Fentanyl or dexmedetomidine combined with desflurane for bariatric surgery

TEDOFA Trial Study Protocol: A Prospective Double-Blind, Randomized, Controlled Clinical Trial Comparing Opioid-Free versus Opioid Anesthesia on the Quality of Postoperative Recovery and Chronic Pain in Patients Receiving Thoracoscopic Surgery

Introduction

Seeking effective multimodal analgesia and anesthetic regimen is the basis for the success of ERAS. Opioid-free anesthesia (OFA) is a multimodal anesthesia associating hypnotics, N-methyl-D-aspartate (NMDA) antagonists, local anesthetics, anti-inflammatory drugs and α-2 agonists. Although previous studies have confirmed that OFA is safe and feasible for VATS surgery, there is great heterogeneity in how to select and combine anti-harm drugs to replace opioids. We hypothesized that the reduced opioid use during and after surgery allowed by OFA compared with standard of care will be associated with a reduction of postoperative opioid-related adverse events and an improvement in the quality of rehabilitation of patients after partial VATS lung resection.

Methods/Analysis

The TEDOFA Study is a prospective double-blind, randomized, controlled clinical trial with a concealed allocation of patients scheduled to undergo elective partial VATS pneumonectomy 1:1 to receive either a standard anesthesia protocol or an OFA. A total of 146 patients were recruited in the study. Primary endpoint was the 15-item recovery quality scale (QoR-15) at 24 hours after surgery.

Ethics and Dissemination

This trial has been approved by the Institutional Review Board of Beijing Friendship Hospital of China Capital University. The TEDOFA trial study protocol was approved on 27 February 2023. The trial started recruiting patients after registered on the Chinese Clinical Trial Registry.

Trial Registration Number

ChiCTR2300069210; Pre-results.

Perioperative Dexmedetomidine Infusion Improves Perioperative Care of Bariatric-Metabolic Surgery: A Single Center Experience with Meta-Analysis

PURPOSE

This study aims to determine the effects of perioperative dexmedetomidine infusion (PDI) on Asian patients undergoing bariatric-metabolic surgery (BMS), focusing on the need for pain medications and management of postoperative nausea and vomiting (PONV), and to investigate the association with these variables, including patients' characteristics and BMS data.

MATERIALS AND METHODS

A retrospective review of prospectively collected data was conducted in an Asian weight management center from August 2016 to October 2021. A total of 147 native patients with severe obesity were enrolled. All patients were informed of the full support of perioperative pain medications for BMS. The pain numeric rating scale scores, events of PONV, needs for pain medications, and the associated patients' characteristics were analyzed. A p-value of < 0.05 was considered statistically significant. Furthermore, to verify the effects of perioperative usage of dexmedetomidine for BMS, a systematic review with meta-analysis of currently available randomized control trials was performed.

RESULTS

Among the 147 enrolled patients, 107 underwent laparoscopic sleeve gastrectomy and 40 underwent laparoscopic Roux-en-Y gastric bypass. PDI has been used as an adjunct multimodal analgesia for BMS in our institution since June 2017 (group D; n = 114). In comparison with those not administered with perioperative dexmedetomidine (group C; n = 33), lower pain numeric rating scale scores (2.52 ± 2.46 vs. 4.27 ± 2.95, p = 0.007) in the postanesthesia care unit, fewer PONV (32.46% vs. 51.52%; p = 0.046), and infrequent needs of additional pain medications (19.47% vs. 45.45%; p = 0.003) were observed in group D. Multivariable analysis demonstrated that type II diabetes mellitus was correlated with the decreased need of pain medications other than PDI (p = 0.035). Moreover, dexmedetomidine seemed to have a better analgesic effect for patients with longer surgical time based on our meta-analysis.

CONCLUSION

Based on our limited experience, PDI could be a practical solution to alleviate pain and PONV in Asian patients undergoing BMS. Moreover, it might reduce the need for rescue painkillers with better postoperative pain management for patients with type II diabetes mellitus or longer surgical time.

Opioid-free anesthesia: A systematic review and meta-analysis

STUDY OBJECTIVE

To evaluate all available evidence thus far on opioid based versus opioid-free anesthesia and its effect on acute and chronic postoperative pain.

DESIGN

Systematic review and meta-analysis of randomized clinical trials.

SETTING

Operating room, postoperative recovery room and ward.

PATIENTS

Patients undergoing general anesthesia.

INTERVENTIONS

After consulting MEDLINE, EMBASE and Cochrane database, studies which compared opioid free anesthesia (OFA) with opioid based anesthesia (OBA) were included (last search April 15th 2022).

MEASUREMENTS

Primary outcomes were acute and chronic pain scores in NRS or VAS. Secondary outcomes were quality of recovery and postoperative opioid consumption. Risk of bias was assessed using the RoB2 tool and a random effects model for the meta-analysis was conducted.

MAIN RESULTS

We identified 1245 citations, of which 38 studies met our inclusion criteria. There is moderate quality evidence showing no clinically relevant difference of Numeric Rating Scale (NRS) scores or opioid consumption in the postoperative period (pooled mean difference of 0.39 points with a CI of 0.19-0.59 and 4.02 MME with a CI of 1.73-6.30). We found only one small-sized study reporting no effect of opioid-free anesthesia on chronic pain. The quality of recovery was superior in patients with opioid-free anesthesia (mean difference of 8.26 points), however, this pooled analysis was comprised of only two studies. Postoperative nausea and vomiting (PONV) occurred less in opioid-free anesthesia, but bradycardia was more frequent.

CONCLUSIONS

We concluded that we cannot recommend one strategy over the other. Future studies could focus on quality of recovery as outcome measure and adequately powered studies on the effects of opioid-free anesthesia on chronic pain are eagerly awaited.

Impact of guided weight-based medication dosing in pediatric patients with obesity

BACKGROUND

Obesity is a common disease state within pediatrics, with 19.7% of children in the United States classified as obese. Medication dosing in this population is a challenge not commonly examined in clinical drug trials. Dosing based on total body weight may not always be appropriate; therefore, ideal body weight (IBW) and adjusted body weight (AdjBW) may provide more effective dosing.

OBJECTIVE

The goal was to implement a dosing protocol for pediatric patients with obesity to improve adherence. The primary endpoint was to evaluate adherence to evidence-based dosing recommendations and the secondary endpoints included cost saving analysis for immune globulin and accurate charting of IBW and AdjBW.

METHODS

This was a single center, quality improvement project composed of pre- and post-implementation groups. An IBW and AdjBW calculator were implemented in our electronic health record, as customized enhancements, along with specific weight ordering options. A literature search of pharmacokinetic and pharmacodynamic dosing recommendations based on IBW and AdjBW was conducted. For both groups, patients were included if they were 3-18 years old, had a body mass index greater than or equal to the 95th percentile, and if they received a specified medication.

RESULTS

A total of 618 patients were identified with 24 and 56 patients included for the pre- and post-implementation groups. There were no statistically significant differences in baseline characteristics of the comparator groups. The usage of correct body weight increased from 1.2% to 24.2% after implementation and education (P < 0.001). Cost savings was analyzed for immune globulin with the potential for a net savings of $9423 ± 3626.92.

CONCLUSION

Dosing medications for our pediatric patients with obesity improved with the implementation of calculated dosing weights in the electronic health record, provision of an evidence-based dosing chart, and education of providers.

Comparison of Ketamine, Dexmedetomidine and Lidocaine in Multimodal Analgesia Management Following Sleeve Gastrectomy Surgery: A Randomized Double-Blind Trial

PURPOSE

The aim of this study was to compare the effects of ketamine, dexmedetomidine, and lidocaine infusions added to the multimodal analgesia regimen on pain scores and analgesic requirement in laparoscopic sleeve gastrectomy.

