1. Balanced Opioid-free Anesthesia with Dexmedetomidine versus Balanced Anesthesia with Remifentanil for Major or Intermediate Noncardiac Surgery
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J. Nadaud, Sylvain Lecoeur, Antoine Roquilly, Elisabeth Dubout, M. Mazerolles, Bruno Laviolle, Emmanuel Futier, Hélène Beloeil, Gilles Lebuffe, Julien Bila, Thomas Godet, Alexandre Gerbaud, Antoine Becret, Nicolas Coullier, Stéphanie Sigaut, Matthias Garot, Pierre-Marie Choinier, Karim Asehnoune, Maxime Esvan, Julie Fayon, Sebastien Oger, Gerald Chanques, Philippe Cuvillon, F. Atallah, CHU Pontchaillou [Rennes], CHU Lille, Génétique, Reproduction et Développement (GReD), Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS)-Université Clermont Auvergne (UCA), Physiologie & médecine expérimentale du Cœur et des Muscles [U 1046] (PhyMedExp), Université de Montpellier (UM)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS), Centre Hospitalier Régional Universitaire [Montpellier] (CHRU Montpellier), Centre d'Investigation Clinique [Rennes] (CIC), Université de Rennes 1 (UR1), Université de Rennes (UNIV-RENNES)-Université de Rennes (UNIV-RENNES)-Hôpital Pontchaillou-Institut National de la Santé et de la Recherche Médicale (INSERM), Service d'Anesthésie Réanimation [Rennes], Unité de réanimation médicale [CHU de Carémeau, Nîmes], Centre Hospitalier Universitaire de Nîmes (CHU Nîmes), Clinique Francheville [Périgueux], Centre hospitalier régional Metz-Thionville (CHR Metz-Thionville), Hôpital Yves LE FOLL [Saint-Brieuc], Pôle Anesthésie Réanimation [CHU de Toulouse], Centre Hospitalier Universitaire de Toulouse (CHU Toulouse), Service de Gastroentérologie [Hôpital Beaujon], Hôpital Beaujon [AP-HP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP), Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP), Service d'anesthésie et réanimation chirurgicale [Nantes], Hôtel-Dieu-Centre hospitalier universitaire de Nantes (CHU Nantes), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Montpellier (UM)-Centre National de la Recherche Scientifique (CNRS), and Université de Rennes (UR)-Hôpital Pontchaillou-Institut National de la Santé et de la Recherche Médicale (INSERM)
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Balanced Anesthesia ,business.industry ,[SDV]Life Sciences [q-bio] ,Remifentanil ,[SDV.SP]Life Sciences [q-bio]/Pharmaceutical sciences ,3. Good health ,03 medical and health sciences ,Desflurane ,0302 clinical medicine ,Anesthesiology and Pain Medicine ,Nefopam ,MESH: Female ,Humans ,Male ,Middle Aged ,Pain, Postoperative / drug therapy ,Prospective Studies ,030202 anesthesiology ,Anesthesia ,Medicine ,Ketamine ,030212 general & internal medicine ,MESH: Remifentanil / therapeutic use ,Single-Blind Method ,Treatment Outcome ,medicine.symptom ,Dexmedetomidine ,business ,Propofol ,Postoperative nausea and vomiting ,medicine.drug ,MESH: Analgesics, Non-Narcotic / therapeutic use ,Analgesics, Opioid / therapeutic use ,Balanced Anesthesia / methods ,Dexmedetomidine / therapeutic use - Abstract
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
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- 2021
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