Dexmedetomidine prevent postoperative nausea and vomiting on patients during general anesthesia: A PRISMA-compliant meta analysis of randomized controlled trials

Optimizing pediatric tonsillectomy outcomes with an opioid sparing anesthesia protocol: Learning and continuously improving with real-world data

INTRODUCTION

This quality improvement initiative is a continued pursuit to optimize outcomes by iteratively improving our opioid sparing anesthesia protocol for tonsillectomy with or without adenoidectomy at our pediatric ambulatory surgical center through data driven Plan-Do-Study-Act cycles.

METHODS

From 1/2015 through 12/2023, our standardized tonsillectomy protocol underwent nine procedure-specific perioperative Plan-Do-Study-Act cycles, three procedure-specific postoperative prescription Plan-Do-Study-Act cycles, and four general ambulatory surgical center enhanced recovery Plan-Do-Study-Act cycles. We analyzed data from the medical record using statistical process control charts. The primary outcome measure was the percent of patients requiring intravenous opioid in the post anesthesia care unit. Secondary outcomes included maximum post anesthesia care unit pain score, the percent of patients requiring treatment for nausea and/or vomiting in the post anesthesia care unit, and the number of postoperative opioid prescription dosages. Balancing measures were average post anesthesia care unit length of stay, percent of patients with prolonged Post Anesthesia Care Unit length of stay (>120 min), and 30-day reoperation rate.

RESULTS

A total of 5654 tonsillectomy with or without adenoidectomy cases were performed at our ambulatory surgical center from 2015 to 2023. The incidence of intravenous opioid administered in the post anesthesia care unit initially rose with opioid free anesthesia launch, but subsequently decreased below the target of 10%. Maximum post anesthesia care unit pain scores rose from mean 3.6 to 4.5, but subsequently returned to the baseline of 3.5, while the incidence of postoperative nausea and/or vomiting improved. The average post anesthesia care unit length of stay increased by 10 min with opioid free anesthesia; however, prolonged post anesthesia care unit stay and 30-day reoperation rates were unchanged.

CONCLUSIONS

The continued refinement of our opioid sparing anesthesia protocol has led to reduced perioperative and home opioid use, stable maximum post anesthesia care unit pain scores, and improved postoperative nausea and vomiting rates, with only a slight increase in mean post anesthesia care unit length of stay.

Dexmedetomidine in Palliative Care: A Versatile New Weapon Against Delirium and Pain-Systematic Review

Introduction: At the end of life, the prevalence of delirium and pain is high. Current therapy is not satisfactory. Dexmedetomidine could be useful in the control of delirium and pain but is not approved outside of intensive care setting. Our objectives are to evaluate existing evidence in the literature that assessed the efficacy of dexmedetomidine in pain and delirium control and its safety in palliative care patients outside intensive care units. This systematic review was prospectively registered with PROSPERO and included a risk of bias assessment. Methods: PubMed and SCOPUS were examined for literature published until 2023. Experimental, cohort, cross-sectional, case-control studies, and case series/reports were included if they evaluate the use of dexmedetomidine in delirium and/or pain management in hospitalized palliative care adult patients. Studies were excluded if they were carried out in intensive care units. Results: Of the initial 529 records, 14 were included. Although only two studies were randomized trials, most were small and only one had low risk of bias. In most case reports and in the two retrospective cohort studies, dexmedetomidine appears to be a better option for these symptoms, although differences were not significant in the randomized trials. Discussion: Dexmedetomidine seems to be a promising option for refractory pain and delirium and may contribute to a reduction in opioid administration to control pain. This is the first systematic review of dexmedetomidine in palliative care. Quality evidence is limited, but clinical properties of dexmedetomidine justify the conduction of controlled trials in palliative care.

Comparison of Intravenous Dexmedetomidine Versus Dexmedetomidine-Dexamethasone Combination for Preventing Postoperative Nausea and Vomiting in Adult Patients After Abdominal Surgeries

INTRODUCTION

 Postoperative nausea and vomiting (PONV) is a common problem following general anesthesia and is one of the most unpleasant side effects that affects the patient after surgery and is the worst memory of the hospital stay. The present prospective randomized comparative study was designed to compare the effect of intravenous dexmedetomidine with dexmedetomidine-dexamethasone combination for preventing PONV following abdominal surgeries in adult patients and evaluating their sedative and analgesic effects.

METHODOLOGY

A total of 75 patients (aged 18-65 years) were assigned to undergo this comparative study via block randomization using a sealed envelope system. They were divided into three groups of 25 each: group A (control) received normal saline, group B received dexmedetomidine, and group C received a combination of dexmedetomidine with dexamethasone over 10 minutes after inducing general anesthesia before skin incision. The primary outcome was to assess PONV, where nausea was assessed by the numerical rating scale and vomiting by the number of gastric content expulsions. The secondary outcome, which is postoperative sedation and pain, was assessed by the Ramsay Sedation Score and Visual Analog Score, respectively, for 24 hours postoperatively.

