Feasibility and Postoperative Opioid Sparing Effect of an Opioid-free Anaesthesia in Adult Cardiac Surgery

A Retrospective Study

Clément Aguerreche; Gaspard Cadier; Antoine Beurton; Julien Imbault; Sébastien Leuillet; Alain Remy; Cédrick Zaouter; Alexandre Ouattara

Disclosures

BMC Anesthesiol. 2021;21(166)

Conclusion

Our study strongly suggests that dexmedetomidine-based OFA in adult cardiac surgery is feasible and provides intraoperative hemodynamic stability. A such anaesthetic approach is responsible for postoperative opioid sparing effect and might have some clinically relevant benefits to improve outcomes.

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Acknowledgments
The authors thank the nursing staff of the intensive care unit for their assistance in the postoperative data collection.

Funding
No funding was used for this work which was solely supported by the Department of Anesthesia and Critical care.

Availability of data and materials
All relevant data was presented within the manuscript and the datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations
Ethics approval and informed consent
The study was approved by the ethics committee of the University Hospital of Bordeaux on August 13th, 2020 (Ethics Committee reference number GP – CE2020–33 by Chair Dr. Thibaud Haaser). Because the current study was a retrospective observational trial with patients treated according to our hospital standard of care, the ethics committee granted an authorisation to waive written informed consent from patients.

Consent for publication
Not applicable.

Table 1. Baseline characteristics of patients receiving opioid-free anaesthesia (OFA) or opioid-based anaesthesia (OBA)
	All patients (n = 80)	OFA (n = 40)	OBA (n = 40)	P-value
Age, years	71 [64–75]	71 [63–74]	71 [67–75]	0.81
Male gender	56 (70)	25 (63)	31 (78)	0.14
Body mass index, kg.m⁻²	25.9 [24.2–30.0]	26.0 [24.3–30.5]	25.8 [24.2–28.6]	0.92
EuroSCORE II, %	3.0 [1.8–6.9]	4.7 [2.1–9.1]	2.0 [1.4–3.9]	< 0.001
Medical history
Redo surgery	9 (11)	4 (10)	5 (13)	> 0.99
Active endocarditis	16 (20)	9 (23)	7 (18)	0.58
COPD	10 (13)	6 (15)	4 (10)	0.50
Obstructive sleep apnea	11 (14)	5 (13)	6 (15)	0.75
Smoking history	14 (18)	3 (8)	11 (28)	0.04
Hypertension	63 (79)	32 (80)	31 (78)	0.78
Dyslipidemia	41 (51)	25 (63)	16 (40)	0.04
Diabetes	18 (23)	13 (33)	5 (13)	0.03
Atrial fibrillation	12 (15)	5 (13)	7 (18)	0.53
History of stroke	8 (10)	3 (8)	5 (13)	0.71
Apfel score	2 [2–2]	2 [2–3]	2 [2–2]	< 0.01
LVEF, %	60 [50–60]	50 [50–60]	60 [55–65]	< 0.001
Creatinine clearance, mL.min⁻¹	78 [62–96]	78 [63–94]	77 [62–101]	0.79
Non elective surgery	25 (31)	20 (50)	5 (13)	< 0.01
Preoperative medication
Beta-blockers	36 (45)	15 (38)	21 (51)	0.18
Calcium channel blocker	23 (29)	13 (33)	10 (25)	0.46
Antiplatelet therapy*	35 (44)	19 (48)	16 (40)	0.18
ACEI	43 (54)	22 (55)	21 (53)	0.82
Statins	28 (35)	17 (43)	11 (28)	0.16

Data are presented as median [Interquartile range] or number (%) of patients. EuroSCORE II European System for Cardiac Operative Risk Evaluation II, COPD Chronic Obstructive Pulmonary Disease, LVEF Left Ventricular Ejection Fraction, * aspirin and/or clopidogrel, ACEI Angiotensin-conversing-enzyme inhibitors. P value refers to comparison between OFA and OBA groups

Table 2. Intraoperative characteristics of patients receiving opioid-free anaesthesia (OFA) or opioid-based anaesthesia (OBA)
	All patients (n = 80)	OFA (n = 40)	OBA (n = 40)	P-value
Anaesthesia time, min	270 [210–316]	293 [222–321]	258 [210–306]	0.38
Maximal target effect-site concentration of propofol for induction, μg.mL⁻¹	2.5 [2.0–3.0]	2.0 [1.0–2.0]	3.0 [3.0–4.0]	< 0.01
Lowest heart rate before CPB	55 [47-60]	55 [48–60]	55 [45–64]	0.74
CPB time, min	80 [66–103]	82 [68–103]	79 [63–105]	0.81
Type of surgery
Valvular surgery	31 (39)	14 (35)	17 (43)	0.49
CABG	22 (28)	14 (35)	8 (20)	0.13
Combined	25 (31)	11 (28)	14 (35)	0.47
Ascending aorta	2 (3)	1(3)	1 (3)	> 0.99
Intraoperative fluid, ml.kg⁻¹	15 [9–23]	14 [8–23]	17 [10–22]	0.43
RBC transfusion	25 (31)	11 (28)	14 (35)	0.47
Urapidil use	3 (4)	3 (8)	0 (0)	0.08
Atropine use	2 (3)	0 (0)	2 (5)	0.15
Vasopressors requirements
Norepinephrine (IV infusion)	40 (50)	17 (43)	23 (58)	0.18
Norepinephrine (boluses)	29 (36)	17 (43)	12 (30)	0.24
Ephedrine	9 (11)	1 (3)	8 (20)	0.03
Inotropes use*	9 (11)	4 (10)	5 (13)	1.00