DESIGN

A prospective randomized double-blind trial. Seventy-three patients aged 18 to 65 years (ASA II-III) undergoing laparoscopic sleeve gastrectomy were included. The patients were divided into 3 groups. Intravenous (IV) ketamine (0.5 mg/kg/h), dexmedetomidine (0.5 mcg/kg/h), and lidocaine (2 mg/kg/h) were administered to Groups K, D and L, respectively. Postoperative infusions were continued for 12 hours.

METHODS

Visual Analog Scale (VAS) scores (during rest and movement) in the admission to postanesthesia care unit, 1, 3, 6, 12, 24, 48 hours, and on day 15 were assessed postoperatively. Rescue analgesia requirement, the number of patients with nausea, retching, and vomiting, time to mobilization, and hospital length of stay (LOS) were recorded.

FINDINGS

VAS_rest values during all measurements in the first 24 hours, and VAS_movement values in the first 6 hours and at 24 hours were lower in Group L when compared to Group K and Group D (P < .001, P < .001, P = .008, respectively). VAS_rest at 48 hours and VAS_movement at 12 and 48 hours were lower in Group L when compared to Group K (P = .044, P = .001 and P = .011, respectively). There was no statistically significant difference between Group D compared to the other two groups at these times (P > .05). The requirement of rescue analgesia on postoperative day 1 was significantly higher in Group K (P < .001). Hospital LOS was shorter in Group L than in the other groups (P = .002).

CONCLUSIONS

IV lidocaine added to multimodal analgesia provided better pain control in the early postoperative period compared to dexmedetomidine and ketamine and decreased the hospital LOS.

Intraoperative lidocaine infusion as a sole analgesic agent versus morphine in laparoscopic gastric bypass surgery

Background

The aim of this study was to assess the effect of intra-operative intra-venous (IV) lidocaine infusion compared to IV morphine, on the post-operative pain at rest, the intra-operative and post-operative morphine requirements, the sedation and the Modified Aldrete scores in the post-anesthesia care unit (PACU), the hemodynamic parameters; mean values of the mean blood pressure (MBP) and the heart rate (HR), the peri-operative changes in the SpO2, and the respiratory rate (RR) in laparoscopic Roux-en-y gastric bypass. Sixty patients ˃ 18 years old, with body mass index (BMI) ˃ 35 kg/m2, American Society of Anesthesiologists (ASA) physical status II or III, were randomly divided into 2 groups: the lidocaine (L) group patients received intra-operative IV lidocaine infusion, and the morphine (M) group patients received intra-operative IV morphine.

Results

The post-operative numeric pain rating scale (NPRS) at rest was statistically significant less in group L than in group M patients, in the post-operative 90 min in the PACU. This was reflected on the post-operative morphine requirements in the PACU, as 26.6% of patients in group M required morphine with a mean total dose of 10.8 mg. The mean values of the MBP and HR recorded after intubation were comparable between patients of both groups, indicating attenuation of the stress response to endotracheal intubation by both lidocaine and morphine. However, the mean values of the MBP and HR recorded after extubation were statistically significant lower in patients of group L, indicating the attenuation of the stress response to extubation by lidocaine. Patients in group M showed statistically significant lower mean values of the MBP; before pneumoperitoneum and after 15 min from the pneumoperitoneum, this was reflected on statistically significant higher mean values of the HR. Patients in group L showed statistically significant lower mean values of the MBP and the HR; at 30 and 45 min from the pneumoperitoneum. Patients in group L showed statistically significant lower mean values of the MBP; 60 min from the pneumoperitoneum, after release of pneumoperitoneum and in the PACU. Patients of both groups showed comparable mean values of the HR after 60 min from the pneumoperitoneum, after release of the pneumoperitoneum and in the PACU. No patient in either groups developed post-operative respiratory depression in the PACU. Patients in group L showed statistically significant higher median sedation score, which was reflected on statistically but not clinically significant less Modified Aldrete score in patients of group L.

Conclusions

In morbid obese patients, the intra-operative IV lidocaine infusion offered post-operative analgesia in the PACU, on the expense of a higher sedation score, which didn’t affect the Modified Aldrete score clinically, with attenuation of the stress response to endotracheal intubation and extubation.

Trial registrations

FMASU R16/2021. Registered 1st February 2021, with Clinical Trials Registry (NCT05150756) on 10/08/2021.

The efficacy and safety of an adapted opioid-free anesthesia regimen versus conventional general anesthesia in gynecological surgery for low-resource settings: a randomized pilot study

Introduction

There is scarce data on the safety and efficacy of opioid-free anesthesia (OFA), in resource-limited settings due to the non-availability of dexmedetomidine, the reference OFA agent. We aimed to demonstrate the feasibility, efficacy and safety of a practical OFA protocol not containing dexmedetomidine, adapted for low-resource environments in very painful surgeries like gynecological surgery.

Methods

We conducted a randomized pilot study on ASA I and II women undergoing elective gynecological surgery at a tertiary care hospital in Cameroon. Patients were matched in a ratio of 1:1 into an OFA and a conventional general anesthesia (CGA) group. The OFA protocol entailed the intravenous (IV) magnesium sulfate, lidocaine, ketamine, dexamethasone, propofol, and rocuronium, followed by isoflurane and a continuous infusion of a calibrated mixture of magnesium sulfate, ketamine and clonidine. The CGA protocol was IV dexamethasone, diazepam, fentanyl, propofol, and rocuronium, followed by isoflurane and reinjections of fentanyl propofol and a continuous infusion of normal saline as placebo. The primary endpoints were the success rate of OFA, isoflurane consumption and intraoperative anesthetic complications. The secondary endpoints were postoperative pain intensity, postoperative complications, patient satisfaction assessed using the QoR-40 questionnaire and the financial cost of anesthesia.

Results

We enrolled a total of 36 women undergoing gynecological surgery; 18 in the OFA group and 18 in the CGA group. The success rate of OFA was 100% with significant lesser consumption of isoflurane in the OFA group, no significant intraoperative complication and better intraoperative hemodynamic stability in the OFA group. Postoperatively, compared to the CGA group, the OFA group had statistically significantly less pain during the first 24 h, no morphine consumption for pain relief, had less hypoxemia during the first six hours, less paralytic ileus, less nausea and vomiting, no pruritus and better satisfaction. The mean financial cost of this adapted OFA protocol was statistically significant lesser than that of CGA.

Conclusion

This OFA regimen without dexmedetomidine for a low-resource setting has a promising success rate with few perioperative complications including mild intraoperative hemodynamic changes, decrease postoperative complications, pain, and opioid consumption in patients undergoing elective gynecology surgery.

Trial registration

This study was registered at clinicaltrials.gov on 03/02/2021 under the registration number NCT04737473.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01856-6.

Opioid-Sparing Techniques in Orthopedic Anesthesia-One Step to Opioid-Free Anesthesia?

Opioid-free anesthesia is a multimodal anesthesia aimed at avoiding the negative impact of intraoperative opioid on patient's postoperative outcomes. It is based on the physiology of pathways involved in intraoperative nociception. It has been shown to be feasible but the literature is still scarce on the clinically meaningful benefits as well as on the side effects and/or complications that might be associated with it. Moreover, most studies involved abdominal and/or bariatric surgery. Procedure-specific studies are lacking, especially in orthopedics.

Impact of Opioid-Free Anesthesia on Analgesia and Recovery Following Bariatric Surgery: a Meta-Analysis of Randomized Controlled Studies

This meta-analysis aimed at exploring the impact of opioid-free anesthesia (OFA) on pain score and opioid consumption in patients undergoing bariatric surgery (BS). Literature search identified eight eligible trials. Forest plot revealed a significantly lower pain score (mean difference (MD) =  - 0.96, p = 0.0002; 318 patients), but not morphine consumption (MD =  - 5.85 mg, p = 0.1; 318 patients) at postoperative 24 h in patients with OFA than in those without. Pooled analysis also showed a lower pain score (p = 0.002), morphine consumption (p = 0.0003) in the postanesthetic care unit, and risk of postoperative nausea/vomiting (p = 0.0003) in the OFA group compared to the controls. In conclusion, this meta-analysis demonstrated that opioid-free anesthesia improved pain outcomes immediately and at 24 h after surgery without a beneficial impact on opioid consumption at postoperative 24 h. KEY POINTS: • Roles of opioid-free anesthesia (OFA) in bariatric surgery (BS) were investigated. • Outcomes included postoperative pain score, opioid use, and nausea/vomiting risk. • OFA was associated with lower 24-h pain score but not opioid consumption. • Lower pain score and opioid consumption were noted in the postanesthetic care unit. • OFA correlated with a lower risk of postoperative nausea/vomiting.