RESULT

 During the first 24 hours after surgery, the incidence of PONV was similar in both dexmedetomidine and combination groups but lower than the control group. Postoperative sedation and analgesia were both statistically and clinically adequate and similar in dexmedetomidine and combination groups. No major side effects requiring pharmacological intervention were reported.

CONCLUSION

 Dexmedetomidine alone is as effective as its combination with dexamethasone in preventing PONV in adult patients following abdominal surgeries.

Opioid-free versus opioid-based anesthesia in major spine surgery: a prospective, randomized, controlled clinical trial

BACKGROUND

Major spine surgery is associated with severe postoperative pain and increased opioid consumption. Opioid-free anesthesia (OFA) is thought to provide adequate intraoperative analgesia with reduced postoperative opioid consumption. The aim of this study is to compare the impact of intraoperative OFA approach to the conventional opioid-based anesthesia (OBA) on postoperative pain, opioid consumption, and related side effects in patients undergoing multilevel spinal fusion surgery.

METHODS

Forty-eight patients undergoing elective major spine surgery were randomly allocated to either receive intraoperative dexmedetomidine and lidocaine (OFA group) or fentanyl during induction and intraoperative remifentanil (OBA group). All patients received intraoperative sevoflurane, propofol, rocuronium, ketamine, dexamethasone, ondansetron and postoperative paracetamol and patient-controlled analgesia device set to deliver intravenous morphine for 48 hours after surgery. Postoperative pain was measured using numerical rating scale. Opioid side effects were documented, when present.

RESULTS

OFA group required less morphine in the first 24 hours post-surgery (17.28±12.25 mg versus 27.96±19.75 mg, P<0.05). The incidence of postoperative nausea and vomiting (PONV) was significantly lower in the OFA group. More patients in the OFA group required antihypertensive medications compared to patients in the OBA group (P<0.05). In the post anesthesia care unit, OFA patients had a significantly longer stay than OBA patients (114.1±49.33 min versus 89.96±30.71 min, P<0.05).

CONCLUSIONS

OFA can be an alternative to OBA in patients undergoing multilevel spine fusion surgery. OFA reduces opioids consumption in the first 24 hours and PONV.

Impact of intravenous dexmedetomidine on postoperative gastrointestinal function recovery: an updated meta-analysis

BACKGROUND

Postoperative ileus (POI) is a complication that may occur after abdominal or nonabdominal surgery. Intravenous dexmedetomidine (Dex) has been reported to accelerate postoperative gastrointestinal function recovery; however, updated evidence is required to confirm its robustness.

METHODS

To identify randomized controlled trials examining the effects of perioperative intravenous Dex on gastrointestinal function recovery in patients undergoing noncardiac surgery, databases including MEDLINE, EMBASE, Google Scholar, and Cochrane Library were searched on August 2023. The primary outcome was time to first flatus. Secondary outcomes included time to oral intake and defecation as well as postoperative pain scores, postoperative nausea/vomiting (PONV), risk of hemodynamic instability, and length of hospital stay (LOS). To confirm its robustness, subgroup analyses and trial sequential analysis were performed.

RESULTS

The meta-analysis of 22 randomized controlled trials with 2566 patients showed that Dex significantly reduced the time to flatus [mean difference (MD):-7.19 h, P <0.00001), time to oral intake (MD: -6.44 h, P =0.001), time to defecation (MD:-13.84 h, P =0.008), LOS (MD:-1.08 days, P <0.0001), and PONV risk (risk ratio: 0.61, P <0.00001) without differences in hemodynamic stability and pain severity compared with the control group. Trial sequential analysis supported sufficient evidence favoring Dex for accelerating bowel function. Subgroup analyses confirmed the positive impact of Dex on the time to flatus across different surgical categories and sexes. However, this benefit has not been observed in studies conducted in regions outside China.

CONCLUSIONS

Perioperative intravenous Dex may enhance postoperative gastrointestinal function recovery and reduce LOS, thereby validating its use in patients for whom postoperative ileus is a significant concern.

Comparison of remimazolam and dexmedetomidine for intraoperative sedation in patients undergoing lower extremity surgery under spinal anesthesia: a randomized clinical trial

BACKGROUND

Dexmedetomidine sedation has advantages, such as low incidence of respiratory depression and prolonged block duration, but also significant disadvantages, such as slow onset, high rate of sedation failure, and a long context-sensitive half-life. Remimazolam provides rapid sedation and recovery, high sedation efficacy and has minimal hemodynamic effects. We hypothesized that patients who received remimazolam would require less rescue midazolam than dexmedetomidine.

