2021年 · 第101卷第20期

It has been speculated that opioid-free anesthesia may provide adequate pain control while reducing postoperative opioid consumption. However, there is currently no evidence to support this speculation. The study hypothesized that balanced anesthesia combined with dexmedetomidine reduced postoperative opioid-related adverse events compared to balanced anesthesia with remifentanil. In this single-blind randomized controlled study, patients undergoing medium to large non-cardiac surgery from 10 centers in France were randomly assigned to remifentanil plus morphine (remifentanil) and dexmedetomidine (opioid-free). All patients received intraoperative analgesia with propofol, desflurane, dexamethasone, lidocaine, ketamine and muscle relaxants, and postoperative analgesia with lidocaine, paracetamol, nefopam and patient-controlled morphine. The primary outcome measure was the occurrence of opioid-related adverse events (hypoxemia, intestinal obstruction, or cognitive dysfunction) within 48 h after extubation. Secondary measures included postoperative opioid consumption, pain, and the occurrence of nausea and vomiting. The results showed that the study was discontinued prematurely due to severe bradycardia in 5 patients in the opioid-free group. Compared with 105 of 156 patients (67%) in the remifentanil group, the primary outcome event occurred in 122 of the opioid-free patients (78%) (RR=1.16，95%CI：1.01~1.33，P=0.031)。 The incidence of hypoxemia was 72% (110/152) in the opioid-free group and 61% (94/155) in the remifentanil group (RR=1.19，95%CI：1.02~1.40，P=0.030)。 There was no significant difference between the two groups in terms of intestinal obstruction or cognitive dysfunction. Cumulative morphine dosage [11 (5, 21) mg vs. 6 (0, 17) mg] and incidence of nausea and vomiting (37% vs. 24%,RR=0.64，95%CI: 0.45~0.90) were both less, but the analgesic effects were similar in the two groups. Patients in the opioid-free group had a longer delay in extubation and a longer stay in the recovery room after anesthesia. Opioid-free balanced anesthesia with dexmedetomidine did not reduce the occurrence of postoperative opioid-related adverse events compared with remifentanil. On the contrary, it results in a higher incidence of serious adverse events, particularly hypoxemia and bradycardia.

A formula based on serum creatinine (Scr) is commonly used to estimate glomerular filtration rate (eGFR) in daily clinical practice. The most commonly used formulas are the Childhood Chronic Kidney Disease Study (CKiD) formula, and the Adult Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula, both of which are currently recommended by authoritative guidelines in the field of kidney disease. However, both formulas have certain limitations, and when patients transition from adolescence to adulthood, applying these two formulas at the same time will lead to large differences in the estimated eGFR results. The full-age spectrum (FAS) formula overcomes this problem, but will overestimate the eGFR of patients with low Scr values and chronic kidney disease. Based on the above status quo, the overall goal of this study is to develop and validate a new SCR-based formula that can be applied to all ages and different renal functions, combining the characteristics of FAS and CKD-EPI formulas. The investigators used 19 629 patient data from 13 cohorts for formula development and internal and external validation. Seven of these cohorts (n=11 251) were randomized to develop (n=8 473) and internal validation (n=2 778) dataset, and the remaining 6 cohorts (n=8 378) for external verification. After absorbing the advantages of the FAS and CKD-EPI formulas, the basic form of the new formula was firstly determined: eGFR = A × (Scr/Q)^B× [C^(Age-AgeCO)if Age>AgeCO]. Where a, B, C are unknown parameters, where B is in Scr/Q<Take different values when 1 and ≥1, respectively, C^{(Age-AgeCO) is}The age term in the formula, AgeCO represents the cut-off value of age. The Q value (median of Scr) in the formula was taken from a recent study. Multivariate linear regression was used to compare the results from 3 European hospitals (n=83 157, aged 2 to 40 years), and the relationship between Q and Age can be obtained: Men aged 2 to 25 years: ln (Q) =3.200+0.259× Age-0.543× ln (Age) -0.007 63× Age²+0.000 079× Age³； Females 2-25 years old: ln (Q) =3.080+0.177× Age-0.223× ln (Age) -0.005 96× Age²+0.000 068 6× Age³； Male>25 years old: Q =80 μ mol/L; Women>25 years old: Q =62 μ mol/L. The basic form of the new formula is logarithmically transformed and fitted by least squares linear regression method to obtain the unknown parameters in the formula. The study retained a =107.3 and AgeCO =40 in the FAS formula, and then pooled the development and internal validation datasets to determine the final new formula, which was named the EKFC formula: age 2~40 years, Scr/Q<At 1, eGFR =107.3× (SCr/Q)^-0.322When Scr/Q ≥1, eGFR =107.3× (Scr/Q)^-1.132； Age>40 years, Scr/Q<At 1, eGFR =107.3× (SCr/Q)^-0.322×0.990^(Age-40)When Scr/Q ≥1, eGFR =107.3× (Scr/Q)^-1.132×0.990^(Age-40)。 The study proposes a new formula that combines the advantages of the FAS and CKD-EPI formulas, thereby generally reducing bias in different age and renal function populations, and the EKFC formula has higher accuracy and precision than the currently recommended formulas, enabling continuity across the entire age range, avoiding transition problems between adolescent and adult eGFR.