Effects of opioid-free anesthesia on postoperative morphine consumption after bariatric surgery

STUDY OBJECTIVES

The objective of this study was to determine whether postoperative morphine requirement in obese patients undergoing laparoscopic bariatric surgery was reduced by opioid-free anesthesia (OFA), as compared to an anesthetic strategy using opioids (opioid balanced anesthesia (OBA)) and to investigate the differences that may exist between the use of clonidine and dexmedetomidine in the context of OFA.

DESIGN

Retrospective cohort study.

SETTING

Academic medical center in Lyon, France.

PATIENTS

257 patients who underwent laparoscopic bariatric surgery between March 2017 and March 2019. 77 patients were included in the OBA group and 180 in the OFA group. The OFA group was subdivided in two: 90 patients received OFA with clonidine (OFAC) and 90 received OFA with dexmedetomidine (OFAD).

MEASUREMENTS

Proportion of patients who did not receive morphine during the first 24 postoperative hours.

MAIN RESULTS

During the first 24 postoperative hours, the proportion of patients who did not require morphine was significantly higher in the OFA (87%) than in the OBA (52%) group (OR: 6.31; 95% CI [3.38; 11.80], P < 0.001). This difference remained significant after adjustment for age, body mass index, sex, type and duration of surgery (OR: 7.99; 95% CI [4.05; 16.48], P < 0.001). A greater proportion of patients in the OFAD (93%) than in the OFAC group (81%, P = 0.026) did not receive morphine during the same period.

CONCLUSIONS

OFA is associated with a lower morphine requirement than with OBA during the first 24 h after bariatric surgery. In addition, OFAD seems to be more effective than OFAC in order to reduce morphine consumption.

Opioid-free anesthesia in oncologic surgery: the rules of the game

BACKGROUND

Opioids are frequently used in the postoperative period due to their analgesic properties. While these drugs reduce nociceptive somatic, visceral, and neuropathic pain, they may also lead to undesirable effects such as respiratory depression, urinary retention, nausea and vomiting, constipation, itching, opioid-induced hyperalgesia, tolerance, addiction, and immune system disorders. Anesthesiologists are in the critical position of finding balance between using opioids when they are necessary and implementing opioid-sparing strategies to avoid the known harmful effects. This article aims to give an overview of opioid-free anesthesia.

MAIN BODY

This paper presents an overview of opioid-free anesthesia and opioid-sparing anesthetic techniques. Pharmacological and non-pharmacological strategies are discussed, highlighting the possible advantages and drawbacks of each approach.

CONCLUSIONS

Choosing the best anesthetic protocol for a patient undergoing cancer surgery is not an easy task and the available literature provides no definitive answers. In our opinion, opioid-sparing strategies should always be implemented in routine practice and opioid-free anesthesia should be considered whenever possible. Non-pharmacological strategies such as patient education, while generally underrepresented in scientific literature, may warrant consideration in clinical practice.

Low-dose fentanyl reduces pain perception, muscle sympathetic nerve activity responses, and blood pressure responses during the cold pressor test

Our knowledge about how low-dose (analgesic) fentanyl affects autonomic cardiovascular regulation is primarily limited to animal experiments. Notably, it is unknown if low-dose fentanyl influences human autonomic cardiovascular responses during painful stimuli in humans. Therefore, we tested the hypothesis that low-dose fentanyl reduces perceived pain and subsequent sympathetic and cardiovascular responses in humans during an experimental noxious stimulus. Twenty-three adults (10 females/13 males; 27 ± 7 yr; 26 ± 3 kg·m^-2, means ± SD) completed this randomized, crossover, placebo-controlled trial during two laboratory visits. During each visit, participants completed a cold pressor test (CPT; hand in ∼0.4°C ice bath for 2 min) before and 5 min after drug/placebo administration (75 μg fentanyl or saline). We compared pain perception (100-mm visual analog scale), muscle sympathetic nerve activity (MSNA; microneurography, 11 paired recordings), and beat-to-beat blood pressure (BP; photoplethysmography) between trials (at both pre- and postdrug/placebo timepoints) using paired, two-tailed t tests. Before drug/placebo administration, perceived pain (P = 0.8287), ΔMSNA burst frequency (P = 0.7587), and Δmean BP (P = 0.8649) during the CPT were not different between trials. After the drug/placebo administration, fentanyl attenuated perceived pain (36 vs. 66 mm, P < 0.0001), ΔMSNA burst frequency (9 vs. 17 bursts/min, P = 0.0054), and Δmean BP (7 vs. 13 mmHg, P = 0.0174) during the CPT compared with placebo. Fentanyl-induced reductions in pain perception and Δmean BP were moderately related (r = 0.40, P = 0.0641). These data provide valuable information regarding how low-dose fentanyl reduces autonomic cardiovascular responses during an experimental painful stimulus.

Effect of intraperitoneal local anesthesia on enhanced recovery outcomes after bariatric surgery: a randomized controlled pilot study

Background:

Patients with extreme obesity are at high risk for adverse perioperative events, especially when opioid-centric analgesic protocols are used, and perioperative pain management interventions in bariatric surgery could improve safety, outcomes and satisfaction. We aimed to evaluate the impact of intraperitoneal local anesthesia (IPLA) on enhanced recovery after bariatric surgery (ERABS) outcomes.

Methods:

We conducted a prospective double-blind randomized controlled pilot study in adherence to an a priori peer-reviewed protocol. Patients undergoing laparoscopic Roux-en-Y gastric bypass surgery (LRYGB) with an established ERABS protocol between July 2014 and February 2015 were randomly allocated to receive either IPLA with 0.2% ropivacaine (intervention group) or normal saline (control group). We measured pain scores, analgesic consumption and adverse effects. Functional prehabilitation outcomes, including peak expiratory flow (PEF) and the Six Minute Walk Test (6MWT) and Quality of Recovery Survey-40 (QoR-40) scores, were assessed before surgery, and 1 day and 7 days postoperatively.

Results:

One hundred patients were randomly allocated to the study groups, of whom 92 completed the study, 46 in each group. There were no statistically significant differences between the 2 groups in baseline characteristics or any primary or secondary outcomes. Pain scores and analgesic consumption were low in both groups. There were no adverse events. Significant declines in PEF and 6MWT and QoR-40 scores were noted on postoperative day 1 in both groups; the values returned to baseline on postoperative day 7 in both groups.

Conclusion:

Intraperitoneal local anesthesia with ropivacaine did not reduce postoperative pain or analgesic consumption when administered intraoperatively to patients undergoing LRYGB. Standardization of the ERABS protocol benefited patients, with functional prehabilitation outcomes returning to baseline postoperatively. Trial registration:ClinicalTrials.gov no. NCT 02154763

Benefits of dexmedetomidine on postoperative analgesia after bariatric surgery: a systematic review and meta-analysis

INTRODUCTION

Anesthetic management of morbidly obese patients is challenging, particularly in those undergoing bariatric surgery. Dexmedetomidine is a α2-adrenergic receptor agonist that is increasingly used in the perioperative setting for its beneficial properties including sedation, anxiolysis, analgesia with opioid-sparing effects, and minimal impact on respiration. The objective of this study was to evaluate the effect of dexmedetomidine on postoperative analgesia and recovery-related outcomes among patients undergoing bariatric surgery.

