Dexmedetomidine, morphine, propofol vs midazolam, morphine, propofol for conscious sedation in rhinoplasty under local anesthesia. A prospective, randomized study

Minimizing Narcotic Use in Rhinoplasty: An Updated Narrative Review and Protocol

Opioids are commonly used to reduce pain after surgery; however, there are severe side effects and complications associated with opioid use, with addiction being of particular concern. Recent practice has shifted to reduce opioid consumption in surgery, although a specific protocol for rhinoplasty is still in progress. This paper aims to expand on the protocol previously established by the senior author based on updated evidence and details. This was accomplished by first high-lighting and summarizing analgesic agents with known opioid-reducing effects in the surgical field, with a particular focus on rhinoplasty, then compiling these analgesic options into a recommended protocol based on the most effective timing of administration (preoperative, intraoperative, postoperative). The senior author's previous article on the subject was referenced to compile a list of analgesic agents of importance. Each analgesic agent was then searched in PubMed in conjunction with "rhinoplasty" or "opioid sparing" to find relevant primary sources and systematic reviews. The preferred analgesic agents included, as follows: preoperative, 1000 mg oral acetaminophen, 200 mg of oral celecoxib twice daily for 5 days, and 1200 mg oral gabapentin; intraoperative, 0.75 μg/kg of intravenous dexmedetomidine and 1-2 mg/kg injected lidocaine with additional 2-4 mg/kg per hour or 1.5 cc total bupivacaine nerve block injected along the infraorbital area bilaterally and in the subnasal region; and postoperatively, 5 mg oral acetaminophen and 400 mg of oral celecoxib. When choosing specific analgesic agents, considerations include potential side effects, contraindications, and the drug-specific mode of administration.

Dexmedetomidine versus remifentanil in nasal surgery: a systematic review and meta-analysis

BACKGROUND

Nasal surgeries, addressing anatomical variations for form and function, require careful anesthesia administration, including dexmedetomidine and remifentanil. This meta-analysis evaluates their safety and efficacy variations in nasal surgeries, emphasizing patient comfort and optimal outcomes.

METHODS

Four electronic databases (PubMed, Scopus, Web of Science, and CINAHL Complete) were searched for records in English. Studies that measure the effect of dexmedetomidine versus remifentanil on patients underwent nasal surgery were included. The Cochrane Collaboration's tool was used to assess the quality of the included studies. A random-effect model was preferred and statistical analysis was performed by Stata software version 17.

RESULTS

Out of an initial pool of 63 articles, five studies were selected for this analysis. All of these chosen studies were Randomized Controlled Trials (RCTs). The meta-analysis involved a total of 302 participants, with 152 in the remifentanil group and 150 in the dexmedetomidine group. The analysis aimed to compare the effects of Dexmedetomidine and Remifentanil on heart rate (HR) and mean arterial pressure (MAP) during surgery. Both groups exhibited similar MAP and HR, with the exception of a slightly lower HR in the remifentanil group at the 15th minute of surgery (Standardized Mean Difference: -0.24 [-0.83, 0.34]). Furthermore, when evaluating the impact of these medications on post-surgery outcomes, including pain levels, the use of pain relief medications, patient-surgeon satisfaction, agitation scores, and recovery time, no significant differences were observed between the two medications in any of these aspects.

CONCLUSION

In summary, the study compared Dexmedetomidine and Remifentanil in nasal surgeries anesthesia. No significant differences were found in heart rate, blood pressure, satisfaction, pain, agitation, or recovery time. The study had limitations, and future research should establish standardized protocols and consider various surgical factors.

Reporting Outcomes and Outcome Measures in Open Rhinoplasty: A Systematic Review

BACKGROUND

Comparative studies have shown little statistical difference in outcomes following rhinoplasty, demonstrating near equivalent results across all surgical techniques. Cross-study comparisons of these trials are difficult because variation in outcome reporting prevents statistical pooling and analysis.

OBJECTIVES

The authors sought to identify all outcomes and outcome measures used to evaluate postoperative results in rhinoplasty.

METHODS

An extensive computerized database search of MEDLINE and EMBASE was performed; all trials involving n ≥ 20 patients, aged 18 years and older undergoing a primary, open rhinoplasty procedure, were included for review.

RESULTS

Of the 3235 citations initially screened, 72 studies met the stated inclusion criteria. A total of 53 unique outcomes and 55 postoperative outcome measures were identified. Outcomes were divided into 6 unique domains: objective signs, subjective symptom severity, physical function related to activities of daily living, patient satisfaction, surgeon satisfaction, and quality of life. The identified outcome measures consisted of 5 nasal-specific, author-reported instruments; 5 nasal specific, patient-reported instruments; 5 patient-reported, generic instruments; and 40 author-generated instruments. Of the outcome measures identified, the Rhinoplasty Outcomes Evaluation, Sino-Nasal Outcome Test-22, and FACE-Q were the only instruments to demonstrate adequate validity, reliability, and responsiveness to change in patients who underwent a rhinoplasty procedure.

CONCLUSIONS

There is heterogeneity in the outcomes and outcome measures employed to assess postsurgical outcomes following rhinoplasty. A standardized core outcome set is urgently needed to make it possible for future investigators to compare results of various techniques in rhinoplasty surgery.