Data are presented as median [interquartile range] or number (%) of subjects. CPB: cardiopulmonary bypass; CABG coronary artery bypass graft, RBC red blood cell; *: dobutamine and/or milrinone. P value refers to comparison between OFA and OBA groups

Table 3. Peri-operative analgesia in patients receiving opioid-free anaesthesia (OFA) and opioid-based anaesthesia (OBA)
	All patients (n = 80)	OFA (n = 40)	OBA (n = 40)	P-value
Intraoperative analgesia
Paracetamol	79 (99)	39 (98)	40 (100)	> 0.99
Nefopam	72 (90)	38 (95)	34 (85)	0.26
Ketoprofen	44 (55)	32 (80)	12 (30)	< 0.01
Tramadol	2 (3)	2 (5)	0 (0)	0.49
Morphine	33 (41)	1 (3)	32 (80)	< 0.01
Ketamine, n (%)	76 (95)	40 (100)	36 (90)	0.12
Ketamine dose, mg	75 [50–100]	90 [75–100]	50 [30–70]	< 0.001
Lidocaine, n (%)	50 (63)	40 (100)	10 (25)	< 0.01
MgSO ₄ ²⁻	48 (60)	40 (100)	8 (20)	< 0.01
Morphine titration	51 (64)	23 (58)	28 (70)	0.24
Rescue analgesia during first 48 h
Ketoprofen use	30 (38)	18 (45)	12 (30)	0.17
Ketoprofen dose, mg	100 [50–150]	100 [75–200]	100 [50–100]	0.18
Tramadol use	7 (9)	5 (13)	2 (5)	0.43
Tramadol dose, mg	200 [125–425]	200 [100–400]	325 [125–425]	0.57
Oxycodone oral	23 (29)	9 (23)	14 (35)	0.22
Ketamine use	8 (10)	2 (5)	6 (15)	0.26

Data are presented as median [Interquartile range] or number (%) of patients. P value refers to comparison between OFA and OBA groups

Table 4. Postoperative outcomes patients receiving opioid-free anaesthesia (OFA) and opioid-based anaesthesia (OBA)
	All patients (n = 80)	OFA (n = 40)	OBA (n = 40)	P-value
PaO₂/FiO₂ ratio at ICU arrival	309 ± 99	327 ± 112	291 ± 81	0.10
Lowest PaO₂/FiO₂ ratio during first 48 h	238 [188–278]	244 [189–288]	226 [186–273]	0.49
Noninvasive ventilation use	29 (36)	10 (25)	19 (48)	0.04
Time to extubation, hours	3 [2–5]	2 [2–3]	4 [2–7]	< 0.01
Reintubation	4 (5)	2 (5)	2 (5)	1.00
Vomiting and/or nausea	8 (10)	3 (8)	5 (13)	0.71
Surgical re-exploration	7 (9)	1 (3)	6 (15)	0.11
Need for vasopressors ≥6 h	23 (29)	13 (33)	10 (25)	0.46
Need for inotropes ≥6 h	9 (11)	4 (10)	5 (13)	> 0.99
New onset of atrial fibrillation	23 (29)	7 (18)	16 (40)	0.03
Ventricular arrhythmias*	5(6)	2 (5)	3 (8)	> 0.99
Atrioventricular block^£	1 (1)	0	1 (3)	> 0.99
Delirium	8 (10)	1 (3)	7 (18)	0.06
ARF (KDIGO stage 2 or 3)	5 (6)	1 (3)	4 (10)	0.36
Hs-cTnI at 12 h, ng. L⁻¹	1700 [918–4925]	1700 [900–3500]	1700 [1000–8200]	0.44
ICU length of stay, hours	48 [41–73]	47 [35–84]	49 [42–73]	0.55
Hospital length of stay, days	12 [9–15]	11 [10–15]	13 [9–15]	0.48

Data are presented as median [Interquartile range] or mean ± standard deviation or number (%) of patients. ICU intensive care unit, * ventricular or fibrillation, ^£ high-grade atrioventricular block requiring pacemaker implantation, ARF acute renal failure, KDIGO Kidney Disease Improving Global Outcomes, Hs-cTnI high-sensitivity cardiac troponin I. P value refers to comparison between OFA and OBA groups