7. Combined strategies for analgesia

interventions and superior alternatives in pain management toolkits. It offers a superior anal-

Analgesic adjuvants such as Ketamine, Dexmedetomidine, and Clonidine may also decrease postoperative opioid

Perioperative management by regional analgesic techniques rather than systemic opioids has been recommended by the American Society of Anesthesiologists since 2014, with an aim to reduce the likelihood of OSA-related perioperative adverse outcomes. The beneficial effects of perioperative regional analgesic techniques on patient outcomes have been proved in general surgical population [70, 71]. Still, the evidence in OSA patients is inconclusive as it was driven

Neuraxial analgesia is a modality with high efficacy and can be used effectively as a sole analgesic approach. Its beneficial effects on respiratory functions such as superior spirometry in the immediate postoperative period and lower postoperative pulmonary complications have been consistently documented in many studies [73, 74]. The risks in morbidly obese patients include respiratory depression secondary to a rostral spread of neuraxial opioids that could lead to a postoperative respiratory arrest [75, 76]. Therefore, the ASA task force recom-

Technical difficulty with procedure failure has been proposed as another challenge in OSA patients, who are often obese. Yet, these concerns lack conclusive evidence, and most have been driven from opinion-based reports. Studies in obese pregnant have showed that the incidence of technical difficulty for epidural anesthesia is overrated. The success was correlated with optimal positioning prior to placement and good quality of palpable surface landmarks [77]. Preprocedural ultrasonography (US) of the spine could accurately identify the intervertebral space and predict the needle insertion depth in intrathecal space thus facilitating placement of an epidural catheter. Systematic review and meta-analysis have shown that spine US has a greater accuracy than manual palpation of surface anatomical landmarks [78]. This could lead to a decreased risk of technical failures and the number of needle punctures.

PNB modality is another pillar of opioid-sparing analgesic techniques. It includes upper extremity, lower extremity, and planar blocks such as transversus abdominis plane (TAP) block, paravertebral block, and erector spinae plane block (ESP). Initially, studies showed that

) is independent risk factor for block failure. [45] However, other

gesic effect and minimizes the need for systemic analgesics [68, 69].

Table 2. Opioid-sparing techniques include a combination of the following.

Regional analgesia with local anesthetic (e.g., peripheral nerve blocks, epidural analgesia)

6.2. Neuraxial analgesia techniques

Nonopioid analgesics include

120 Pain Management in Special Circumstances

Acetaminophen,

requirements.

Nonsteroidal anti-inflammatory drugs (NSAIDs),

6.3. Peripheral nerve blocks (PNB)

obesity (BMI > 25 kg/m2

mainly from case reports or small retrospective case–control studies [67, 72].

mends that expected benefits should be weighed against the potential risks.

Preemptive analgesia could obtund nociceptive responses prior to surgical stimulus and possibly decrease postoperative pain. Moreover, it could possibly decrease the probability of conversion of acute pain to chronic pain [81]. Postoperative patient-controlled intravenous analgesia (PCA) or epidural analgesia (PCEA) have been shown to decrease narcotic consumption and provide a high degree of patient satisfaction [82]. Other techniques like long-acting local anesthetic infusions at the surgical wound site or even intraperitoneal infusion have shown promising results [83, 84].

Poor pain management of morbidly obese patients increases postoperative complications [85]. Therefore, the use of multimodal analgesia can solve this problem, consequently improving patient satisfaction and reduce postoperative morbidity.

Developing an optimal evidence-based pain management protocol tailored to obese patients with OSA is a challenging task. The majority of current recommendations are either based on studies with small sample size or lacking a scientifically rigorous study design. Given the paucity of literature in obese patients with sleep apnea, it is difficult to draw a definitive conclusion. Yet, the obvious benefits of multimodal analgesic regimen make it popular in regular clinical practice.
