Balanced Opioid-free Anesthesia with Dexmedetomidine versus Balanced Anesthesia with Remifentanil for Major or Intermediate Noncardiac Surgery.

BACKGROUND: It 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. METHODS: Patients 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. RESULTS: The 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. CONCLUSIONS: This 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.

How green is my reusable bronchoscope?

INTRODUCTION: Single-use bronchoscopes have replaced reusable ones in many institutions. This study aimed to evaluate the environmental and financial impacts of both strategies: reusable and single-use bronchoscopes. MATERIAL AND METHODS: We conducted a pragmatic study in a 21-bed polyvalent ICU, in Saint-Brieuc, Bretagne, France. The eco-audit consisted of estimating greenhouse gas (GHG) emissions, considering the life cycle of each strategy. Greenhouse gas (GHG) emissions related to construction, packaging, transport and waste elimination were compared between 2 devices: the reusable bronchoscope, a Pentax® FI-16RBS that was disinfected twice daily; and the single-use bronchoscope, the bronchoflex agile® from TSC. RESULTS: For the reusable bronchoscope, GHG emissions were marginally impacted by the number of bronchoscopies performed (from 185 kg eq.CO2 per year to 192 kg eq.CO2 for 10 or 110 bronchoscopies per year). For the reusable device, GHG emissions directly depended on the number of bronchoscopies performed with 3.82 kg eq.CO2 emitted per bronchoscopy. The breakeven point for the reusable bronchoscope was estimated at 50 bronchoscopies in terms of GHG emissions and 96 bronchoscopies for financial considerations. CONCLUSION: Considering current practice in our ICU, reusable bronchoscopes have lower GHG emissions when used more than 50 times a year and a lower cost when used more than 96 times a year as compared with single-use bronchoscopes.