Effect of dexmedetomidine on intraocular pressure in patients undergoing robot-assisted laparoscopic radical prostatectomy under total intravenous anesthesia: A randomized, double blinded placebo controlled clinical trial

The intraoperative management of robotic-assisted laparoscopic prostatectomy

PURPOSE OF REVIEW

Robotic-assisted laparoscopic radical prostatectomy has become the second most commonly performed robotic surgical procedure worldwide, therefore, anesthesiologists should be aware of the intraoperative pathophysiological consequences. The aim of this narrative review is to report the most recent updates regarding the intraoperative management of anesthesia, ventilation, hemodynamics and central nervous system, during robotic-assisted laparoscopic radical prostatectomy.

RECENT FINDINGS

Surgical innovations and the advent of new technologies make it imperative to optimize the anesthesia management to provide the most holistic approach possible. In addition, an ageing population with an increasing burden of comorbidities requires multifocal attention to reduce the surgical stress.

SUMMARY

Total intravenous anesthesia (TIVA) and balanced general anesthesia are similar in terms of postoperative complications and hospital stay. Reversal of rocuronium is associated with shorter hospital stay and postanesthesia recovery time. Adequate PEEP levels improve oxygenation and driving pressure, and the use of a single recruitment maneuver after the intubation reduces postoperative pulmonary complications. Restrictive intravenous fluid administration minimizes bladder-urethra anastomosis complications and facial edema. TIVA maintains a better autoregulation compared with balanced general anesthesia. Anesthesiologists should be able to optimize the intraoperative management to improve outcomes.

Anesthetic concerns for robotic-assisted laparoscopic radical prostatectomy: an update

The anesthetic concerns of patients undergoing robotic-assisted laparoscopic radical prostatectomy (RALP) are primarily related to the use of pneumoperitoneum in the steep Trendelenburg position. This combination will affect cerebrovascular, ocular, respiratory, and hemodynamic homeostasis. Possible non-surgical complications range from mild subcutaneous emphysema to devastating ischemic optic neuropathy. The anesthetic management of RALP patients involves a thorough preoperative evaluation, careful positioning on the operative table, managing ventilation issues, and appropriate fluid management. Close coordination between the anesthesia and surgical teams is required for a successful surgery. This updated review will discuss the anesthetic concerns and perioperative management of patients presenting for RALP.

Effectiveness and safety of intravenous dexmedetomidine sedation for ophthalmic surgery under regional anesthesia

PURPOSE

To assess the effectiveness and safety of intravenous (IV) dexmedetomidine for sedation in ophthalmic surgery.

METHODS

Prospective, observational, uncontrolled, single-center study. Patients were sedated with a continuous dexmedetomidine IV infusion started 15 min before regional anesthesia administration and maintained up to the end of surgery. Effectiveness of dexmedetomidine was assessed by the Modified Observer's Assessment of Alertness and Sedation (MOAA/S) targeted at 5. Safety was assessed by the incidence of patients' movements/snoring and by the incidence of respiratory and haemodynamic complications. An eleven-point numerical rating scale (NRS) was used to assess the level of satisfaction of both the surgeon and the patient.

RESULTS

123 patients (73 males, mean age: 63 ± 13) were included; 81 (81/123; 65.8%) patients reached the requested MOAA/S score of 5. Any intraoperative movement - mostly voluntary - occurred in 34 (34/123; 27.6%) cases with no need for a switch to general anaesthesia; no ocular complications related to the intraoperative movements occurred. Intraoperative snoring occurred in 30 (30/123; 24.4%) patients and it did not affect the surgical manoeuvres. Respiratory drive depression requiring manual or mechanical ventilation never occurred. Bradycardia occurred in 14 (14/123; 11.3%), cases but only 4 (4/123; 3.2%) patients required atropine administration, which was always effective. Intraoperative analgesia was consistently obtained and both the surgeons and the patients reported a high NRS satisfaction score.

CONCLUSION

Dexmedetomidine provided adequate sedation in patients undergoing ocular surgery under local anaesthesia and showed a good effectiveness and safety profile. Upper airway obstruction, apnoea and snoring can occur.

