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Verret M, Le JBP, Lalu MM, Jeffers MS, McIsaac DI, Nicholls SG, Turgeon AF, Ramchandani R, Li H, Hutton B, Zivkovic F, Graham M, Lê M, Geist A, Bérubé M, O'Hearn K, Gilron I, Poulin P, Daudt H, Martel G, McVicar J, Moloo H, Fergusson DA. Effectiveness of dexmedetomidine on patient-centred outcomes in surgical patients: a systematic review and Bayesian meta-analysis. Br J Anaesth 2024; 133:615-627. [PMID: 39019769 DOI: 10.1016/j.bja.2024.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 05/23/2024] [Accepted: 06/13/2024] [Indexed: 07/19/2024] Open
Abstract
BACKGROUND Dexmedetomidine is increasingly used for surgical patients requiring general anaesthesia. However, its effectiveness on patient-centred outcomes remains uncertain. Our main objective was to evaluate the patient-centred effectiveness of intraoperative dexmedetomidine for adult patients requiring surgery under general anaesthesia. METHODS We conducted a systematic search of MEDLINE, Embase, CENTRAL, Web of Science, and CINAHL from inception to October 2023. Randomised controlled trials (RCTs) comparing intraoperative use of dexmedetomidine with placebo, opioid, or usual care in adult patients requiring surgery under general anaesthesia were included. Study selection, data extraction, and risk of bias assessment were performed by two reviewers independently. We synthesised data using a random-effects Bayesian regression framework to derive effect estimates and the probability of a clinically important effect. For continuous outcomes, we pooled instruments with similar constructs using standardised mean differences (SMDs) and converted SMDs and credible intervals (CrIs) to their original scale when appropriate. We assessed the certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Our primary outcome was quality of recovery after surgery. To guide interpretation on the original scale, the Quality of Recovery-15 (QoR-15) instrument was used (range 0-150 points, minimally important difference [MID] of 6 points). RESULTS We identified 49,069 citations, from which 44 RCTs involving 5904 participants were eligible. Intraoperative dexmedetomidine administration was associated with improvement in postoperative QoR-15 (mean difference 9, 95% CrI 4-14, n=21 RCTs, moderate certainty of evidence). We found 99% probability of any benefit and 88% probability of achieving the MID. There was a reduction in chronic pain incidence (odds ratio [OR] 0.42, 95% CrI 0.19-0.79, n=7 RCTs, low certainty of evidence). There was also increased risk of clinically significant hypotension (OR 1.98, 95% CrI 0.84-3.92, posterior probability of harm 94%, n=8 RCTs) and clinically significant bradycardia (OR 1.74, 95% CrI 0.93-3.34, posterior probability of harm 95%, n=10 RCTs), with very low certainty of evidence for both. There was limited evidence to inform other secondary patient-centred outcomes. CONCLUSIONS Compared with placebo or standard of care, intraoperative dexmedetomidine likely results in meaningful improvement in the quality of recovery and chronic pain after surgery. However, it might increase clinically important bradycardia and hypotension. SYSTEMATIC REVIEW PROTOCOL PROSPERO (CRD42023439896).
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Affiliation(s)
- Michael Verret
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Ottawa, The Ottawa Hospital, Ottawa, ON, Canada; Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), CHU de Québec - Université Laval Research Center, Québec City, QC, Canada; Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec City, QC, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; Quebec Pain Research Network, Sherbrooke, QC, Canada.
