Opioid-Free General Anesthesia for Short-Duration Orthopedic Procedures: A Randomized Controlled Trial

Abstract

Objective: To evaluate the clinical efficacy and perioperative safety of a multimodal opioid-free anesthesia (OFA) regimen in patients undergoing short-duration orthopedic procedures. Methods: Sixty patients scheduled for elective orthopedic procedures between January 2024 and June 2026, with American Society of Anesthesiologists (ASA) physical status I or II and an expected surgical duration of <2 h, were randomized 1:1 to an OFA group or an opioid-based anesthesia (OBA) group (n=30 each). The OFA regimen was based on dexmedetomidine, esketamine, and intravenous lidocaine, whereas the OBA regimen used sufentanil for induction and remifentanil for maintenance. Heart rate (HR) and mean arterial pressure (MAP) were recorded before induction (T0), immediately after induction (T1), after laryngeal mask airway (LMA) insertion (T2), 10 min after induction (T3), before LMA removal (T4), and after LMA removal (T5). Time to LMA removal, post-anesthesia care unit (PACU) length of stay, Steward recovery score at PACU discharge, resting numerical rating scale (NRS) pain scores in the PACU and at 24 h, Richards-Campbell Sleep Questionnaire (RCSQ) score on postoperative day 1, rescue analgesia, postoperative nausea and vomiting (PONV), hypoxemia, bradycardia, hypotension, and other adverse events were recorded. Results: Compared with the OBA group, the OFA group had higher HR and MAP at T1, T3, and T4 (all P<0.05), whereas values at T0, T2, and T5 were comparable between groups. The 24-h resting NRS score was lower in the OFA group than in the OBA group (2.2±1.2 vs. 3.2±1.1; P=0.002), while the PACU NRS score did not differ significantly. The postoperative day 1 RCSQ score was higher with OFA (70.1±8.0 vs. 57.3±10.7; P<0.001). Time to LMA removal (12.7±2.0 vs. 10.2±2.0 min; P<0.001) and PACU stay (40.9±4.8 vs. 36.4±4.9 min; P<0.001) were longer in the OFA group. PONV occurred less frequently in the OFA group (6.7% vs. 30.0%; P=0.020). The incidences of rescue analgesia, hypoxemia, bradycardia, and hypotension were not significantly different between groups. Conclusion: A multimodal OFA regimen based on dexmedetomidine, esketamine, and lidocaine was feasible for short-duration orthopedic procedures and was associated with lower 24-h pain scores, better first-night subjective sleep quality, and less PONV. These potential benefits were accompanied by modestly prolonged emergence and PACU recovery, indicating that recovery efficiency and hemodynamic safety should be considered when implementing OFA.