title: Opioid-free perioperative analgesia for hemicolectomy in a patient with opioid-induced delirium: a case report and review of the analgesic efficacy of the alpha-2 agonist agents.
abstract: Surgical pain in patients with documented opioid-induced delirium can be difficult to treat. We present a case of a patient undergoing laparoscopic hemicolectomy effectively treated with an opioid-free, alpha-2 adrenoreceptor agonist analgesic regimen.
  
  
  METHODS
  A 21-year-old woman with persistent abdominal pain presented to the operating room for laparoscopic hemicolectomy for redundant right colon. Her medical history included a recently diagnosed postoperative opioid-induced delirium. Epidural infusion with local anesthetic offered partial pain relief with sensory levels of T9-L2. With the addition of dexmedetomidine infusion in the immediate postoperative period, the patient was comfortable with pain scores of 1 to 2/10 on Numerical Rating Scale (NRS). On postoperative day 1, the infusion was discontinued and the clonidine, 12 μg/hours was added to the epidural bupivacaine. With increased sedation 48 hours later, neuraxial clonidine was discontinued in favor to transdermal clonidine 0.1 mg/week, which was maintained until hospital discharge. Pain scores were maintained at 2 to 3/10 on NRS for the next 3 days when increased abdominal distention because of abscess formation rendered a new surgical intervention. The analgesia for the exploratory laparoscopy was maintained using epidural clonidine and bupivacaine infusion as well as intravenous dexmedetomidine, which were maintained another 2 days. Pain scores remained minimal until discharged home 3 day later.
  
  
  CONCLUSIONS
  Nonopioid analgesic regimens are beneficial in patients at risk of postoperative cognitive dysfunction attributable to opioids. Successful postoperative analgesia was achieved in our patient by alternating various routes of administration of alpha-2 adrenoreceptor agonists.
authors.affiliation: Anesthesia and Critical Care Medicine, University of Chicago Medical Center, Chicago, IL, USA.
authors.forename: Sheetal K
authors.initials: SK
authors.lastname: Patil
authors.forename: Magdalena
authors.initials: M
authors.lastname: Anitescu
mesh_terms: D018784:Abdominal Abscess / Q000601:surgery; D058647:Adrenergic alpha-2 Receptor Agonists / Q000008:administration & dosage*; D015360:Analgesia, Epidural; D018712:Analgesics, Non-Narcotic / Q000008:administration & dosage*; D000701:Analgesics, Opioid / Q000009:adverse effects; D018686:Anesthetics, Intravenous; D002045:Bupivacaine / Q000008:administration & dosage; D003000:Clonidine / Q000008:administration & dosage; D003082:Colectomy / Q000009:adverse effects; D003693:Delirium / Q000139:chemically induced; D020927:Dexmedetomidine / Q000008:administration & dosage*; D005260:Female; D006801:Humans; D007262:Infusions, Intravenous; D010149:Postoperative Pain / Q000188:drug therapy*; D011183:Postoperative Complications / Q000601:surgery; D015742:Propofol / Q000008:administration & dosage; D055815:Young Adult
chemical_list: D058647:Adrenergic alpha-2 Receptor Agonists; D018712:Analgesics, Non-Narcotic; D000701:Analgesics, Opioid; D018686:Anesthetics, Intravenous; D020927:Dexmedetomidine; D003000:Clonidine; D002045:Bupivacaine; D015742:Propofol