• Philippe Guerci, Guillaume Jay, Chloé Arnout, Delphine Herbain, Noureddine Baka, Olivier Poirel, Emmanuel Novy, Hervé Bouaziz, and Florence Vial.
• From the Department of Anaesthesiology and Critical Care Medicine, University Hospital of Nancy-Brabois, Institut Lorrain du Coeur et des Vaisseaux (PG, GJ, EN), Department of Obstetric Anaesthesia and Critical Care Unit, Maternity Hospital, University Hospital of Nancy (GJ, CA, DH, NB, OP, HG, FV, HB) and INSERM U1116, Faculty of Medicine, University of Lorraine, Nancy, France (PG).
• Eur J Anaesthesiol. 2021 Sep 1; 38 (9): 975-984.

BackgroundAnalysis of pupillary reflex dilation (PRD) assesses the balance of nociception--antinociception. Laparoscopic surgery induces haemodynamic variations that are misleading. During laparoscopy, PRD guidance helps differentiate haemodynamic changes because of excess nociception from secondary changes related to the reflex release of endocrine factors.ObjectiveThe present study evaluated the effect of PRD-guided antinociception on the administration of intra-operative remifentanil and immediate postoperative morphine consumption in patients undergoing elective laparoscopic surgery.DesignThe study was a single-blind, randomised controlled trial.SettingThe study took place at two sites at the University Hospital of Nancy from March 2014 to November 2017.PatientsA total of 100 patients who underwent scheduled laparoscopic surgery were included.InterventionsPatients were randomly given remifentanil guided by PRD (PRD-guided) or standard anaesthesia care (control).Main Outcome MeasuresThe primary outcome was intra-operative remifentanil consumption. Secondary outcomes included morphine consumption in the immediate postoperative period and the number of intra-operative haemodynamic events.ResultsData from 95 patients were analysed. Intraoperative remifentanil consumption was lower in the PRD-guided group than in the control group: median [IQR], 0.09 [0.07 to 0.11] vs. 0.14 [0.12 to 0.16] μg kg-1 min-1, with a mean difference (95% confidence Interval, CI) of 0.048 (0.035 to 0.060) μg kg-1 min-1; P < 0.0001. Morphine consumption was 0.13 [0.1 to 0.5] vs. 0.15 [0.11 to 0.4] mg kg-1 (P  = 0.52) in the PRD-guided and control groups, respectively. The number of hypertensive and tachycardia events was greater in the PRD-guided group than in the control group: Hypertensive events 60.4% vs. 32.6%, relative risk 1.85 (95% CI, 1.24 to 2.84), P = 0.004; tachycardia events 31.6% vs. 4.3%, relative risk 2.09 (95% CI, 1.45 to 2.84), P < 0.001.ConclusionsWhen PRD is used to differentiate between haemodynamic events arising from noxious stimuli and those events because of other nonsurgical stimuli, then intra-operative remifentanil administration is reduced intra-operatively during laparoscopic surgery but there was no change in postoperative morphine consumption.Trial RegistrationClinicaltrials.gov NCT02116868.Copyright © 2021 European Society of Anaesthesiology and Intensive Care. Unauthorized reproduction of this article is prohibited.

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