Beloeil et al. present a compelling pragmatic trial comparing dexmedetomidine with remifentanil in a balanced anesthetic. We congratulate them on executing such a challenging trial and reinforcing that “opioid-free” is not “complication-free.” Their work raises important questions about the future of balanced anesthetics, especially the use of non-opioid infusions. Although the authors primarily compared a dexmedetomidine infusion (to make it “opioid-free”) with a remifentanil infusion, their underlying anesthetic also included ketamine and lidocaine infusions. Of these infusions, we are concerned about the ubiquitous use of intravenous lidocaine for assumed benefit without regard to risk.

Intravenous lidocaine is fashionable for its analgesic properties in the opioid-sparing epoch. Given the high median lethal dose, short half-life, and rapid dissociation from voltage-gated sodium channels, most practitioners believe that lidocaine infusions are benign. However, clinicians have reported life-threatening events associated...

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