EVIDENCE ACQUISITION

We conducted a systematic review and meta-analysis of MEDLINE, EMBASE, and CENTRAL databases from conception to September 2021 for randomized controlled trials (RCTs) using dexmedetomidine in bariatric patients on postoperative outcomes. Outcomes were pooled using random effects model and presented as relative risks (RR) or mean differences (MD) with 95% confidence intervals (CI).

EVIDENCE SYNTHESIS

In total, 20 RCTs with 665 patients in the dexmedetomidine group and 671 patients in the control groups were included. Among RCTs, the dexmedetomidine group had significantly lower opioid usage at 24-hours postoperatively (MD: -5.14, 95%CI: -10.18 to -0.10; moderate certainty), reduced pain scores on a 10-point scale at PACU arrival (MD: -1.69, 95%CI: -2.79 to -0.59; moderate certainty) and 6 hours postoperatively (MD: -1.82, 95%CI: - 3.00 to -0.64; low certainty), and fewer instances of nausea (RR: 0.59, 95%CI: 0.45 to 0.75; moderate certainty) and vomiting (RR: 0.25, 95%CI: 0.15 to 0.43; moderate certainty), compared to control groups.

CONCLUSIONS

Dexmedetomidine is an efficacious anesthesia adjunct in patients undergoing bariatric surgery. These benefits of dexmedetomidine may be considered in the multi-modal analgesic management and enhanced recovery pathways in this high-risk population.

Comparison between dexmedetomidine and fentanyl bolus in attenuating the stress response to laryngoscopy and tracheal intubation: a randomized double-blind trial

Background and objectives

Laryngoscopy and tracheal intubation lead to a sympathoadrenal response. We compared the efficacy of dexmedetomidine with fentanyl bolus to attenuate this response.

Methods

One hundred patients admitted for routine surgical procedures under general anesthesia were enrolled in this double blind, randomized, controlled study. Patients were randomly assigned to two groups: Group F received injection of fentanyl 2 μg.kg^-1 and Group D received injection of dexmedetomidine 0.5 μg.kg^-1 diluted up to 5 mL by adding normal saline intravenously over 60 seconds. Five minutes thereafter, following induction with propofol and vecuronium, tracheal intubation was performed after 3 minutes of mask ventilation. Hemodynamic parameters were observed at an interval of 2 minutes before tracheal intubation and at an interval of 1 minute for 5 minutes after tracheal tube cuff inflation. Continuous variables are presented as mean with 95% confidence interval, and t-test was applied for comparing the difference of means between two groups after checking the normality condition. Chi-square test was applied to test the independence of attributes of categorical variables. Repeated measures two-way ANOVA was performed to compare the outcome variables between the two groups.

Results

The difference in heart rate and mean arterial pressure of patients in two groups after laryngoscopy and intubation was not statistically significant at any point of time. The hemodynamic changes did not require any intervention in the form of administration of rescue medication.

Conclusions

Dexmedetomidine 0.5 μg.kg^-1 is as effective as fentanyl 2 μg.kg^-1 in attenuating the hemodynamic response accompanying laryngoscopy and tracheal intubation.

Clinical trial number & registry URL

CTRI/2017/09/009857 [ctri.nic.in]

Opioid-Free Anesthesia Benefit-Risk Balance: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Opioid-free anesthesia (OFA) is used in surgery to avoid opioid-related side effects. However, uncertainty exists in the balance between OFA benefits and risks. We searched for randomized controlled trials (RCTs) comparing OFA to opioid-based anesthesia (OBA) in five international databases. The co-primary outcomes were postoperative acute pain and morphine consumption at 2, 24, and 48 h. The secondary outcomes were the incidence of postoperative chronic pain, hemodynamic tolerance, severe adverse effects, opioid-related adverse effects, and specific adverse effects related to substitution drugs. Overall, 33 RCTs including 2209 participants were assessed. At 2 h, the OFA groups had lower pain scores at rest MD (0.75 (−1.18; −0.32)), which did not definitively reach MCID. Less morphine was required in the OFA groups at 2 and 24 h, but with very small reductions: 1.61 mg (−2.69; −0.53) and −1.73 mg (p < 0.05), respectively, both not reaching MCID. The reduction in PONV in the OFA group in the PACU presented an RR of 0.46 (0.38, 0.56) and an RR of 0.34 (0.21; 0.56), respectively. Less sedation and shivering were observed in the OFA groups with an SMD of −0.81 (−1.05; −0.58) and an RR of 0.48 (0.33; 0.70), respectively. Quantitative analysis did not reveal differences between the hemodynamic outcomes, although severe side effects have been identified in the literature. No clinically significant benefits were observed with OFA in terms of pain and opioid use after surgery. A clear benefit of OFA use was observed with respect to a reduction in PONV. However, more data on the safe use of OFAs should be collected and caution should be taken in the development of OFA.

Comparison of the Effect of Dexmedetomidine and Remifentanil on Pain Control After Spinal Surgery: A Double-Blind, Randomized Clinical Trial

Background

A variety of spinal surgery procedures are performed on patients with different cardiac, vascular, and respiratory comorbidities. Postoperative pain management is a major determinant of hemodynamic and respiratory status in these patients and promotes clinical results, prevents complications, saves health services, and improves the quality of life of patients.

Objectives

We compared the effects of dexmedetomidine and remifentanil on pain control after spinal surgery.

Methods

Sixty patients aged 18 - 65 years undergoing spinal surgery were randomized into the two groups of dexmedetomidine and remifentanil. The dexmedetomidine group (group D, n = 30) received dexmedetomidine infusion (0.6 mcg/kg/h), and the remifentanil group (group R, n = 30) received remifentanil infusion (0.1 mcg/kg/min) from induction of anesthesia until extubation. Propofol (1.5 mg/kg) and fentanyl (2mcg/kg) were used to initiate anesthesia, and propofol (100 - 150 mcg/kg/min) was infused to maintain anesthesia. Postoperative pain, hemodynamic parameters, and recovery characteristics were evaluated after surgery.

Results

The mean pain intensity in the dexmedetomidine group was significantly lower than in the remifentanil group (2.98 ± 1.29 vs. 3.80 ± 1.1; P < 0.001). Hemodynamic changes in the dexmedetomidine group (MAP: 92.60 ± 5.56, HR: 73.07 ± 7) were less, and their condition was significantly more stable than in the remifentanil group (MAP: 93.85 ± 4.78, HR: 79.15 ± 7.03; P < 0.05). The mean arterial oxygen saturation (O₂ sat) in the dexmedetomidine group was significantly higher and more stable than in the remifentanil group (98.87 ± 0.51 vs. 97.92 ± 0.46; P < 0.05). The incidence of nausea and vomiting was significantly lower in the dexmedetomidine group compared to the remifentanil group (P < 0.05). The administration of analgesics in the post-anesthetic care unit (PACU) was significantly higher in the remifentanil group than the dexmedetomidine group (P = 0.016).

Conclusions

Anesthetic maintenance with either dexmedetomidine or remifentanil infusion until extubation provided more smooth and hemodynamically stable conditions, without complications. However, dexmedetomidine provides better analgesia, causes a more stable hemodynamic state, and reduces postoperative nausea-vomiting, shivering, and the need for analgesics.

Balanced Opioid-free Anesthesia with Dexmedetomidine versus Balanced Anesthesia with Remifentanil for Major or Intermediate Noncardiac Surgery

BACKGROUND

It is speculated that opioid-free anesthesia may provide adequate pain control while reducing postoperative opioid consumption. However, there is currently no evidence to support the speculation. The authors hypothesized that opioid-free balanced anesthetic with dexmedetomidine reduces postoperative opioid-related adverse events compared with balanced anesthetic with remifentanil.

