Buprenorphine is a partial mu receptor agonist and kappa/delta antagonist commonly
used for the treatment of opioid dependence or as an analgesic. It has a long plasma halflife and a high binding affinity for opioid receptors. This affinity is so high, that the effects
are not easily antagonized by competitive antagonists, such as naloxone. The high affinity
also prevents binding of other opioids, at commonly used clinical doses, to receptor sites
– preventing their analgesic and likely minimum alveolar concentration (MAC) reducing
benefits.
This case report contrasts the anesthetic requirements of a patient undergoing emergency
cervical spine surgery while taking buprenorphine with anesthetic requirements of the
same patient undergoing a similar procedure after weaning of buprenorphine. Use of
intraoperative neurophysiological monitoring prevented use of paralytics and inhalational
anesthetics during both cases, therefore total intravenous anesthesia (TIVA) was maintained
with propofol and remifentanil infusions. During the initial surgery, intraoperative patient
movement could not be controlled with very high doses of propofol and remifentanil. The
patient stopped moving in response to surgical stimulation only after the addition of a
ketamine. Buprenorphine-naloxone was discontinued postoperatively. Five days later the
patient underwent a similar cervical spine surgery. She had drastically reduced anesthetic
requirements during this case, suggesting buprenorphine’s profound effect on anesthetic
dosing. This case report elegantly illustrates that discontinuation of buprenorphine is
likely warranted for patients who present for major spine surgery, which necessitates
the avoidance of volatile anesthetic and paralytic agents. The addition of ketamine may
be necessary in patients maintained on buprenorphine in order to ensure a motionless
surgical field.
Key words: Buprenorphine, anesthesiology, intraoperative, total intravenous anesthesia,
pharmacology
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