Effect of Oxycodone Combined With Dexmedetomidine for Intravenous Patient-Controlled Analgesia After Video-Assisted Thoracoscopic Lobectomy

Effect of dexmedetomidine on postoperative nausea and vomiting in female patients undergoing radical thoracoscopic lung cancer resection

Introduction: Postoperative nausea and vomiting (PONV) is a prevalent postsurgical complication. The objective of our study was to compare the effect of different doses of dexmedetomidine on PONV in female patients undergoing radical thoracoscopic lung cancer resection. Methods: A total of 164 female patients undergoing elective thoracoscopic radical lung cancer surgery were enrolled and assigned to one of four groups. Patients received 0.2 μg/kg/h, 0.4 μg/kg/h, 0.8 μg/kg/h dexmedetomidine and normal saline in the Dex1, Dex2, Dex3 and Control groups, respectively. The primary outcome was the incidence of PONV during 48 h postoperatively. The second outcomes included the incidence of PONV and postoperative vomiting (POV) at four time points postoperatively (T1: PACU retention period; T2: PACU discharge to postoperative 12 h; T3: postoperative 12 h-postoperative 24 h; T4: postoperative 24 h-postoperative 48 h), the area under the curve of PONV grade (PONVAUC), PONV grade, POV grade and other postoperative recovery indicators. Results: The incidence of PONV differed among the four groups. The Dex2 group (29.27%) was lower than that in the Dex1 group (61.90%) and Control group (72.50%). The incidence of PONV at T2 in the Dex1 group (11.90%) and Dex2 group (9.76%) was lower than that in the Control group (42.50%). The incidence of PONV at T3 in the Dex2 group (29.27%) was lower than that in the Dex1 group (61.90%) and Control group (62.50%). The PONVAUC was lower in the Dex2 group than in the Control group. The incidence of POV at T3 in the Dex2 and Dex3 groups was lower than that in the Control group. The consumption of remifentanil, norepinephrine, PACU dwell time, VAS scores, postoperative PCA press frequency, and the time for the first postoperative oral intake were different among the four groups. The regression model shows that the Dex2 group is a protective factor for PONV. Conclusion: Dexmedetomidine can reduce the incidence of PONV and accelerate postoperative recovery in female patients undergoing radical thoracoscopic lung cancer resection. Compared with the other two dosages, 0.4 μg/kg/h dexmedetomidine is preferable. Clinical Trial Registration: chictr.org.cn, identifier ChiCTR2300071831.

Paravertebral vs Epidural Anesthesia for Video-assisted Thoracoscopic Surgery: A Randomized Trial

BACKGROUND

The choice of postoperative pain management for patients who experience moderate to severe acute pain after thoracoscopic surgery is debatable. This study aimed to determine whether paravertebral block (PVB) provides more benefits than thoracic epidural analgesia (TEA) for thoracoscopic surgery.

METHODS

From February 2020 to April 2022, patients without chronic pain who were scheduled to undergo thoracoscopic surgery were randomly assigned to the PVB group or the TEA group. The visual analogue scale score was used to measure the degree of pain when the patients were at rest or coughing.

RESULTS

In total, 176 eligible patients were enrolled in this study. No significant difference in the visual analogue scale score was found between the 2 groups at rest (P = .395) or with coughing (P = .157). Additionally, there was no significant difference in the average pain score between these 2 states (P = .221). The median time for catheter placement in the PVB group was 5 minutes, which was shorter than that (14 minutes) in the TEA group (P < .001). Moreover, the catheter placement failure rate in the PVB group was lower than that in the TEA group (P = .038). The incidence of hypotension (P = .016) and urinary retention (P = .006) in the PVB group was lower than that in the TEA group.

CONCLUSIONS

PVB can provide pain relief that is similar to that of TEA but with no additional puncture pain, a shorter catheter placement time, and fewer side effects in patients undergoing video-assisted thoracoscopic surgery.

Comparison of erector spinae plane block with paravertebral block for thoracoscopic surgery: a meta-analysis of randomized controlled trials

INTRODUCTION

The efficacy of erector spinae plane block versus paravertebral block for thoracoscopic surgery remains controversial. We conduct a systematic review and meta-analysis to explore the impact of erector spinae plane block versus paravertebral block on thoracoscopic surgery.

