was supplemented by a low thoracic epidural. Intraoperatively and postoperatively, complete avoidance of opioids was achieved.

Results We demonstrated a paradigm of complete avoidance of systemic intravenous administration of opioids intraoperatively and postoperatively in an elderly patient with comorbidities scheduled for pancreatoduodenectomy.

Conclusions An opioid-free anesthetic is feasible and can be delivered successfully even in open gastrointestinal surgical procedures, where analgesia has traditionally relied on the use of opioids.

Attachment Ethics committee approval.pdf