| | - John B P Le
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Manoj M Lalu
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Ottawa, The Ottawa Hospital, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Matthew S Jeffers
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Daniel I McIsaac
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Ottawa, The Ottawa Hospital, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Stuart G Nicholls
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; Ottawa Methods Centre, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Alexis F Turgeon
- Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), CHU de Québec - Université Laval Research Center, Québec City, QC, Canada; Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec City, QC, Canada
| | - Rashi Ramchandani
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Hongda Li
- MDCM, Faculty of Medicine and Health Science, McGill University, Montreal, QC, Canada
| | - Brian Hutton
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Fiona Zivkovic
- Patient Partner, The Ottawa Hospital, Ottawa, ONT, Canada
| | - Megan Graham
- Patient Partner, The Ottawa Hospital, Ottawa, ONT, Canada
| | - Maxime LĂŞ
- Patient Partner, The Ottawa Hospital, Ottawa, ONT, Canada
| | - Allison Geist
- Patient Partner, The Ottawa Hospital, Ottawa, ONT, Canada
| | - Mélanie Bérubé
- Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), CHU de Québec - Université Laval Research Center, Québec City, QC, Canada; Quebec Pain Research Network, Sherbrooke, QC, Canada; Faculty of Nursing, Université Laval, Québec City, QC, Canada
| | - Katie O'Hearn
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Ian Gilron
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ONT, Canada
| | - Patricia Poulin
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, University of Ottawa and The Ottawa Hospital Pain Clinic, Ottawa, ON, Canada
| | | | - Guillaume Martel
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Jason McVicar
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; Royal Inland Hospital, Kamloops, BC, Canada
| | - Husein Moloo
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada; Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada; Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
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Kamal FA, Fernet LY, Da Silva NK, Briceño G, Iyoob N, Aleman Paredes K, Martinez Ramirez M, Arruarana VS. Comparing Perioperative Outcomes of Total Intravenous Anesthesia (TIVA) With Volatile Anesthesia in Patients With Obesity: A Systematic Review. Cureus 2024; 16:e54094. [PMID: 38487133 PMCID: PMC10937615 DOI: 10.7759/cureus.54094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2024] [Indexed: 03/17/2024] Open
Abstract
In this systematic review, the perioperative outcomes of total intravenous anesthesia (TIVA) and volatile anesthesia were compared in obese adults (BMI ≥ 30 kg/m²) undergoing elective surgery. The review analyzed data from 12 randomized-controlled trials involving 935 patients, sourced from PubMed/MEDLINE (Medical Literature Analysis and Retrieval System Online), Cochrane, Scopus, and Web of Science databases. The focus was on intraoperative vital signs, emergence time, postoperative nausea and vomiting (PONV), duration of post-anesthesia care unit (PACU) stay, and ICU admission rates. Findings showed that TIVA (using propofol) might reduce PONV, but there were no significant differences in other outcomes compared to volatile anesthesia (with desflurane as the most common agent). The review highlights the need for more research, especially comparing sevoflurane with TIVA, to establish clear clinical guidelines for anesthesia in obese patients.
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Affiliation(s)
- Faiza A Kamal
- General Practice, University of Nottingham, Nottingham, GBR
| | - Lucas Y Fernet
- General Practice, University of Nottingham, Nottingham, GBR
| | | | - Gabriela Briceño
- Obstetrics and Gynecology, Universidad de Oriente Núcleo de Anzoátegui, Barcelona, VEN
| | - Nusrath Iyoob
- Internal Medicine, Vinnytsia National Pirogov Medical University, Vinnytsya, UKR
| | - Kenneth Aleman Paredes
- Surgery, Hospital General Regional IMSS (Instituto Mexicano del Seguro Social) No. 220 "General José Vicente Villada", Toluca, MEX
| | | | - Victor S Arruarana
- Internal Medicine, Brookdale University Hospital Medical Center, New York City, USA
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Liou JY, Kuo IT, Chang WK, Ting CK, Tsou MY. Pharmacodynamic modeling of moderate sedation and rationale for dosing using midazolam, propofol and alfentanil. BMC Pharmacol Toxicol 2023; 24:3. [PMID: 36647160 PMCID: PMC9843845 DOI: 10.1186/s40360-023-00642-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 01/03/2023] [Indexed: 01/18/2023] Open