METHODS

We have searched PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through March 2022 for randomized controlled trials (RCTs) assessing the effect of erector spinae plane block versus paravertebral block on thoracoscopic surgery. This meta-analysis is performed using the random-effect model.

RESULTS

Seven RCTs are included in the meta-analysis. Overall, compared with erector spinae plane block for thoracoscopic surgery, paravertebral block results in significantly reduced pain scores at 12 h (SMD = 1.12; 95% CI 0.42 to 1.81; P = 0.002) and postoperative anesthesia consumption (SMD = 1.27; 95% CI 0.30 to 2.23; P = 0.01), but these two groups have similar pain scores at 1-2 h (SMD = 1.01; 95% CI - 0.13 to 2.15; P 0.08) and 4-6 h (SMD = 0.33; 95% CI - 0.16 to 0.81; P = 0.19), as well as incidence of nausea and vomiting (OR 0.93; 95% CI 0.38 to 2.29; P = 0.88).

CONCLUSIONS

Paravertebral block may be better for the pain relief after thoracoscopic surgery than erector spinae plane block.

The Effect of Dexmedetomidine on the Mini-Cog Score and High-Mobility Group Box 1 Levels in Elderly Patients with Postoperative Neurocognitive Disorders Undergoing Orthopedic Surgery

Dexmedetomidine prevents postoperative cognitive dysfunction by inhibiting high-mobility group box 1 (HMGB1), which acts as an inflammatory marker. This study investigated the HMGB1 levels and the cognitive function using a Mini-Cog© score in elderly patients undergoing orthopedic surgery with dexmedetomidine infusion. In total, 128 patients aged ≥ 65 years were analyzed. The patients received saline in the control group and dexmedetomidine in the dexmedetomidine group until the end of surgery. Blood sampling and the Mini-Cog© test were performed before the surgery and on postoperative days 1 and 3. The primary outcomes were the effect of dexmedetomidine on the HMGB1 levels and the Mini-Cog© score in terms of postoperative cognitive function. The Mini-Cog© score over time differed significantly between the groups (p = 0.008), with an increase in the dexmedetomidine group. The postoperative HMGB1 levels increased over time in both groups; however, there was no significant difference between the groups (p = 0.969). The probability of perioperative neurocognitive disorders decreased by 0.48 times as the Mini-Cog© score on postoperative day 3 increased by 1 point. Intraoperative dexmedetomidine has shown an increase in the postoperative Mini-Cog© score. Thus, the Mini-Cog© score is a potential tool for evaluating cognitive function in elderly patients.

Comparative Efficacy of Adjuvant Nonopioid Analgesia in Adult Cardiac Surgical Patients: A Network Meta-Analysis

OBJECTIVES

To compare the relative efficacy of adjuvant nonopioid analgesic regimens in adult cardiac surgical patients.

DESIGN

This frequentist, random-effects network meta-analysis (NMA) was prospectively registered on PROSPERO (CRD42021282913) and conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analyses for Network Meta-Analyses (PRISMA-NMA). The risk of bias (RoB) and confidence of evidence were assessed by RoB 2 and Confidence in Network Meta-Analysis, respectively. Relevant databases were searched from inception to October 9, 2021.

SETTING

A total of 124 (N = 26,257) randomized controlled trials were included, of which 110 were analyzed.

PARTICIPANTS

Trials enrolling adults (≥18 years of age) undergoing cardiac surgery that compared nonopioid analgesics against other nonopioid analgesics, placebo, or no additional treatment, as adjuvants to standard analgesic management, and reported at least 1 of the outcomes of interest.

MEASUREMENT AND MAIN RESULTS

Outcomes of interest included resting postoperative pain scores at 24 hours. Compared with standard care and/or placebo, pain scores were reduced significantly by 10 different regimens, including acetaminophen (N = 176; mean difference [MD] -0.66 points, 95% CI -1.16 to -0.15 points; high confidence), magnesium (N = 323; -0.05 points, 95% CI -0.07 to -0.02 points; high confidence), gabapentin (N = 96; MD -0.40 points, 95% CI -0.71 to -0.09; moderate confidence), and clonidine (N = 64; MD v0.38 points, 95% CI -0.73 to v0.04 points; moderate confidence). Indomethacin, diclofenac, magnesium, and gabapentin significantly reduced 24-hour opioid consumption. Four regimens significantly decreased the intensive care unit length of stay. Hydrocortisone, dexmedetomidine, and clonidine significantly decreased the duration of mechanical ventilation. Magnesium decreased, while methylprednisolone significantly increased, the risk of myocardial infarction.