METHODS

Patients were randomized to receive a standard balanced anesthetic with either intraoperative remifentanil plus morphine (remifentanil group) or dexmedetomidine (opioid-free group). All patients received intraoperative propofol, desflurane, dexamethasone, lidocaine infusion, ketamine infusion, neuromuscular blockade, and postoperative lidocaine infusion, paracetamol, nefopam, and patient-controlled morphine. The primary outcome was a composite of postoperative opioid-related adverse events (hypoxemia, ileus, or cognitive dysfunction) within the first 48 h after extubation. The main secondary outcomes were episodes of postoperative pain, opioid consumption, and postoperative nausea and vomiting.

RESULTS

The study was stopped prematurely because of five cases of severe bradycardia in the dexmedetomidine group. The primary composite outcome occurred in 122 of 156 (78%) dexmedetomidine group patients compared with 105 of 156 (67%) in the remifentanil group (relative risk, 1.16; 95% CI, 1.01 to 1.33; P = 0.031). Hypoxemia occurred 110 of 152 (72%) of dexmedetomidine group and 94 of 155 (61%) of remifentanil group patients (relative risk, 1.19; 95% CI, 1.02 to 1.40; P = 0.030). There were no differences in ileus or cognitive dysfunction. Cumulative 0 to 48 h postoperative morphine consumption (11 mg [5 to 21] versus 6 mg [0 to 17]) and postoperative nausea and vomiting (58 of 157 [37%] versus 37 of 157 [24%]; relative risk, 0.64; 95% CI, 0.45 to 0.90) were both less in the dexmedetomidine group, whereas measures of analgesia were similar in both groups. Dexmedetomidine patients had more delayed extubation and prolonged postanesthesia care unit stay.

CONCLUSIONS

This trial refuted the hypothesis that balanced opioid-free anesthesia with dexmedetomidine, compared with remifentanil, would result in fewer postoperative opioid-related adverse events. Conversely, it did result in a greater incidence of serious adverse events, especially hypoxemia and bradycardia.

EDITOR’S PERSPECTIVE

In the Arms of Morpheus without Morphia; Mitigating the United States Opioid Epidemic by Decreasing the Surgical Use of Opioids

The opioid epidemic is a major public health issue in the United States. Exposure of opioid naïve-patients to opioids in the perioperative period is a well-documented source of continued use with one in 20 opioid-naïve surgical patients continuing to use opioids beyond 90 days. There is no association with magnitude of surgery, major versus minor, and the strongest predictor of continued use is surgical exposure. Causal factors include over reliance on opioids for intraoperative and postoperative analgesia and excessive ambulatory opioid prescribing. Opioid-induced hyperalgesia can paradoxically result from intraoperative (anesthesia controlled) opioid administration. Increasing size of initial prescription is a strong predictor of continued use necessitating procedure specific supplies limited to under 3-days. Alternative multimodal pain management (non-opioid medications and regional anesthesia) that limit opioid use must be a high priority with opioids reserved for severe breakthrough pain. Barriers to implementation of opioid-sparing pathways include reluctance to adopt protocols and apprehension about opioid elimination. Considering the number of surgeries performed annually in the United States, perioperative physicians must aggressively address modifiable factors in surgical patients. Patient care pathways need to be constructed collaboratively by surgeons and anesthesiologists with continuing feedback to optimize patient outcomes including iatrogenic opioid dependence.

AGA Technical Review on Intragastric Balloons in the Management of Obesity

Several strategies are available to address the obesity epidemic and range from noninvasive lifestyle interventions to medications and bariatric surgical procedures. Endoscopic bariatric techniques, such as intragastric balloons, have become an attractive alternative as a tool for weight loss that can augment the effect of lifestyle interventions. This technical review includes multiple systematic reviews performed to support a clinical practice guideline by the American Gastroenterological Association on the role of intragastric balloons as a tool for weight loss. The systematic reviews targeted a priori selected clinical questions about the effectiveness and periprocedural care of intragastric balloons and concomitant and subsequent weight-loss strategies.

The effect of opioid-free anesthesia on the quality of recovery after gynecological laparoscopy: study protocol for a prospective randomized controlled trial

BACKGROUND

Because of the indiscriminate use of opioids during the perioperative period, opioid-free anesthesia (OFA) has been increasingly required. Nevertheless, the studies on the detailed techniques and effects of OFA are not sufficient. The Quality of Recovery-40 (QoR-40) questionnaire is a validated assessment tool for measuring recovery from general anesthesia. However, no study has used the QoR-40 to determine if OFA leads to better recovery than standard general anesthesia. Therefore, we aim to perform this study to determine the effects of OFA using dexmedetomidine and lidocaine on the quality of recovery as well as the various postoperative outcomes.

METHODS

The participants (n = 78) will be allocated to one of the two groups; the study group will receive bolus and infusion of dexmedetomidine and lidocaine, and the control group will receive remifentanil infusion during general anesthesia for gynecological laparoscopy. The other processes including anesthetic and postoperative care will be performed similarly in the two groups. Intraoperative hemodynamic, anesthetic, and nociceptive variables will be recorded. Postoperative outcomes such as QoR-40, pain severity, and opioid-related side effects will be assessed. Additionally, an ancillary cytokine study (inflammatory cytokine, stress hormone, and reactive oxygen species) will be performed during the study period.

DISCUSSION

This will be the first study to determine the effect of OFA, using the combination of dexmedetomidine and lidocaine, on the quality of recovery after gynecological laparoscopy compared with standard general anesthesia using remifentanil. The findings from this study will provide scientific and clinical evidence on the efficacy of OFA.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04409964 . Registered on 28 May 2020.

Novel Opiate-Free Anesthetic Technique for Major Urologic Procedures

OBJECTIVES

We postulated that an opiate-free (OF) general anesthesia (GA) technique could adequately control a patient's pain without adversely affecting recovery. We compared patients undergoing major urologic procedures with and without opiate-based GA.

METHODS

A propensity-matched analysis was performed comparing hospital length of stay, postoperative nausea and vomiting, ileus occurrence, postanesthesia care unit, and total opiate consumption, as well as sedation and hemodynamic variables. The data are expressed as medians and were analyzed with the Wilcoxon rank-sum test. P < 0.05 indicate statistical significance.

RESULTS

In total, 166 patients were evaluated in both the OF group and the opiate-based treatment group. American Society of Anesthesiologists classification and age were comparable, with most surgeries being laparoscopic and confined to the bladder, kidney, and prostate gland. The median opiate consumption in morphine equivalents in the postanesthesia care unit was 7.7 mg (range 5-11.7 mg) for the OF cohort versus 11.7 mg (range 5-17.3 mg) for the control group (P < 0.001). Similarly, the median total postoperative opiate consumption in morphine equivalents was 23.9 mg (range 13.8-42.4 mg) for the OF group compared with 32.1 mg (range 17.38-57.51 mg) for the control group (P = 0.0081). The median hospital length of stay for the OF group was 1.4 days (range 1.2-2.3 days) versus 1.3 days (range 1.2-2.4 days) for the control group (P = 0.8466).

CONCLUSIONS

There was a statistically significant difference in opiate consumption postoperatively for patients who underwent an OF technique compared with a conventional opiate-based technique. This technique appears to be a possible alternative approach, without any apparent untoward consequences during admission.

Effects of intravenous lidocaine, dexmedetomidine, and their combination on IL-1, IL-6 and TNF-α in patients undergoing laparoscopic hysterectomy: a prospective, randomized controlled trial

BACKGROUND

Surgical-related inflammatory responses have negative effects on postoperative recovery. Intravenous (IV) lidocaine and dexmedetomidine inhibits the inflammatory response. We investigated whether the co-administration of lidocaine and dexmedetomidine could further alleviate inflammatory responses compared with lidocaine or dexmedetomidine alone during laparoscopic hysterectomy.