Abstract
PURPOSE Regulations have broadened to allow moderate sedation administration for gastrointestinal endoscopy by non-anesthesia personnel. The line between moderate and deep sedation is ambiguous. Deep sedation offers patient comfort as well as greater safety concerns. Unintended deep sedation can occur if drug interactions are overlooked. We present a pharmacodynamic model for moderate sedation using midazolam, alfentanil and propofol. The model is suitable for training and devising rationales for appropriate dosing. METHODS The study consists of two parts: modeling and validation. In modeling, patients scheduled for esophagogastroduodenoscopy (EGD) or colonoscopy sedation are enrolled. The modified observer's assessment of alertness/sedation (MOAA/S) score < 4 is defined as loss of response to represent moderate sedation. Two patient groups receiving bronchoscopy or endoscopic retrograde cholangiopancreatography (ERCP) are used for validation. Model performance is assessed by receiver operating characteristic (ROC) curves and area under the curve (AUC). Simulations are performed to demonstrate how the model is used to rationally determine drug regimen for moderate sedation. RESULTS Interaction between propofol and alfentanil is stronger than the other pairwise combinations. Additional synergy is observed with three drugs. ROC AUC is 0.83 for the modeling group, and 0.96 and 0.93 for ERCP and bronchoscopy groups respectively. Model simulation suggests that 1 mg midazolam, 250 µg alfentanil and propofol maximally benefits from drug interactions and suitable for moderate sedation. CONCLUSION We demonstrate the accurate prediction of a three-drug response surface model for moderate sedation and simulation suggests a rational dosing strategy for moderate sedation with midazolam, alfentanil and propofol.
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Affiliation(s)
- Jing-Yang Liou
- grid.278247.c0000 0004 0604 5314Department of Anesthesia, Taipei Veterans General Hospital, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Beitou District, 11217 Taipei, Taiwan ,grid.260539.b0000 0001 2059 7017Department of Biomedical Engineering, National Yang-Ming Chiao Tung University, Taipei, Taiwan ,grid.260539.b0000 0001 2059 7017School of Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan
| | - I-Ting Kuo
- grid.278247.c0000 0004 0604 5314Department of Anesthesia, Taipei Veterans General Hospital, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Beitou District, 11217 Taipei, Taiwan ,grid.260539.b0000 0001 2059 7017Department of Biomedical Engineering, National Yang-Ming Chiao Tung University, Taipei, Taiwan
| | - Weng-Kuei Chang
- grid.278247.c0000 0004 0604 5314Department of Anesthesia, Taipei Veterans General Hospital, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Beitou District, 11217 Taipei, Taiwan ,grid.260539.b0000 0001 2059 7017School of Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan
| | - Chien-Kun Ting
- grid.278247.c0000 0004 0604 5314Department of Anesthesia, Taipei Veterans General Hospital, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Beitou District, 11217 Taipei, Taiwan ,grid.260539.b0000 0001 2059 7017Department of Biomedical Engineering, National Yang-Ming Chiao Tung University, Taipei, Taiwan ,grid.260539.b0000 0001 2059 7017School of Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan ,grid.260539.b0000 0001 2059 7017Institute of Emergency and Critical Care Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Mei-Yung Tsou
- grid.278247.c0000 0004 0604 5314Department of Anesthesia, Taipei Veterans General Hospital, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Beitou District, 11217 Taipei, Taiwan ,grid.260539.b0000 0001 2059 7017School of Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan
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Vellinga R, Valk BI, Absalom AR, Struys MMRF, Barends CRM. What's New in Intravenous Anaesthesia? New Hypnotics, New Models and New Applications. J Clin Med 2022; 11:jcm11123493. [PMID: 35743563 PMCID: PMC9224877 DOI: 10.3390/jcm11123493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/10/2022] [Accepted: 06/14/2022] [Indexed: 02/01/2023] Open
Abstract
New anaesthetic drugs and new methods to administer anaesthetic drugs are continually becoming available, and the development of new PK-PD models furthers the possibilities of using arget controlled infusion (TCI) for anaesthesia. Additionally, new applications of existing anaesthetic drugs are being investigated. This review describes the current situation of anaesthetic drug development and methods of administration, and what can be expected in the near future.
