Evaluation of the Advantageous Anesthetic Properties of Dexmedetomidine Used as Hypotensive Agent Compared With Nitroglycerin in Orthognathic Surgery

Perioperative care in orthognathic surgery - A systematic review and meta-analysis for enhanced recovery after surgery

The aim of this study was to determine whether implementing ERAS (Enhanced Recovery After Surgery) elements/protocols improves outcomes in orthognathic surgery (OGS) compared to conventional care. To achieve this, ERAS-specific perioperative elements were identified and literature on ERAS for OGS was systematically reviewed. Using PRISMA methodology and GRADE approach, 44 studies with 49 perioperative care elements (13 pre-, 15 intra-, 21 postoperative) were analyzed. While 39 studies focused on single elements, only five presented multimodal protocols, with three related to ERAS. Preoperative elements included antimicrobial and steroid prophylaxis and prevention of postoperative nausea and vomiting. Intraoperative aspects, especially anesthesiological, showed high evidence. Outcome parameters were heterogeneous: complications and postoperative pain were well-investigated with high evidence, while length of stay (LOS) and patient satisfaction received low to medium evidence. ICU LOS, healthcare costs, and readmission rates were underreported. The meta-analysis revealed significant results for pain reduction and trends towards fewer complications and shorter LOS in the ERAS group. Overall, ERAS protocols are not established in OMFS, particularly OGS. Further research is needed in pre- and postoperative care and standardized multimodal analgesia. The next step should be developing a comprehensive OGS protocol through a consensus conference and implementing it in clinical practice.

Optimizing drug regimens and supplementation in orthognathic surgery: A comprehensive and practical guide

OBJECTIVE

This study aimed to comprehensively review the literature and provide a practical guide for optimizing drug regimens and supplementation related to orthognathic surgery.

METHODS

The authors conducted a thorough review of the existing literature, following the PRISMA-ScR guidelines. Various types of studies except case reports and reviews were included. The study applied specific inclusion criteria, focusing on perioperative and/or postoperative drugs, medications, or supplementation related to orthognathic surgery.

RESULTS

This guide included 78 studies on various medications in orthognathic surgery. It encompasses clinical trials, cohort studies, cross-sectional studies, prospective and retrospective studies. The topics covered include antibiotics, analgesics, corticosteroids, antiemetics, hemostatic agents, local anesthetics, herbal medicine, and botulinum toxin. Pain and edema control involved specific medications, while local anesthesia utilized ropivacaine and bupivacaine. The guide also discusses mineral and vitamin supplementation. The effectiveness of hemostatic agents and antiemetics was highlighted.

CONCLUSION

Pain management, reduced swelling, enhanced wound healing, and faster recovery are among the advantages. In addition to the standard drugs and medications, the inclusion of vitamin and mineral supplements, tranexamic acid, postoperative anesthetic blocks, and preemptive antiemetics is anticipated to offer various benefits in orthognathic surgery, despite the limited available evidence.

The Beneficial Effect of Preoperative dexmedetomidine in controlling postoperative pain, nausea, and Vomiting After Orthognathic Surgery: A Triple-blind Randomized Clinical Trial

PURPOSE

Controlling postoperative pain and nausea (PONV) following orthognathic surgery can be challenging. The aim of the study was to assess the efficacy of dexmedetomidine (DEX) in reducing pain and preventing nausea and vomiting in subjects undergoing orthognathic surgery.

METHODS

The authors implemented a triple-blinded, randomized clinical trial. Healthy adults with class III jaw deformity scheduled for bimaxillary orthognathic surgery were included. Subjects were randomized to the DEX or placebo groups. The DEX group received premedication with DEX 1 μg/kg IV over 10 minutes followed by a maintenance dose (0.2 μg/kg/hour). while the placebo group received normal saline. The primary outcome variables were postoperative pain, postoperative nausea, and postoperative vomiting . Pain was assessed using a visual analog scale at 1, 3, 6, 12, 18, and 24 hours, postoperatively). Nausea and vomiting were recorded throughout the postoperative period. Statistical analysis was performed using χ², t test, and repeated measures ANOVA with a P value < .05 considered significant.