CONCLUSIONS

Given the increasing emphasis on enhanced recovery after surgery(ERAS) protocols and the eventual goal of limiting opiate prescriptions postoperatively, the authors' data suggested far greater use of nonopioid adjuncts to minimize pain and enhance recovery following cardiac surgery.

Efficacy and safety evaluation of dexmedetomidine for postoperative patient controlled intravenous analgesia: A systematic review and meta-analysis

Objective: To investigate the efficacy and safety of dexmedetomidine (DEX) for postoperative patient controlled intravenous analgesia (PCIA). Measurements: Two investigators independently searched Pubmed, Embase, Scopus, Cochrane Library and CBM for randomized controlled trials of DEX for PCIA. Main results: Thirty-seven studies with a total of 5,409 patients were included in this meta-analysis. Compared with analgesics alone, DEX for PCIA reduced pain score at 24 h [mean difference (MD) = -0.70; 95% confidence interval (CI): -0.85, -0.54; p < 0.00001, I ² = 90%] and 48 h postoperatively (MD = -0.43; 95% CI: -0.52, -0.34; p < 0.00001, I ² = 96%). Moreover, DEX reduced analgesics consumption during the first 24 h [standardized mean difference (SMD) = -0.25; 95% CI: -0.34, -0.16; p < 0.00001, I ² = 91%] and the number of resuscitation analgesics administered [odds ratio (OR) = 0.54; 95% CI: 0.44, 0.66; p < 0.00001, I ² = 72%]. Furthermore, DEX improved patient satisfaction (OR = 3.55; 95% CI: 2.36, 5.35; p < 0.00001, I ² = 60%), and reduced incidence of side effects, such as postoperative nausea and vomiting (PONV) (OR = 0.47; 95% CI: 0.39, 0.57; p < 0.00001, I ² = 59%) and pruritus after surgery (OR = 0.45; 95% CI: 0.30, 0.68; p = 0.0001, I ² = 0%). Besides, DEX attenuates inflammatory cytokine levels, such as IL-6 (MD = -5.73; 95% CI: -8.34, -3.12; p < 0.00001, I ² = 91%) and TNF-α (MD = -0.63; 95% CI: -0.76, -0.50; p < 0.00001, I ² = 89%). Finally, DEX increased the risk of bradycardia (OR = 1.66; 95% CI: 1.12, 2.45; p = 0.01, I ² = 15%), but the complication of hypotension did not differ between the two groups (OR = 1.30; 95% CI: 0.84, 2.04; p = 0.25, I ² = 0%). Conclusion: DEX is used for postoperative PCIA analgesia, which can significantly improve the analgesic effect, effectively control postoperative inflammatory response, reduce the dosage and adverse reactions of analgesics, and improve postoperative patient satisfaction. Of course, the impact of the immunosuppressive effect of DEX on the prognosis of patients needs further study. Systematic review registration: CRD42022340933, https://www.crd.york.ac.uk/prospero/.

Application Effect of Dexmedetomidine and Dezocine in Patients Undergoing Lung Cancer Surgery under General Anesthesia and Analysis of Their Roles in Recovery Time and Cognitive Function

Objective. To explore the application influence of dexmedetomidine (DEX) and dezocine in patients undergoing lung cancer surgery under general anesthesia and analysis of their roles in recovery time and cognitive function. Methods. A total of 120 patients who accepted thoracoscopic pulmonary wedge resection in our hospital from November 2021 to April 2022 were selected and randomly divided into group A ( $n$  =60) and group B ( $n$  =60). DEX combined with dezocine-assisted anesthesia was performed to group A, and the equal dose of normal saline was administered to group B, so as to compare their inflammatory influence level, brain function, arterial blood gas index, and cognitive function. Results. Compared with group B, group A obtained significantly lower intraoperative and postoperative inflammatory factor levels ( $P<0.001$ ), better postoperative brain function and arterial blood gas index ( $P<0.001$ ), and lower Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) scores after surgery ( $P<0.001$ ). Combining DEX with dezocine-assisted general anesthesia can improve the inflammatory factors level of patients undergoing lung cancer surgery and maintain their brain function and oxygen saturation, so that they have better postoperative cognitive function. Therefore, such anesthesia modality should be promoted in practice.