METHODS

A total of 160 patients were randomly allocated into four groups following laparoscopic hysterectomy: the control group (group C) received normal saline, the lidocaine group (group L) received lidocaine (bolus infusion of 1.5 mg/kg over 10 min, 1.5 mg/kg/h continuous infusion), the dexmedetomidine group (group D) received dexmedetomidine (bolus infusion of 0.5 μg/kg over 10 min, 0.4 μg/kg/h continuous infusion), and the lidocaine plus dexmedetomidine group (group LD) received a combination of lidocaine (bolus infusion of 1.5 mg/kg over 10 min, 1.5 mg/kg/h continuous infusion) and dexmedetomidine (bolus infusion of 0.5 μg/kg over 10 min, 0.4 μg/kg/h continuous infusion). The levels of plasma interleukin-1 (IL-1), interleukin-6 (IL-6), and tumor necrosis factor-α (TNF-α) at different time points were the primary outcomes. Secondary outcomes included hemodynamic variables, postoperative visual analogue scale (VAS) scores, time to first flatus, and incidence of nausea and vomiting after surgery.

RESULTS

The levels of plasma IL-1, IL-6, and TNF-α were lower in groups D and LD than in group C and were lowest in group LD at the end of the procedure and 2 h after the operation (P < 0.05). The VAS scores were decreased in groups D and LD compared with group C (P < 0.05). The heart rate (HR) was decreased at the end of the procedure and 2 h after the operation in groups D and LD compared to groups C and L (P < 0.001). The mean blood pressure (MBP) was lower at 2 h after the operation in groups L, D, and LD than in group C (P < 0.001). There was a lower incidence of postoperative nausea and vomiting (PONV) in group LD than in group C (P < 0.05).

CONCLUSIONS

The combination of lidocaine and dexmedetomidine significantly alleviated the inflammatory responses, decreased postoperative pain, and led to fewer PONV in patients undergoing laparoscopic hysterectomy.

TRIAL REGISTRATION

ClinicalTrials.gov ( NCT03276533 ), registered on August 23, 2017.

Evaluation of the perioperative effects of dexmedetomidine on tympanoplasty operations

PURPOSE

This randomized double-blind study aimed to evaluate the effects of dexmedetomidine on hemodynamic parameters and the quality of surgery and recovery criteria in tympanoplasty operations.

MATERIALS AND METHODS

A total of 75 patients 18-55 years undergoing tympanoplasty, who were graded as American Society of Anesthesiologists physical status I-II, were randomly divided into three groups. Group 1 included patients receiving remifentanil alone, Group 2 included patients receiving dexmedetomidine + remifentanil and Group 3 included patients receiving dexmedetomidine + ½ remifentanil. Anesthesia was induced with propofol and cisatracurium. For maintenance of anesthesia, a mixture of 2-2.5% sevoflurane, 40-60% oxygen/air was used. The groups were compared in terms of hemodynamic parameters, surgical area, recovery criteria, modified Aldrete, pain scores, additional analgesic requirements and adverse effects.

RESULTS

Mean arterial pressure and heart rate values of Group 1 were higher at the time of intubation, incision, spontaneous breathing and extubation compared to Group 2 and Group 3. Surgical field satisfaction was higher in Group 2 and Group 3 than Group 1. Spontaneous breathing, eye opening and verbal cooperation times were shorter in Group 3 compared to Group 2. Eye opening and verbal cooperation times were longer in Group 2 compared to Group 1. The 30-minute modified Aldrete scores was higher in Group 3 compared to Group 1. There was no difference between the groups in terms of postoperative pain and adverse effects.

CONCLUSION

The use of dexmedetomidine during tympanoplasty operations may provide better hemodynamic control and surgical view, may provide faster recovery and may reduce remifentanil consumption.

Effectiveness Comparison of Dexmedetomidine and Remifentanil for Perioperative Management in Patients Undergoing Endoscopic Sinus Surgery

BACKGROUND

For patients undergoing endoscopic sinus surgery, intranasal injection of epinephrine can cause acute increases in heart rate and blood pressure.

OBJECTIVE

Among the drugs for reducing hyperdynamic effects, dexmedetomidine and remifentanil are expected to blunt the acute hemodynamic responses after intranasal injection of epinephrine. Our study compared a difference in the 2 drugs in their abilities to blunt the hemodynamic responses in intraoperative period and postoperative profile.

METHODS

In this study, the patients were randomly divided into the dexmedetomidine and remifentanil groups. During the intraoperative period, the hemodynamic values were recorded. The surgical condition was assessed by a single surgeon. During the postoperative period, hemodynamic values, sedation scale score, and pain score were recorded.

RESULT

No significant differences in hemodynamic variables were found between the groups before and after intranasal injection of epinephrine. Comparison of the group mean values before endotracheal intubation revealed that the blood pressure values in the remifentanil group were significantly lower than those in the dexmedetomidine group. At 2 minutes after endotracheal intubation, blood pressure and heart rate values in the remifentanil group were significantly lower than those in the dexmedetomidine group. The sedation score was significantly lower in the dexmedetomidine group on arrival and at 30 minutes after arrival at the postanesthetic care unit (P < .001 and P = .001, respectively). At 30 and 60 minutes after the operation, the pain scores were significantly lower in the dexmedetomidine group (P = .015 and P = .001, respectively).

CONCLUSION

Dexmedetomidine had better postoperative sedative and analgesic effects than remifentanil for patients undergoing endoscopic sinus surgery in this study. Remifentanil and dexmedetomidine attenuated acute hemodynamic responses to be within normal ranges after intranasal injection of epinephrine, and no significant differences in terms of hemodynamic variables. Remifentanil was superior to dexmedetomidine in inducing hypotension during endotracheal intubation.

The effects of different doses of dexmedetomidine on the requirements for propofol for loss of consciousness in patients monitored via the bispectral index: a double-blind, placebo-controlled trial

BACKGROUND

The α₂-adrenergic agonist dexmedetomidine (DEX) is a sedative and can be used as an adjunct to hypnotics. The study sought to evaluate the effects of different doses of DEX on the requirements for propofol for loss of consciousness (LOC) in patients monitored via the bispectral index (BIS).

METHODS

In this randomized, double-blind, three arm parallel group design and placebo-controlled trial, 73 patients aged between 18 and ~ 65 years with a BMI range of 18.0-24.5 kg·m^- 2 and an American Society of Anesthesiologists (ASA) grade I or II who were scheduled for general anesthesia at the General Hospital of Ningxia Medical University were included in this study. Anesthesiologists and patients were blinded to the syringe contents. All patients were randomly assigned in a 1:1:1 ratio to receive a 0.5 μg·kg^- 1 DEX infusion (0.5 μg·kg^- 1 DEX group; n = 24), a 1.0 μg·kg^- 1 DEX infusion (1.0 μg·kg^- 1 DEX group; n = 25) or a saline infusion (control group; n = 24) for 10 min. Propofol at a concentration of 20 mg·kg^- 1·h^- 1 was then infused at the end of the DEX or saline infusion. The propofol infusion was stopped when the patient being infused lost consciousness. The primary endpoint were propofol requirements for LOC and BIS value at LOC.

RESULTS

The data from 73 patients were analyzed. The propofol requirements for LOC was reduced in the DEX groups compared with the control group (1.12 ± 0.33 mg·kg^- 1 for the 0.5 μg·kg^- 1 DEX group vs. 1.79 ± 0.39 mg·kg^- 1 for the control group; difference, 0.68 mg·kg^- 1 [95% CI, 0.49 to 0.87]; P = 0.0001) (0.77 ± 0.27 mg·kg^- 1 for the 1.0 μg·kg^- 1 DEX group vs. 1.79 ± 0.39 mg·kg^- 1 for the control group; difference, 1.02 mg·kg^- 1 [95% CI, 0.84 to 1.21]; P = 0.0001). The propofol requirements for LOC was lower in the 1.0 μg·kg^- 1 DEX group than the 0.5 μg·kg^- 1 DEX group (0.77 ± 0.27 mg·kg^- 1 vs. 1.12 ± 0.33 mg·kg^- 1, respectively; difference, 0.34 mg·kg^- 1 [95% CI, 0.16 to 0.54]; P = 0.003). At the time of LOC, the BIS value was higher in the DEX groups than in the control group (67.5 ± 3.5 for group 0.5 μg·kg^- 1 DEX vs. 60.5 ± 3.8 for the control group; difference, 7.04 [95% CI, 4.85 to 9.23]; P = 0.0001) (68.4 ± 4.1 for group 1.0 μg·kg^- 1 DEX vs. 60.5 ± 3.8 for the control group; difference, 7.58 [95% CI, 5.41 to 9.75]; P = 0.0001).

