Total intravenous-opioid-free anesthesia/analgesia (OFAA) for a morbid obese patient with a body mass index of 99 kg/m² undergoing gastric bypass: a case report

Background: Bariatric surgery has been established as an effective intervention for weight reduction and the improvement of comorbidities. In this context, the use of opioid-free anesthesia with multimodal analgesia is gaining importance because of its ability to minimize respiratory complications and other opioid-related adverse effects in these patients. In the reviewed literature we found no reports of the use of opioid-free anesthesia/analgesia with total intravenous anesthesia based on propofol/lidocaine/ketamine/dexmedetomidine in bariatric surgery for patients with morbid obesity with a body mass index greater than 60 kg/m². Case presentation: The anesthetic management of a 50-year-old white-Hispanic female patient was documented. The patient suffered from morbid obesity with weight 260 kg, height 1.62 m, and a body mass index of 99 kg/m². She was American Society of Anesthesiologists III with obesity hypoventilation syndrome, and chronic heart failure.The patient was scheduled for laparoscopic gastric bypass. Opioid-free anesthesia/analgesia was performed via total intravenous anesthesia based on propofol and standard multimodal analgesia. Low-dose infusions of lidocaine, ketamine, and dexmedetomidine were continued for 48 hours. The patient had a good level of satisfaction during the postoperative period, without the need for postoperative rescue opioids. There was effective pain control (VAS < 3) and an absence of postoperative nausea and vomiting. No respiratory, cardiovascular, or gastric complications were observed during the hospital stay, and she was discharged on the eleventh postoperative day, indicating a high level of satisfaction without complications or adverse effects. Conclusions: This case shows that opioid-free anesthesia/analgesia can be feasible and safe. The mandatory use of anesthetic depth monitoring together with the validation of target-control infusion models for propofol in obese patients are both recommended to facilitate the more frequent use of total intravenous anesthesia-target-control infusion in this population.