Effect of dexmedetomidine supplementation for thoracoscopic surgery: a meta-analysis of randomized controlled trials

Introduction

The efficacy of dexmedetomidine supplementation for thoracoscopic surgery remains controversial. We conduct a systematic review and meta-analysis to explore the impact of dexmedetomidine for thoracoscopic surgery.

Methods

We have searched PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through September 2020 for randomized controlled trials (RCTs) assessing the effect of dexmedetomidine supplementation on thoracoscopic surgery. This meta-analysis is performed using the random-effect model.

Results

Six RCTs involving 510 patients are included in the meta-analysis. Overall, compared with control group for thoracoscopic surgery, dexmedetomidine supplementation results in significantly reduced pain scores (SMD = − 1.50; 95% CI = − 2.63–− 0.37; P = 0.009), anesthetic consumption (SMD = − 3.91; 95% CI = − 6.76–− 1.05; P = 0.007), mean heart rate (SMD = − 0.41; 95% CI = − 0.65–− 0.18; P = 0.0007), and the risk ratio (RR) of ICU stay (RR = 0.39; 95% CI = 0.19–0.80; P = 0.01), but showed no obvious effect on mean blood pressure (SMD = − 0.07; 95% CI = − 0.45–0.31; P = 0.72) or hospital stay (SMD = − 0.61; 95% CI = − 1.30–0.08; P = 0.08).

Conclusions

Dexmedetomidine supplementation can substantially improve the analgesic efficacy for thoracoscopic surgery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-022-01803-z.

The Effect of Dexmedetomidine on Postoperative Nausea and Vomiting in Patients Undergoing Thoracic Surgery-A Meta-Analysis of a Randomized Controlled Trial

Background

Dexmedetomidine reduces the occurrence of postoperative nausea and vomiting (PONV); however, the effect of dexmedetomidine on PONV in patients undergoing thoracic surgery remains inconclusive. In addition, the effect of different dexmedetomidine application methods, anesthetics, and surgical procedures on the effects of dexmedetomidine on PONV remains unclear. Therefore, the purpose of this meta-analysis was to study the effect of dexmedetomidine on PONV in patients undergoing thoracic surgery.

Methods

Electronic databases were searched to identify randomized controlled trials studying the effects of dexmedetomidine on nausea and vomiting after thoracic surgery. In total, 12 articles that met the inclusion criteria were obtained. The primary outcome of this comprehensive analysis was the incidence of PONV; secondary outcomes included the incidence of postoperative nausea, the incidence of postoperative vomiting, postoperative visual analog score (VAS), the amount of intraoperative sufentanil, and the number of times postoperative salvage analgesia was administered.

Results

Twelve trials involving 905 participants undergoing thoracic surgery were included. Compared with placebo, dexmedetomidine reduced the incidence of nausea and vomiting after thoracic surgery [12 trials; 905 participants; risk ratio (RR) = 0.32; 95% CI (0.23, 0.44); P < 0.00001, I2 = 0%]. The subgroup analysis revealed that dexmedetomidine reduces the occurrence of PONV in both thoracotomy and thoracoscopic surgery. In addition, both intravenous and local infusion of dexmedetomidine can reduce the occurrence of PONV, and intravenous or inhaled anesthetics do not affect the effect of dexmedetomidine on reducing PONV. Dexmedetomidine can reduce the postoperative resting VAS of patients, and no statistically significant differences in the amount of intraoperative sufentanil and the number of salvage analgesia procedures after surgery were noted.