CONCLUSION

The study showed that DEX (both 0.5 and 1.0 μg·kg^- 1 DEX) reduced the propofol requirements for LOC. DEX pre-administration increased the BIS value for LOC induced by propofol.

CLINICAL TRIAL REGISTRATION

The study was registered at ClinicalTrials.gov (trial ID: NCT02783846 on May 26, 2016).

Postoperative nausea and vomiting after bariatric surgery and dexmedetomidine anesthetic: a propensity-weighted analysis

BACKGROUND

Patients undergoing laparoscopic bariatric surgery have high rates of postoperative nausea and vomiting (PONV). Dexmedetomidine based anesthetic could reduce PONV rates.

OBJECTIVES

To determine if PONV rates differ in patients undergoing laparoscopic bariatric surgery with anesthesia primarily based on dexmedetomidine or standard anesthetic management with inhalational agents and opioids.

SETTING

University hospital.

METHODS

From January 2014 to April 2018, 487 patients underwent laparoscopic bariatric surgery and met inclusion criteria (dexmedetomidine, n = 174 and standard anesthetic, n = 313 patients). In both groups, patients received preoperative PONV prophylaxis. We analyzed rates of PONV and moderate-to-deep sedation. A propensity score was calculated and outcomes were assessed using generalized estimating equations with inverse probability of treatment weighting.

RESULTS

Perioperative opioids and volatile anesthetics were reduced in dexmedetomidine patients. During anesthesia recovery the incidence of PONV was similar between dexmedetomidine and standard anesthetic patients (n = 37 [21.3%] versus n = 61 [19.5%], respectively; inverse probability of treatment weighting odds ratio = 1.35; 95% confidence interval .78-2.32, P = .281), and the incidence of sedation higher in dexmedetomidine patients (n = 86 [49.4%] versus n = 75 [24.0%]; inverse probability of treatment weighting odds ratio = 2.43; 95% confidence interval 1.47-4.03, P < 0.001). Rates of PONV and sedation were similar during the remainder of the hospital stay. A secondary sensitivity analysis was performed limited to dexmedetomidine patients who did not receive volatile and results were similar.

CONCLUSIONS

While dexmedetomidine-based anesthesia was associated with reduced opioid and volatile agents use, it was not associated with a reduction of PONV. The higher rates of moderate-to-deep sedation during anesthesia recovery observed with dexmedetomidine may be undesirable in morbidly obese patients.

Society of Anesthesia and Sleep Medicine Guideline on Intraoperative Management of Adult Patients With Obstructive Sleep Apnea

The purpose of the Society of Anesthesia and Sleep Medicine Guideline on Intraoperative Management of Adult Patients With Obstructive Sleep Apnea (OSA) is to present recommendations based on current scientific evidence. This guideline seeks to address questions regarding the intraoperative care of patients with OSA, including airway management, anesthetic drug and agent effects, and choice of anesthesia type. Given the paucity of high-quality studies with regard to study design and execution in this perioperative field, recommendations were to a large part developed by subject-matter experts through consensus processes, taking into account the current scientific knowledge base and quality of evidence. This guideline may not be suitable for all clinical settings and patients and is not intended to define standards of care or absolute requirements for patient care; thus, assessment of appropriateness should be made on an individualized basis. Adherence to this guideline cannot guarantee successful outcomes, but recommendations should rather aid health care professionals and institutions to formulate plans and develop protocols for the improvement of the perioperative care of patients with OSA, considering patient-related factors, interventions, and resource availability. Given the groundwork of a comprehensive systematic literature review, these recommendations reflect the current state of knowledge and its interpretation by a group of experts at the time of publication. While periodic reevaluations of literature are needed, novel scientific evidence between updates should be taken into account. Deviations in practice from the guideline may be justifiable and should not be interpreted as a basis for claims of negligence.

Fentanyl vs fentanyl-dexmedetomidine in lumbar foraminotomy surgery

Aim

Lumbar foraminotomy surgery requires a potent opioid with short duration and rapid onset of action. In the present study we intended to compare the efficacy of fentanyl alone vs the combination of dexmedetomidine and fentanyl during lumbar foraminotomy surgery.

Methods

The duration and requirements for first postoperative analgesics, hemodynamic stability, and respective side effects were studied. A prospective, randomized, double blind study of 40 patients (fentanyl group [Fen group] and fentanyl-dexmedetomidine group [Fen-Dex group], n=20 each) scheduled for lumbar foraminotomy surgery under pharmaceutical care intervention was carried out. Patients were classified as class I or II, according to the American Society of Anesthesiologists physical status classification. Patients received intraoperative propofol, sevoflurane, atracurium, and either fentanyl loading dose of 1.0 μg/kg and maintenance infusion dose of 0.2 μg/kg/h in both groups. The patients of the Fen group received normal saline (0.9%) placebo, while the patients of the Fen-Dex group received dexmedetomidine infusion (0.5 μg/kg/h) along with the fentanyl infusion. Postoperative morphine doses were given. Hemodynamic stability, pain, postoperative analgesia requirement, side effects of drugs, and other effects were monitored.

Results

In the Fen-Dex group, the pain score was significantly less than in the Fen group (p<0.05). The time to first postoperative analgesia request was prolonged in the Fen-Dex group compared to the Fen group. On the other hand, requirement of morphine, and postoperative symptoms and episodes of nausea and vomiting were significantly greater in the Fen group than in the Fen-Dex group (p<0.05).

Conclusion

The present study suggests the addition of dexmedetomidine during lumbar foraminotomy surgery at different levels would be beneficial to reduce morphine consumption and any adverse drug reaction.

Dexmedetomidine: present and future directions

Dexmedetomidine is a potent, highly selective α-2 adrenoceptor agonist, with sedative, analgesic, anxiolytic, sympatholytic, and opioid-sparing properties. Dexmedetomidine induces a unique sedative response, which shows an easy transition from sleep to wakefulness, thus allowing a patient to be cooperative and communicative when stimulated. Dexmedetomidine may produce less delirium than other sedatives or even prevent delirium. The analgesic effect of dexmedetomidine is not strong; however, it can be administered as a useful analgesic adjuvant. As an anesthetic adjuvant, dexmedetomidine decreases the need for opioids, inhalational anesthetics, and intravenous anesthetics. The sympatholytic effect of dexmedetomidine may provide stable hemodynamics during the perioperative period. Dexmedetomidine-induced cooperative sedation with minimal respiratory depression provides safe and acceptable conditions during neurosurgical procedures in awake patients and awake fiberoptic intubation. Despite the lack of pediatric labelling, dexmedetomidine has been widely studied for pediatric use in various applications. Most adverse events associated with dexmedetomidine occur during or shortly after a loading infusion. There are some case reports of dexmedetomidine-related cardiac arrest following severe bradycardia. Some extended applications of dexmedetomidine discussed in this review are promising, but still limited, and further research is required. The pharmacological properties and possible adverse effects of dexmedetomidine should be well understood by the anesthesiologist prior to use. Moreover, it is necessary to select patients carefully and to determine the appropriate dosage of dexmedetomidine to ensure patient safety.