LEVEL OF EVIDENCE: 2

Comparision of Vital Surgical Parameters, after Administration of Midazolam and Dexmedetomidine for Conscious Sedation in Minor Oral Surgery

Aim:

The aim of this study is to compare the efficacy between midazolam and dexmedetomidine in relation to vital parameters, sedation score, pain score, cognitive judgment, and postoperative amnesia to the event in conscious sedation for minor oral surgical procedure.

Materials and Methods:

A sample size of 30 patients were selected in each group: Group M (midazolam) and Group D (dexmedetomidine).

Results:

The mean heart rate (HR) and systolic and diastolic blood pressure measurements were significantly higher in Group M after the 20^th min when compared to Group D. The visual analog scale (VAS) scores of pain were not statistically significant between the two groups during the procedure, but at the time of discharge, statistically significant VAS scores were found between the two groups. Nine (30%) patients in Group D and 21 (70%) patients in Group M showed cognitive judgment impairment with the Stroop Color and Word Test at the 30^th min.

Conclusion:

The dexmedetomidine group of patients had reduced blood pressure and HR. No significant differences were noted in oxygen saturation or in respiratory rate between the two drugs. Patients had better sedation, analgesia, lesser cognitive impairment, and amnesia in the dexmedetomidine group.

Efficacy of external nasal nerve block following nasal surgery : A randomized, controlled trial

BACKGROUND

Pain is the major determinant factor which affects the quality of recovery and postoperative agitation following nasal surgery with the patient under general anesthesia. Our objectives were to test the hypothesis that an external nasal nerve block will decrease pain intensity, decrease drug consumption, decrease the incidence of postoperative emergence agitation and improve quality of recovery.

MATERIAL AND METHODS

In this study 100 adult patients who were scheduled for elective external nasal surgery with the patient under general anesthesia and nasal packing on each side, received external nasal nerve blocks postoperatively for 24 h with saline (group I) or 2% xylocaine (group II) with 1:200,000 epinephrine. Postoperative pain was measured at the postanesthesia care unit (PACU) utilizing a visual analog scale (VAS). Narcotics consumption was also measured. Emergence agitation and quality of recovery were also assessed.

RESULTS

Pain scores were statistically significant between both groups. Requirements of equivalent morphine doses in the PACU were lower in group II (block) than group I (control) with a significant P value <0.001. Group II (block) patients required significantly less intraoperative fentanyl than group I (control) patients (p = 0.001). Group II (block) showed higher scores in pain dimension of QoR-40 in comparison with group I (P <0.001). The incidence of emergence agitation was lower in group II (block) than in group I (control, 24% vs. 48%, P = 0.012).

CONCLUSION

External nasal nerve block is an effective technique for reducing postoperative pain, drug consumption and quality of recovery. It also reduces emergence agitation. The effects are mainly due to profound analgesia and effective pain control that lead to decreased drug usage and reduced discomfort.

Dexmedetomidine Supported Office Based Genioplasty: A Pilot Study

INTRODUCTION

Despite the availability of wide variety of pharmacological agents for dental procedural sedation, there has always been a continuous search for newer sedative agents. Dexmedetomidine is a newer sedative agent for provision of short-term sedation (<24 h) in adult patients in the intensive care unit setting. It is a selective α2 adrenergic receptor agonist. The reports on off-label use of this drug in a variety of settings for invasive and non invasive procedural sedation have provided encouraging results.

MATERIAL AND METHODS

The present paper reports a pilot study observing clinical efficacy of the newer drug dexmedetomidine in patients undergoing office based sliding genioplasty for correction of facial asymmetry. Subjects were sedated with dexmedetomidine with a loading dose of 0.5 mcg/kg over 10 min followed by a continuous infusion dose of 0.1 mcg/kg/h, the recovery process was observed for 60 min after the dexmedetomidine infusion was stopped. The patients were observed pre operatively, intra operatively (every 10 min) and postoperatively for the following parameters-oxygen saturation (SpO2), mean arterial pressure (MAP), heart rate (HR), and Ramsay sedation score (RSS), respiratory rate, pain scale.

Dexmedetomidine improves the quality of the operative field for functional endoscopic sinus surgery: systematic review

BACKGROUND

Intra-operative bleeding diminishes visualisation during functional endoscopic sinus surgery and can cause unfavourable outcomes. Dexmedetomidine is a potent alpha-2 agonist, with sympatholytic effects. This systematic review aimed to assess whether dexmedetomidine decreases intra-operative bleeding and improves operative field quality.

METHODS

All randomised, controlled trials that assessed the ability of dexmedetomidine to provide good operative fields for functional endoscopic sinus surgery were identified from Medline and Embase. The outcomes of interest were: operative field quality, intra-operative bleeding, operative time and adverse events.

RESULTS

Five studies (254 patients) met the inclusion criteria. When compared to saline, dexmedetomidine improved the quality of the operative field. The operative time was similar between groups. When compared to other drugs, dexmedetomidine was as effective as esmolol and remifentanil. There were no adverse incidents.

CONCLUSION

Dexmedetomidine is beneficial in providing good visibility during functional endoscopic sinus surgery. Controlled hypotensive anaesthesia with this medicine decreases intra-operative bleeding and enhances surgical field quality.