Conclusion

Compared with placebo, dexmedetomidine can reduce the occurrence of PONV in patients undergoing thoracic surgery, and this effect is not affected by the method of dexmedetomidine administration, use of minimally invasive surgery, and use of a combination of intravenous or inhalation anesthetics.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/#myprospero, PROSPERO, identifier: CRD42021269358.

PROSPECT guidelines for video-assisted thoracoscopic surgery: a systematic review and procedure-specific postoperative pain management recommendations

Video‐assisted thoracoscopic surgery has become increasingly popular due to faster recovery times and reduced postoperative pain compared with thoracotomy. However, analgesic regimens for video‐assisted thoracoscopic surgery vary significantly. The goal of this systematic review was to evaluate the available literature and develop recommendations for optimal pain management after video‐assisted thoracoscopic surgery. A systematic review was undertaken using procedure‐specific postoperative pain management (PROSPECT) methodology. Randomised controlled trials published in the English language, between January 2010 and January 2021 assessing the effect of analgesic, anaesthetic or surgical interventions were identified. We retrieved 1070 studies of which 69 randomised controlled trials and two reviews met inclusion criteria. We recommend the administration of basic analgesia including paracetamol and non‐steroidal anti‐inflammatory drugs or cyclo‐oxygenase‐2‐specific inhibitors pre‐operatively or intra‐operatively and continued postoperatively. Intra‐operative intravenous dexmedetomidine infusion may be used, specifically when basic analgesia and regional analgesic techniques could not be given. In addition, a paravertebral block or erector spinae plane block is recommended as a first‐choice option. A serratus anterior plane block could also be administered as a second‐choice option. Opioids should be reserved as rescue analgesics in the postoperative period.

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.

Effect of Oxycodone hydrochloride combined with Dexmedetomidine on quality of recovery and stress response after general anesthesia in patients who had Laparoscopic Cholecystectomy

OBJECTIVE

To explore the effect of oxycodone hydrochloride combined with dexmedetomidine on the recovery quality and stress response during anesthesia in patients undergoing laparoscopic cholecystectomy (LC).

METHODS

Ninety patients who had LC in Cangzhou Hospital of Integrated TCM-WM of Hebei from December 2016 to December 2019 were selected and divided into dexmedetomidine group (DEX group), oxycodone hydrochloride group (Q group), dexmedetomidine + oxycodone hydrochloride group (DQ group) by a random number table method, with 30 cases in each group. At the time before anesthesia induction (T0), and immediately (T1), 1 min (T2), 10 min (T3) and 30 minutes (T4) after extubation, the general vital signs of three groups were observed, and plasma cortisol (COR), epinephrine (E), norepinephrine (NE) and blood glucose (GLU) were measured. The spontaneous respiration recovery time, wake-up time, VAS score of each time period after extubation, extubation quality score, and adverse event rate were recorded.

RESULTS

The vital signs at each time point of extubation, recovery time of spontaneous respiration, wake-up time, and extubation quality of DQ group were better than those of DEX group and Q group (P<0.05). The incidence of agitation, VAS score at T2 and T3, plasma concentrations of Cor, E, NE and Glu at T1, T3 and T4 in DQ group were significantly lower than those in Q group and DEX group (P<0.05).

CONCLUSION

Oxycodone hydrochloride combined with dexmedetomidine can improve the recovery quality and reduce stress response in patients with LC after anesthesia, and can be safely used in patients with LC.

Dexmedetomidine as an Analgesic Agent with Neuroprotective Properties: Experimental and Clinical Aspects

Dexmedetomidine (Dexdor or Precedex®) is considered as a sedative agent which is widely used as an adjuvant in general anesthesia and critical care practice. There is extensive evidence indicating its neuroprotective properties especially in various ischemic and hemorrhagic brain injury models of animals. Clinical trials have shown that dexmedetomidine (DEX) can improve the outcome of intensive care unit (ICU) patients. Also, DEX is appropriate as a non-opioid analgesic therapy whenever minimizing opioid-related side effects is necessary. The present article reviews the recent advances in the use of DEX as a neuroprotective agent in both animal and human studies including newest findings about the mechanism of the drug as well as analgesic efficacy of this drug at all perioperative stages. In spite of the beneficial effects of the drug on the nervous system, there are potential adverse effects, such as hypotension and bradycardia, which can be treated pharmacologically and must be taken into consideration by clinicians.