Attenuation of the increase in intraocular pressure with dexmedetomidine: Systematic review with meta-analysis and trial sequential analysis

STUDY OBJECTIVE

Whether dexmedetomidine effectively attenuates the increase in intraocular pressure (IOP) remains inconclusive. We aim to evaluate the effects of dexmedetomidine on IOP in adult patients undergoing surgery which requires general anesthesia and endotracheal intubation.

DESIGN

Systematic review and meta-analysis.

INTERVENTIONS

Intravenous administration of dexmedetomidine during surgery.

MEASUREMENTS

Intraocular pressure.

METHODS

We searched PubMed, Embase, Scopus, Web of Science, Cochrane Library, Google Scholar, Wanfang Data, and China National Knowledge Infrastructure from the inception through April 14, 2020. Randomized control trials which involved adult patients undergoing surgery that required general anesthesia and endotracheal intubation, which compared intravenous administration of dexmedetomidine with placebo regarding the IOP levels, which also provided sufficient information for meta-analysis were considered eligible.

MAIN RESULTS

Twenty-nine randomized control trials were included. The IOP levels are significantly lower in patients receiving dexmedetomidine after the administration of dexmedetomidine [mean difference (MD), -2.04 mmHg; 95% confidence interval (CI), -2.40 mmHg to -1.67 mmHg], after the injection of succinylcholine (MD, -3.84 mmHg; 95% CI, -4.80 mmHg to -2.88 mmHg), after endotracheal intubation (MD, -3.64 mmHg; 95% CI, -4.46 mmHg to -2.82 mmHg), after pneumoperitoneum (MD, -3.12 mmHg; 95% CI, -3.93 mmHg to -2.30 mmHg), and after the patients being placed in a steep Trendelenburg position (MD, -4.12 mmHg; 95% CI, -5.39 mmHg to -2.85 mmHg). Trial sequential analyses for these outcomes are conclusive.

CONCLUSIONS

Dexmedetomidine effectively attenuates the increase in IOP levels, and should be considered especially for at-risk patients.

The Effect of Increased Intraocular Pressure During Steep Trendelenburg Positioning in Robotic Prostatectomy and Hysterectomy on Structural and Functional Ocular Parameters

BACKGROUND

Robotic prostatectomy and robotic hysterectomy require steep Trendelenburg positioning. Many authors documented significant increases in intraocular pressure (IOP) during steep Trendelenburg. However, the long-term biological effect of a significant increase in IOP on the structural and functional ocular system is unknown. This study examines the effect of a significant increase in IOP on the visual acuity, retinal nerve fiber layer thickness (RNFLT), and ganglion cell complex (GCC) thickness in 52 patients without preexisting ocular disease of both genders before and 3 months after their procedures.

METHODS

This was a prospective cohort study. The total number of patients included was 56, then 3 females and 1 male case were excluded, totaling 28 robotic hysterectomies and 24 robotic prostatectomies were performed. Patients underwent complete eye examination before the procedure and 3 months after, measuring the main outcome of RNFLT and the secondary outcomes of GCC thickness, foveal threshold (FT), mean deviation (MD), and pattern standard deviation (PSD). These outcomes were analyzed using linear mixed-effects models. On the day of surgery, we examined the IOP after induction of anesthesia, at the end of steep Trendelenburg, and in the recovery room.

RESULTS

There were significant differences in IOP values at the end of steep Trendelenburg versus after induction and 45-60 minutes post-awakening (P < .001 for both groups). No difference between IOP 45 and 60 minutes post-awakening and IOP after induction was observed in either group. The highest IOPs occurred at the end of the steep Trendelenburg time point for both groups. The mean duration of steep Trendelenburg in robotic prostatectomy was 184.6 minutes (standard deviation [SD] = 30.8), while the mean duration in robotic hysterectomy was 123.0 minutes (SD = 29.8). All ophthalmologic examinations were normal preoperatively and 3 months postoperatively. The ocular parameters in the retina and optic disk did not differ significantly before surgery and 3 months after.

CONCLUSIONS

There is a significant increase in IOP during steep Trendelenburg positioning. There was no significant difference in the ocular parameters examined 3 months after the procedure in this cohort.