RESULTS

A total of 60 consecutive subjects with a mean age of 24.6 ± 3.5 years completed the study. There were 38 females (63.33%) and 22 males (36.66%). The mean visual analog scalewas significantly lower in the DEX group at all time-points (P < .05). There was a significantly greater demand for rescue analgesics in the placebo group compared to the DEX group (P = .01). Fourteen subjects (46.7%) in the placebo group and one subject (3.3%) in the DEX group reported nausea (P < .001). Postoperative vomiting was not observed in any of the subjects.

CONCLUSION

Premedication with DEX can be considered a viable treatment option for reducing postoperative pain and postoperative nausea after bimaxillary orthognathic surgery.

Comparison of Efficacy of Dexmedetomidine and Clonidine Infusion to Produce Hypotensive Anesthesia in Patients Undergoing Orthognathic Surgery: A Randomized Controlled Trial

PURPOSE

The purpose of the study was to compare the efficacy of dexmedetomidine (DEX) and clonidine (CLON) infusion to produce hypotensive anesthesia in patients undergoing orthognathic surgery.

MATERIAL AND METHODS

The investigators designed a randomized controlled trial on patients undergoing orthognathic surgery. Patients were randomized into 2 groups (DEX and CLON group). The DEX group patients received loading dose of 1 ug/kg DEX over 10 minutes followed by 0.2 to 0.5 ug/kg/hour as maintenance dose. Similarly, CLON group patients received 3 ug/kg loading dose followed by maintenance dose of 0.3 to 2 ug/kg/hour. Primary objectives were to compare the quality of surgical field, duration of surgery, amount of blood loss and secondary objectives were to compare total and rescue analgesia used, need for blood transfusion and associated adverse effects. The P value of <.05 was taken significant at confidence interval of 95%.

RESULTS

The study sample included 30 patients (15 in each group), (m:f = 1:1.1) requiring orthognathic surgery. Single jaw cases were 11 (DEX:CLON = 4:7) and bijaw cases were 19 (DEX:CLON = 11:8) in number. There was statistically insignificant difference in quality of surgical field between 2 groups (P = .15). Duration of surgery was 293.33 ± 58.75 and 247 ± 70.45 minutes in the DEX and the CLON group, respectively (P = .06). Blood loss was more in the DEX group (316.61 ± 147.19 mL) than the CLON group (263.33 ± 112.54 mL), (P = .71). Total drug used (P = .33) and rescue analgesia (P = .25) was less in the DEX group. Adverse effects were more in the CLON than the DEX group.

CONCLUSION

The results of the present study showed no significant difference between the 2 groups for any parameter. It can be concluded that both dexmedetomidine and clonidine are effective and safe in achieving controlled hypotension and safe operative field visibility.

Comparative Evaluation of IV Paracetamol Versus IV Dexmedetomidine in Inpatient Oral and Maxillofacial Surgery: A Double-Blinded Randomized Controlled Study

Purpose

Reconstructive surgeries following fractures in the maxillofacial region often involve considerable bone manipulation, and paracetamol is a commonly used analgesic medication in both intraoperative and postoperative periods. Dexmedetomidine, an alpha-2 adrenoceptor agonist, has both sedative and analgesic properties with minimal cardiorespiratory effects and has been used primarily for its sedative properties in oral and maxillofacial surgery.

Aims and Objectives

To compare the intraoperative analgesic requirements among patients undergoing oral and maxillofacial surgery who receive IV paracetamol versus IV dexmedetomidine. The time to requirement for the first postoperative analgesic dose and safety and adverse events of both medications were also assessed.

Patients and Methods

In total, 64 patients needing primary reconstructive surgery for facial fractures were recruited and divided into two groups for this double-blinded study. Patients were randomized to receive a preinduction dose of either IV paracetamol 1 g (Group P) or IV dexmedetomidine 1 µg/kg (Group D). Sedation scores (Ramsay sedation scale), maximal interincisal distance and pain scores at maximal mouth opening (visual analogue scale) were assessed in both groups just prior to and after the administration of the study drugs. After induction, Group P and Group D received a maintenance dose of normal saline and dexmedetomidine (0.5 µg/kg/h) during the intraoperative period, respectively. Standard noninvasive cardiorespiratory monitoring was done for the entire duration of surgery. Following extubation, postoperative pain scores and the time to request for first analgesic dose in either group were recorded.