Dexmedetomidine combined with sufentanil and dezocine-based patient-controlled intravenous analgesia increases female patients' global satisfaction degree after thoracoscopic surgery

Background

There are no studies on the use of dexmedetomidine combined with sufentanil and dezocine-based patient-controlled intravenous analgesia (PCIA) in females undergoing thoracic surgery. We postulate that introducing dexmedetomidine to a combination of dezocine-based PCA drugs and sufentanil will increase female patients’ global satisfaction degree.

Methods

One hundred fifty-two female patients with physical classification type I or II according to the American Society of Anesthesiologists undergoing thoracoscopic surgery were arbitrarily classified into two categories, either receiving sufentanil and dezocine-based PCIA (group C) or incorporating dexmedetomidine with sufentanil and dezocine-based PCIA (group D). The patients’ global satisfaction degree, postoperative nausea and vomiting (PONV), PCA bolus, rescue analgesia requirements, drug-related adverse effects, rest and coughing visual analogue scale (VAS) ratings, and Ramsay sedation scores (RSS) were measured at 6, 12, 24, 36 and 48 h after surgery.

Results

Compared with the C group, the patient satisfaction degree was significantly higher; pain scores at rest and coughing were significantly different at 6, 12, 24, 36 and 48 h postoperatively; less rescue analgesia and PCA bolus were required; and a lower incidence of PONV was found in the D group. There were non-significant trends for the sedation scores and drug-related adverse effects in both groups.

Conclusions

Dexmedetomidine combined with sufentanil and dezocine increased female patients’ global satisfaction degree after thoracoscopic surgery. This effect could be linked to the improvement in postoperative analgesia and reduction in postoperative nausea and vomiting; the combined treatment did not increase drug-related adverse effects in female patients.

Trial registration

Chinese Clinical Trial Registry number, ChiCTR2000030429. Registered on March 1, 2020.

Dexmedetomidine with sufentanil in intravenous patient-controlled analgesia for relief from postoperative pain, inflammation and delirium after esophageal cancer surgery

BACKGROUND AND AIMS

Postoperative pain can cause serious adverse reactions that severely affect postoperative outcome. The present study evaluated the effect of dexmedetomidine (DEX) added to sufentanil in intravenous patient-controlled analgesia (PCA) on the relief of pain and inflammatory responses during postoperative recovery of patients undergoing a combined thoracoscopic-laparoscopic esophagectomy (TLE).

METHODS

Sixty patients undergoing TLE were randomly allocated to receive 1 μg/ml of sufentanil alone (Group S) or 1 μg/ml of sufentanil plus 2.5 μg/ml of DEX (Group D) for postoperative intravenous (IV) PCA. Postoperative pain relief, cumulative PCA requirements, inflammatory marker levels, delirium and recovery were assessed.

RESULTS

A joint DEX and sufentanil regimen significantly reduced the area under the curve of numerical rating scores for pain at rest (NRSR) and coughing (NRSC) at 1-48 h postoperatively (P = 0.000) that were associated with lower PCA-delivered cumulative sufentanil consumption and less PCA frequency until 48 h postoperatively (P < 0.05 and P < 0.0001, respectively). The simultaneous administration of DEX and sufentanil significantly reduced plasma IL-6 and TNF-α concentrations and increased IL-10 level (P < 0.0001, P = 0.0003 and P = 0.0345, respectively), accompanied by better postoperative delirium categories and health statuses of patients (P = 0.024 and P < 0.05, respectively). There was no hypotension, bradycardia, respiratory depression or oversedation in Group D.

CONCLUSION

Patients receiving DEX in addition to IV PCA sufentanil for TLE exhibited better postoperative analgesia, fewer inflammatory responses and lower postoperative delirium categories and better health statuses.

Midazolam Dose Optimization in Critically Ill Pediatric Patients With Acute Respiratory Failure: A Population Pharmacokinetic-Pharmacogenomic Study

OBJECTIVES

To develop a pharmacokinetic-pharmacogenomic population model of midazolam in critically ill children with primary respiratory failure.

DESIGN

Prospective pharmacokinetic-pharmacogenomic observational study.

