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BackgroundIt is speculated that opioid-free anesthesia may provide adequate pain control while reducing postoperative opioid consumption. However, there is currently no evidence to support the speculation. The authors hypothesized that opioid-free balanced anesthetic with dexmedetomidine reduces postoperative opioid-related adverse events compared with balanced anesthetic with remifentanil.MethodsPatients were randomized to receive a standard balanced anesthetic with either intraoperative remifentanil plus morphine (remifentanil group) or dexmedetomidine (opioid-free group). All patients received intraoperative propofol, desflurane, dexamethasone, lidocaine infusion, ketamine infusion, neuromuscular blockade, and postoperative lidocaine infusion, paracetamol, nefopam, and patient-controlled morphine. The primary outcome was a composite of postoperative opioid-related adverse events (hypoxemia, ileus, or cognitive dysfunction) within the first 48 h after extubation. The main secondary outcomes were episodes of postoperative pain, opioid consumption, and postoperative nausea and vomiting.ResultsThe study was stopped prematurely because of five cases of severe bradycardia in the dexmedetomidine group. The primary composite outcome occurred in 122 of 156 (78%) dexmedetomidine group patients compared with 105 of 156 (67%) in the remifentanil group (relative risk, 1.16; 95% CI, 1.01 to 1.33; P = 0.031). Hypoxemia occurred 110 of 152 (72%) of dexmedetomidine group and 94 of 155 (61%) of remifentanil group patients (relative risk, 1.19; 95% CI, 1.02 to 1.40; P = 0.030). There were no differences in ileus or cognitive dysfunction. Cumulative 0 to 48 h postoperative morphine consumption (11 mg [5 to 21] versus 6 mg [0 to 17]) and postoperative nausea and vomiting (58 of 157 [37%] versus 37 of 157 [24%]; relative risk, 0.64; 95% CI, 0.45 to 0.90) were both less in the dexmedetomidine group, whereas measures of analgesia were similar in both groups. Dexmedetomidine patients had more delayed extubation and prolonged postanesthesia care unit stay.ConclusionsThis trial refuted the hypothesis that balanced opioid-free anesthesia with dexmedetomidine, compared with remifentanil, would result in fewer postoperative opioid-related adverse events. Conversely, it did result in a greater incidence of serious adverse events, especially hypoxemia and bradycardia.Editor’s PerspectiveWhat We Already Know about This TopicWhat This Article Tells Us That Is New

Resume Objectif Determiner les outils de la decision therapeutique qui conduisent a poser l’indication chirurgicale devant un cancer de la prostate (CaP) non metastatique relevable d’un traitement local. L’evaluation optimalisee de la maladie causale et des eventuelles comorbidites permet d’ameliorer la selection du malade dont le dossier sera presente a la RCP onco-urologique pour valider le Programme personnalise de soins. Materiel et methode Recherche bibliographique a partir de la base de donnees Medline (National Library of Medicine, outil Pubmed) et Med Science selectionnee selon la pertinence scientifique. La recherche a ete centree sur les outils de diagnostic du CaP, l’evaluation des caracteristiques de la maladie et du patient et des elements orientant vers une prise en charge chirurgicale (antecedents medico-chirurgicaux, situation fonctionnelle, comorbidites, esperance de vie). Resultats L’evaluation carcinologique pretherapeutique permet d’estimer le risque lie au CaP, aspect essentiel de la prise de decision therapeutique. Plusieurs criteres cliniques, biologiques, d’imagerie et anatomopathologiques permettent d’orienter la decision selon l’agressivite tumorale et le risque de recidive tout en estimant les resultats des traitements proposes. Parallelement, l’evaluation mictionnelle, de la continence urinaire et du statut sexuel, l’integration des donnees anatomiques et les antecedents medico-chirurgicaux sont indispensables dans la decision therapeutique aidee par les scores de comorbidite (Charlson, ASA, ICD). Ces elements sont indissociables pour decider d’un traitement radical ou conservateur du CaP, ils aboutissent a la prise en charge globale du patient candidat a la chirurgie. L’âge joue un role primordial dans le choix du traitement, meme chez les hommes âges susceptibles de developper un CaP a haut risque avec un impact sur la survie globale a estimer. Conclusion L’evaluation combinee de la maladie et du patient est fondamentale pour ameliorer la prise en charge en cancerologie, notamment dans le CaP non metastatique pour lequel les possibilites curatives sont nombreuses. L’aide de l’anesthesiste dans l’analyse et l’interpretation des comorbidites autour d’outils de plus en plus performants reste fondamentale pour selectionner les bons candidats informes a orienter vers la chirurgie en accord avec les prerogatives de programmes de soins personnalises.

Radical cystectomy is associated with a high postoperative mortality and morbidity in older patients. We aimed to define the predictive value of comorbidity scores and determine the prognostic factors of postoperative complications. Preoperative associated morbidities were collected and graded according to the American Society of Anesthesiologists (ASA) score system, the Adult Comorbidity Evaluation (ACE) scale and the Charlson comorbidity index. Surgical complications were graded according to Clavien classification. Early and late complications were recorded. Data are from 49 consecutive patients aged ≥ 75 years who had an open surgery for bladder cancer. The most commonly associated conditions were smoking, renal insufficiency, and arterial hypertension. Incidence of early and late complications was 49% and 16%, respectively. Four and 25 death events occurred during the early and late follow-up, respectively. The incidence of morbidity and mortality were not related to ASA, ACE or Charlson scores. Preoperative malnutrition, renal insufficiency, higher need of perioperative blood transfusions, and prolonged ileus were identified as risk factors of postoperative morbidity. Late complications seemed related to low weight.

To determine the tools of therapeutic decision that push towards surgical treatment in non metastatic prostate cancer eligible to local treatment. The optimized assessment of the disease and eventual comorbidities improves the selection of patients. Patient's files will be presented in the uro-oncological multidisciplinary discussions to validate the customized therapeutic approach proposed.Literature review using Medline (National library of medicine, Pubmed) and Med Science databases based on the scientific pertinence. Research was focused on the diagnosis of prostate cancer, the evaluation of the disease and patient's characteristics, and finally the elements that are with a surgical treatment (past medical history, past surgical history, functional status, patient's comorbidities, and life expectancy).The pretherapeutic oncologic evaluation allows to estimate the risks associated with prostate cancer; it is an essential aspect of therapeutic decision. Several clinical, biological, imaging and pathological criteria allow to guide decision-making according to tumor aggressiveness and risk of recurrence, estimating the results of the different treatments proposed. On the other hand, the evaluation of lower urinary tract symptoms, urinary continence and sexual function, the integration of anatomical data, past medical and past surgical history are all essential for the therapeutic decision, in addition to the comorbidities (Charlson, ASA, ICD). These elements should be taken all together in order to decide for a radical or conservative management of PCa, they guide decision-making in patients candidate for surgery. For example, age plays a key role in the choice of treatment, even in older men at risk of developing high-risk PCa that can affect overall survival.The combined evaluation of the patient and disease characteristics is of utmost importance in oncology, and especially in the treatment of non-metastatic PCa. The role of the anesthesiologist in the analysis and interpretation of comorbidities remains primordial and it is essential for the selection of the right candidates for surgery after being well informed, and orienting them toward surgery in agreement with the prerogatives programs of customized care.