The Security Rating on Local Ablation and Interventional Therapy for Hepatocellular Carcinoma (HCC) and the Comparison among Multiple Anesthesia Methods

Recently, the interventional therapies are used more often in clinical practice for hepatocellular carcinoma. The most commonly used methodologies include radiofrequency ablation, microwave ablation, laser ablation, and cryotherapy. Most of the interventional operations need local anesthesia combined with intravenous sedation. Also, some interventional therapy centers apply general anesthesia. However, different anesthesia methods can cause diverse effects on patients' pain management, recovery time, and hospitalization time. For the better understanding of the current anesthesia application status, we summarize and analyze multiple anesthesia methods while being applied in interventional therapy for hepatocellular carcinoma; in addition, their characters are also compared in this paper.

Evaluation and Comparison of Fentanyl versus Nalbuphine for Attenuation of Hemodynamic Response to Laryngoscopy and Endotracheal Intubation in General Anesthesia

Background:

General anesthesia administration involves laryngoscopy and endotracheal intubation which are associated with the pressor response and can lead to tachycardia, hypertension, and arrhythmias, which can be deleterious in compromised patients and hence, this response needs to be suppressed.

Aims:

The aim of the study is to compare the effectiveness of intravenous (i.v) fentanyl and nalbuphine on the suppression of hemodynamic response in patients undergoing surgery under general anesthesia.

Setting and Design:

This prospective comparative study was conducted in the department of anesthesiology of a tertiary care center, and patients posted for elective surgery under general anesthesia were included.

Methods:

A total of 100 patients of either sex in the age group of 20–50 years, belonging to the American Society of Anesthesiologists physical status classes I and II undergoing surgery under general anesthesia, were divided into two groups: Group N (n = 50) – who received injection nalbuphine 0.2 mg/kg diluted in 10 mL normal saline i.v and Group F (n = 50) – who received injection fentanyl 2 μg/kg diluted in 10 mL of normal saline i.v over 1 min, 5 min prior to intubation. Technique of anesthesia was standardized for all the patients in the study. Heart rate (HR), blood pressure (systolic, diastolic, and mean arterial pressure [SBP, DBP, and MAP]), and oxygen saturation were recorded at baseline, induction, and at 1, 3, 5, and 10 min after intubation.

Statistical Analysis:

Descriptive statistics were done using mean with standard deviation for quantitative variables, and categorical variables were presented in frequencies along with respective percentages. The statistical comparisons for quantitative variables were done using Student's t-test and for categorical variables, Chi-square was used according to the data. All statistical analyses were performed using SPSS software (Version 22, SPSS Inc., Chicago, IL, USA). All analyses were two tailed, and results were discussed on 5% level of significance, i.e., P < 0.05 was considered statistically significant.

Results:

The demographic characteristics were comparable in both groups. HR was statistically insignificant between the two groups at all intervals. Comparing SBP, DBP, and MAP between the two groups, there was a significant increase in nalbuphine group than fentanyl group postintubation and was statistically significant at all intervals of time. Maximum rise in SBP, DBP, and MAP was 5.49%, 6.03%, and 5.80% for fentanyl group and 12.88%, 9.37%, and 10.86% for nalbuphine group, respectively. Comparison of oxygen saturation in two groups was statistically insignificant.

Conclusion:

Fentanyl is better than nalbuphine in blunting the pressor response of laryngoscopy and endotracheal intubation.

Effect of a low-dose dexmedetomidine infusion on intraoperative hemodynamics, anesthetic requirements and recovery profile in patients undergoing lumbar spine surgery

Background and Aims

Dexmedetomidine has been used as an anesthetic adjuvant; however, hypotension is a concern especially in prone patients. The aim of the study was to evaluate the effect of a low-dose dexmedetomidine infusion on intraoperative hemodynamics, blood loss, anesthetic requirements, and recovery profile in patients undergoing lumbar spine surgery in the prone position.

Material and Methods

The study was conducted in a randomized double-blinded manner in 60 patients scheduled for one- or two-level lumbar laminectomy. After administration of general anesthesia, patients were placed in prone position and allocated to either of two groups of 30 patients each. Patients in Group A received dexmedetomidine infusion at the rate of 0.3 μg kg^-1 hr^-1, whereas, group B patients received a saline infusion. The depth of anesthesia was guided by Bispectral index (BIS) monitoring, maintaining BIS between 40 and 60.

Results

The demographic profile and duration of surgery in both groups were similar. Mean heart rate was statistically similar in both the groups. Mean blood pressure was lower in group A, though the difference was significant only for the initial 30 min. The mean end-tidal sevoflurane requirement in group A was significantly less than that in group B (P = 0.003). Patients in group A had better recovery profile with mean emergence, extubation, and recovery times of 8.08 ± 3.48 min, 9.37 ± 3.64 min, and 11.65 ± 4.03 min, respectively, as compared with 11.27 ± 3.05 min, 12.24 ± 2.39 min, and 14.90 ± 2.63 min, respectively, in group B (P < 0.001). Mean intraoperative blood loss in group A of 263.47 ± 58.66 mL was significantly lower than 347.67 ± 72.90 ml in group B (P = 0.0001).

Conclusion

Group A patients had stable hemodynamic parameters, reduced intraoperative blood loss, less anesthetic requirement, and could be extubated earlier as compared with group B patients.

Influence of dexmedetomidine and lidocaine on perioperative opioid consumption in laparoscopic intestine resection: a randomized controlled clinical trial

Objective

The consumption of opioid analgesics could be reduced by the use of analgesics with different mechanisms of action. We investigated whether additional treatment with dexmedetomidine or lidocaine could reduce opioid consumption.

Methods

We randomized 59 study participants into three groups and examined: (i) fentanyl consumption, (ii) consumption of piritramide, and (iii) cognitive function and neuropathic pain. The control group received continuous propofol infusion and fentanyl boluses. Continuous intravenous infusion of dexmedetomidine (0.5 µg/kg/h) was administered to the dexmedetomidine group and lidocaine (1.5 mg/kg/h) was administered to the lidocaine group.

Results

No reduction in fentanyl consumption was observed among the groups. However, we noted a significantly lower consumption of piritramide on the first and second postoperative day in the lidocaine group. Total consumption of piritramide was significantly lower in the lidocaine group compared with the control group.

Conclusions

Lidocaine and dexmedetomidine reduced intraoperative propofol consumption, while lidocaine reduced postoperative piritramide consumption.

Clinical trial registration: NCT02616523

POFA trial study protocol: a multicentre, double-blind, randomised, controlled clinical trial comparing opioid-free versus opioid anaesthesia on postoperative opioid-related adverse events after major or intermediate non-cardiac surgery

INTRODUCTION

Reducing opioid consumption during and after surgery has been recommended for more than 10 years. Opioid-free anaesthesia (OFA) is a multimodal anaesthesia associating hypnotics, NMDA antagonists, local anaesthetics, anti-inflammatory drugs and α-2 agonists. Proofs of the effect of OFA on reducing opioid-related adverse effects after major or intermediate non-cardiac surgery are still scarce. We hypothesised that the reduced opioid consumption allowed by OFA compared with standard of care will be associated with a reduction of postoperative opioid-related adverse events.

METHODS/ANALYSIS

The POFA trial is a prospective, randomised, parallel, single-blind, multicentre study of 400 patients undergoing elective intermediate or major non-cardiac surgery. Patients will be randomly allocated to receive either a standard anaesthesia protocol or an OFA. The primary outcome measure is the occurrence of a severe postoperative opioid-related adverse event within the first 48 hours after extubation defined as: postoperative hypoxaemia or postoperative ileus or postoperative cognitive dysfunction. In addition, each component of the primary outcome measure will be analysed separately. Data will be analysed on the intention-to-treat principle and a per-protocol basis.

ETHICS AND DISSEMINATION

The POFA trial has been approved by an independent ethics committee for all study centres. Participant recruitment begins in November 2017. Results will be published in international peer-reviewed medical journals.

TRIAL REGISTRATION NUMBER

NCT03316339; Pre-results.