SETTING

Thirteen PICUs across the United States.

PATIENTS

Pediatric subjects mechanically ventilated for acute respiratory failure, weight greater than or equal to 7 kg, receiving morphine and/or midazolam continuous infusions.

INTERVENTIONS

Serial blood sampling for drug quantification and a single blood collection for genomic evaluation.

MEASUREMENTS AND MAIN RESULTS

Concentrations of midazolam, the 1' (1`-hydroxymidazolam metabolite) and 4' (4`-hydroxymidazolam metabolite) hydroxyl, and the 1' and 4' glucuronide metabolites were measured. Subjects were genotyped using the Illumina HumanOmniExpress genome-wide single nucleotide polymorphism chip. Nonlinear mixed effects modeling was performed to develop the pharmacokinetic-pharmacogenomic model. Body weight, age, hepatic and renal functions, and the UGT2B7 rs62298861 polymorphism are relevant predictors of midazolam pharmacokinetic variables. The estimated midazolam clearance was 0.61 L/min/70kg. Time to reach 50% complete mature midazolam and 1`-hydroxymidazolam metabolite/4`-hydroxymidazolam metabolite clearances was 1.0 and 0.97 years postmenstrual age. The final model suggested a decrease in midazolam clearance with increase in alanine transaminase and a lower clearance of the glucuronide metabolites with a renal dysfunction. In the pharmacogenomic analysis, rs62298861 and rs28365062 in the UGT2B7 gene were in high linkage disequilibrium. Minor alleles were associated with a higher 1`-hydroxymidazolam metabolite clearance in Caucasians. In the pharmacokinetic-pharmacogenomic model, clearance was expected to increase by 10% in heterozygous and 20% in homozygous for the minor allele with respect to homozygous for the major allele.

CONCLUSIONS

This work leveraged available knowledge on nonheritable and heritable factors affecting midazolam pharmacokinetic in pediatric subjects with primary respiratory failure requiring mechanical ventilation, providing the basis for a future implementation of an individual-based approach to sedation.

Intramuscular stimulation as a novel alternative method of pain management after thoracic surgery

Background

The purpose of this study was to determine whether electrical twitch-obtaining intramuscular stimulation (ETOIMS) can be an alternative to intravenous patient-controlled analgesia (IV-PCA) for postoperative pain management in pneumothorax patients undergoing single-port video-assisted thoracoscopic surgery (VATS).

Methods

This preliminary prospective randomized study was conducted between March 2017 and July 2017. A total of 26 patients undergoing single-port VATS were randomly assigned to two groups: the ETOIMS group (n=12), which received intramuscular stimulation prior to chest tube insertion toward the end of procedure, and the IV-PCA group (n=14), which received continuous infusion of fentanyl with a basal rate of 10 µg/mL/h. To measure postoperative pain, visual analogue scale (VAS; range, 0-10) was used as the primary endpoint.

Results

Baseline characteristics were not different between the two groups. According to the linear mixed model, there was statistical difference in the serial VAS score between the two groups (P=0.007). The ETOIMS group showed a significantly lower VAS score compared with the IV-PCA group, especially at postoperatively hour 8, day 1, and day 2.

Conclusions

We showed that ETOIMS may be a safe, effective, and simple alternative for pain management after single-port VATS.

The efficacy of thoracic paravertebral block for thoracoscopic surgery: A meta-analysis of randomized controlled trials

BACKGROUND

The efficacy of thoracic paravertebral block for thoracoscopic surgery remains controversial. We conduct a systematic review and meta-analysis to explore the impact of thoracic paravertebral block on thoracoscopic surgery.

METHODS

We search PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through August 2018 for randomized controlled trials (RCTs) assessing the effect of thoracic paravertebral block on thoracoscopic surgery. This meta-analysis is performed using the random-effect model.

RESULTS

Six RCTs involving 300 patients are included in the meta-analysis. Overall, compared with control group for thoracoscopic surgery, thoracic paravertebral block results in significantly reduced pain scores within 6 hours (Std. MD = -2.15; 95% CI = -3.67 to -0.62; P = .006), postoperative anesthesia consumption during 48 hours (Std. MD = -1.81; 95% CI = -3.05 to -0.58; P = .004), and hospital stay (Std. MD = -1.19; 95% CI = -2.13 to -0.26; P = .01), but has no important impact on pain scores at 24 hours (Std. MD = -1.10; 95% CI = -2.77-0.57; P = .20), and 48 hours (Std. MD = -1.25; 95% CI = -2.86-0.36; P = .13).