Results

The time taken to perform the surgery was comparable in both groups. There was a significant difference between the groups in visual analogue scores and interincisal distance after the bolus dose (p < 0.05). Systolic and diastolic blood pressure was significantly lower in Group D at around 150 and 175 min of surgery. While the intraoperative fentanyl consumption was comparable in both groups, the time to request for the first analgesic dose in the postoperative period was significantly delayed in Group P (p < 0.05). No adverse cardiopulmonary events were observed in either group.

Conclusion

The intraoperative anesthetic and analgesic requirements and hemodynamic stability were comparable in IV paracetamol and dexmedetomidine groups. Dexmedetomidine did not confer any enhanced analgesia effect in the postoperative period. More research examining the role of dexmedetomidine for longer duration inpatient oral and maxillofacial surgery is needed.

Clinical Trial Number

http://ClinicalTrials.gov (No. CTRI/2017/08/009468).

omparative Evaluation of the Intranasal Spray Formulation of Midazolam and Dexmedetomidine in Patients Undergoing Surgical Removal of Impacted Mandibular Third Molars: A Split Mouth Prospective Study

Purpose

The purpose of this prospective randomized single blinded split mouth study was to conduct a comparative evaluation of the efficacy of intranasal atomised spray formulation of Dexmedetomidine with Midazolam in patients undergoing surgical removal of bilaterally impacted mandibular third molars.

Methods

This prospective study was conducted in twenty volunteers. Each volunteer underwent the surgical removal of an impacted mandibular third molar at two separate appointments at an interval of two weeks. The first third molar surgery was conducted using either intranasal Midazolam (Group M) or intranasal Dexmedetomidine (Group D). At the second appointment the surgical procedure was performed using the sedative agent not used at the first appointment. The primary testing outcome variables were Plasma oxygen saturation (SpO2), pulse and blood pressure and Modified Observer's Assessment of Alertness/Sedation (OAA/S) scale. These were recorded at predetermined intervals starting 10 min before the administration of local anaesthesia and continued up to 10 min after completion of the procedure. In addition surgeon's opinion regarding the patient cooperation, event amnesia, post operative nausea & vomiting were obtained.

Results

The sample composed of twenty patients (M = 9 and F = 11). There was statistically no significant difference between Group M and Group D with respect to mean SpO2. Minor differences were however noted at 20 and 30 min after sedation. There was no significant difference between the groups with respect to mean pulse rate, blood pressure, OAA/S, event amnesia, post operative nausea and vomiting and patient cooperation.

Conclusion

We conclude that Midazolam and Dexmedetomidine are equivalent and can be used in minor oral surgery with minimal complications. These drugs can be used intranasally using nasal atomization device in routine outpatient basis in otherwise normal healthy but anxious patients. All procedures must however be performed in the presence of an anaesthesiologist and with ready availability of emergency drugs and equipment.

Risks and benefits of pre-operative dexmedetomidine in oral and maxillofacial surgeries: a systematic review

INTRODUCTION

Oral and maxillofacial surgeries might induce anxiety and pain to the patients. Sedative agents are one of the best ways for eliminating such consequences. Dexmedetomidine (DEX) is a recent sedative agent which presents higher sedative quality with greater specificity than other drugs. The aim of present paper is to evaluate the risks and benefits of administrating DEX during oral and maxillofacial surgeries by reviewing high quality released articles. Areas covered: Searches on PubMed, Scopus and Web of Science databases were completed with focus on randomized controlled trials (RCT). Related articles, from 2000 to 2015, were selected based on inclusion criteria and quality assessments factors. Full texts of the selected articles were screened and their significant information were gathered for judgments. Expert opinion: 17 RCTs on a total of 765 patients were screened. Some of the difficulties during reviewing the articles were: different pharmacokinetic and pharmacodynamics of drugs when combined with DEX, different time spots and method of monitoring, including studies on both minor and major surgeries for better data collection. Recent researches are going to focus on application of DEX for in-office procedures because of its desirable properties. Nevertheless, the analgesic and amnesic features of DEX are still questionable.