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Affiliation(s)
- Remco Vellinga
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands; (B.I.V.); (A.R.A.); (M.M.R.F.S.); (C.R.M.B.)
- Correspondence:
| | - Beatrijs I. Valk
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands; (B.I.V.); (A.R.A.); (M.M.R.F.S.); (C.R.M.B.)
- Department of Anesthesiology, University Medical Center Göttingen, 37075 Göttingen, Germany
| | - Anthony R. Absalom
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands; (B.I.V.); (A.R.A.); (M.M.R.F.S.); (C.R.M.B.)
| | - Michel M. R. F. Struys
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands; (B.I.V.); (A.R.A.); (M.M.R.F.S.); (C.R.M.B.)
- Department of Basic and Applied Medical Sciences, Ghent University, 9041 Ghent, Belgium
| | - Clemens R. M. Barends
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands; (B.I.V.); (A.R.A.); (M.M.R.F.S.); (C.R.M.B.)
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8
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Schnider TW, Minto CF, Egan TD, Filipovic M. Relationship Between Propofol Target Concentrations, Bispectral Index, and Patient Covariates During Anesthesia. Anesth Analg 2021; 132:735-742. [PMID: 32833715 DOI: 10.1213/ane.0000000000005125] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Internationally, propofol is commonly titrated by target-controlled infusion (TCI) to maintain a processed electroencephalographic (EEG) parameter (eg, bispectral index [BIS]) within a specified range. The overall variability in propofol target effect-site concentrations (CeT) necessary to maintain adequate anesthesia in real-world conditions is poorly characterized, as are the patient demographic factors that contribute to this variability. This study explored these issues, hypothesizing that the variability in covariate-adjusted propofol target concentrations during BIS-controlled anesthesia would be substantial and that most of the remaining interpatient variability in drug response would be due to random effects, thus suggesting that the opportunity to improve on the Schnider model with further demographic data is limited. METHODS With ethics committee approval and a waiver of informed consent, a deidentified, high-resolution, intraoperative database consisting of propofol target concentrations, BIS values, and vital signs from 13,239 patients was mined to identify patients who underwent general endotracheal anesthesia using propofol (titrated to BIS), fentanyl, remifentanil, and rocuronium that lasted at least 1 hour. The propofol target concentrations and BIS values 30 minutes after incision (CeT30 and BIS30) were considered representative of stable intraoperative conditions. The data were plotted and analyzed by descriptive statistics. Confidence intervals were computed using a bootstrap method. A linear model was fit to the data to test for correlation with factors of interest (eg, age and weight). RESULTS A total of 4584 patients met inclusion criteria and were entered into the analysis. Of the propofol target concentrations, 95% were between 1.5 and 3.5 µg·mL-1. Higher BIS30 values were correlated with higher propofol concentrations. Except for age, all the patient-related variables analyzed entered the regression model linearly. Only 10.2% of the variability in CeT30 was explained by the patient factors of age and weight combined. CONCLUSIONS Our hypothesis was confirmed. The variability in covariate-adjusted propofol CeT30 titrated to BIS in real-world conditions is considerable, and only a small portion of the remaining variability in drug response is explained by patient demographic factors. This finding may have important implications for the development of new pharmacokinetic (PK) models for propofol TCI.
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Affiliation(s)
- Thomas W Schnider
- From the Department of Anesthesia, Intensive Care, Emergency and Pain Medicine, Kantonsspital St.Gallen, St.Gallen, Switzerland
| | - Charles F Minto
- Department of Anesthesia, North Shore Private Hospital, Sydney, Australia
| | - Talmage D Egan
- Department of Anesthesiology, University of Utah, Salt Lake City, Utah
| | - Miodrag Filipovic
- From the Department of Anesthesia, Intensive Care, Emergency and Pain Medicine, Kantonsspital St.Gallen, St.Gallen, Switzerland
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