CONCLUSIONS

Thoracic paravertebral block can substantially enhance pain management for thoracoscopic surgery.

Patient-controlled paravertebral analgesia for video-assisted thoracoscopic surgery lobectomy

Background

Paravertebral block has been proven to be an efficient method to provide post-thoracotomy pain management. This study aimed to compare patient-controlled paravertebral analgesia (PCPA) and intravenous patient-controlled analgesia (IVPCA) in terms of analgesic efficiency, respiratory function, and adverse effects after video-assisted thoracoscopic surgery (VATS) lobectomy.

Patients and methods

The prospective randomized trial study was carried out on 60 patients who underwent VATS lobectomy (randomly allocated 30 patients in each group). In the PCPA group, an initial dose of 0.3 mL/kg of 0.125% bupivacaine with fentanyl 2 µg/mL was administered, followed by a 3 mL/h continuous infusion with patient-controlled analgesia (2 mL bolus, 10-minute lockout interval, 25 mL/4 h limit). In the IVPCA group with morphine 1 mg/mL solution, an infusion device was programmed to deliver a 1.0 mL demand bolus with no basal infusion rate, with a 10-minute lockout interval and a maximum of 20 mL/4 h period. Postoperative pain was assessed by visual analog scale at rest and on coughing. Arterial blood gas and spirometry were monitored and recorded for the first 3 postoperative days. Side effects to include were also recorded.

Results

The PCPA group had statistically significant lower pain scores (P<0.0001) at rest at all times. Lower pain scores on coughing were statistically significant in PCPA group in the first 4 hours. Postoperative spirometry showed that both the groups had comparable recovery trajectories for their pulmonary function. Arterial blood gas analysis showed pH and PaCO₂ were in a normal range in both the groups. The incidence of headache was higher in the IVPCA group (13.3% vs 0%; P=0.038).

Conclusion

PCPA effectively managed pain after VATS lobectomy, with lower pain scores, similar respiratory function, and fewer side effects than standard IVPCA treatment.

Use of Dexmedetomidine in Cardiothoracic and Vascular Anesthesia

Dexmedetomidine is a highly selective α₂-adrenergic agonist with analgesic and sedative properties. In the United States, the Food and Drug Administration approved the use of the drug for short-lasting sedation (24 h) in intensive care units (ICUs) in patients undergoing mechanical ventilation and endotracheal intubation. In October 2008, the Food and Drug Administration extended use of the drug for the sedation of nonintubated patients before and during surgical and nonsurgical procedures. In the European Union, the European Medicine Agency approved the use of dexmedetomidine in September 2011 with a single recognized indication: ICU adult patients requiring mild sedation and awakening in response to verbal stimulus. At present, the use of dexmedetomidine for sedation outside the ICU remains an off-label indication. The benefits of dexmedetomidine in critically ill patients and in cardiac, electrophysiology-related, vascular, and thoracic procedures are discussed.

Dexmedetomidine in perioperative acute pain management: a non-opioid adjuvant analgesic

Many nociceptive, inflammatory, and neuropathic pathways contribute to perioperative pain. Although opioids have long been a mainstay for perioperative analgesia, other non-opioid therapies, and dexmedetomidine, in particular, have been increasingly used as part of a multimodal analgesic regimen to provide improved pain control while minimizing opioid-related side effects. This article reviews the evidence supporting the preoperative, intraoperative, and postoperative efficacy of dexmedetomidine as an adjuvant, and the efficacy of intravenous, spinal canal, and nerve block analgesia with dexmedetomidine for perioperative acute pain treatment. While there have not been any large-scale clinical trials conducted, the current body of evidence suggests that dexmedetomidine is suitable for use as an adjuvant analgesic at all perioperative stages. However, there are potential adverse effects, such as hypotension and bradycardia, which must be taken into consideration by clinicians.