METHODS

Patients (n=103) scheduled for surgery under spinal anesthesia were randomized to receive dexmedetomidine (DEX group) or remimazolam (RMZ group) targeting a Modified Observer's Assessment of Alertness/Sedation score of 3 or 4. Rescue midazolam was administered if the patient failed to be sedated after the initial loading dose or despite infusion rate adjustment.

RESULTS

Rescue midazolam administration was significantly higher in the DEX group (0% vs 39.2%; p<0.001). Patients in the RMZ group reached the target sedation level more rapidly. The incidences of bradycardia (0% vs 25.5%; p<0.001) and hypertension (0% vs 21.6%; p<0.001) were higher in the DEX group. Respiratory depression occurred at a higher rate in the RMZ group (21.2% vs 2.0%; p=0.002), but no patients required manual ventilation. Patients in the RMZ group recovered faster, had a shorter PACU stay and higher satisfaction scores. Hypotensive episodes in the PACU were more frequent in the DEX group (1.9% vs 29.4%; p<0.001).

CONCLUSIONS

Remimazolam showed excellent sedation efficacy, minimal hemodynamic effects, and fewer adverse events in the PACU than dexmedetomidine. However, it is important to note that respiratory depression was more frequent with the use of remimazolam.

TRIAL REGISTRATION NUMBER

NCT05447507.

Advances in Anesthesia for Shoulder Surgery: A Comprehensive Review of Dexmedetomidine-Enhanced Interscalene Brachial Plexus Block

Surgical procedures on the shoulder pose distinctive challenges in managing pain during the perioperative period, underscoring the importance of exploring innovative anesthesia techniques. This comprehensive review article delves into integrating dexmedetomidine, an alpha-2 adrenergic agonist, within interscalene brachial plexus blocks for shoulder surgery. The review initiates by underscoring the pivotal role of effective anesthesia in shoulder surgery and elucidates the rationale behind investigating dexmedetomidine as an adjunct. It meticulously examines the anatomy and physiology of the brachial plexus, emphasizing its critical significance in shoulder surgery. Furthermore, the article expounds on dexmedetomidine's mechanisms of action and pharmacokinetics, encompassing its safety profile and potential side effects. The conventional interscalene brachial plexus block techniques, along with their limitations and challenges, are discussed, laying the foundation for the integration of dexmedetomidine. The review subsequently delves into exploring the role of dexmedetomidine in regional anesthesia, covering previous studies, mechanisms of action, and the potential advantages of incorporating it into nerve blocks. The review's core concentrates on the practical application of dexmedetomidine-enhanced interscalene brachial plexus blocks. This includes discussions on administration techniques, dosage guidelines, and compelling evidence supporting its utilization. Clinical scenarios where this approach proves most advantageous are thoroughly explored, comparing its effectiveness with traditional techniques in terms of pain control and patient outcomes. A comprehensive examination of relevant clinical trials and case studies highlights the evidence supporting its efficacy. The review also underscores safety considerations associated with dexmedetomidine. It proposes strategies for mitigating risks to ensure patient safety. Insights into future directions and research are provided, encompassing ongoing studies, areas necessitating further investigation, and potential refinements in technique. Finally, the article summarizes key findings, emphasizing the practicality of dexmedetomidine-enhanced interscalene brachial plexus blocks in shoulder surgery and its far-reaching implications for clinical practice and patient care.

Feasibility of the pupillary pain index as a guide for depth of analgesia during opioid-sparing anesthesia with continuous infusion of dexmedetomidine

BACKGROUND

The pupillary dilation reflex (PDR) is an objective indicator of analgesic levels in anesthetized patients. Through measurement of the PDR during increasing tetanic stimulation (10-60 mA), it is possible to obtain the pupillary pain index (PPI), a score that assesses the level of analgesia.

OBJECTIVES

The depth of analgesia during opioid-sparing anesthesia (OSA) with continuous infusion of dexmedetomidine in addition to general anesthesia was assessed.

DESIGN

Observational prospective feasibility pilot study SETTING: This study was performed in the operating rooms of the Spedali Civili University-affiliated hospital of Brescia, Italy.

PATIENTS

Forty-five adults who underwent elective open (5-cm incision) surgery under general anesthesia (78% inhalation anesthesia), from Feb. 18th to Aug. 1st, 2019, were enrolled. Exclusion criteria were as follows: implanted pacemaker or ICD, ophthalmological comorbidities, chronic opioid use, peripheral neuropathy, other adjuvant drugs, epidural analgesia, or locoregional block.

MAIN OUTCOME MEASURES

The first aim was to verify the feasibility of applying a study protocol to evaluate the depth of analgesia during intraoperative dexmedetomidine administration using an instrumental pupillary evaluation. The secondary outcome was to evaluate appropriate analgesia, drug dosage, anesthesia depth, heart rate, blood pressure, transient side effects, postoperative nausea and vomiting (PONV), and pain numerical rating scale (NRS) score.

RESULTS

Thirty out of 50 patients (60%) treated with dexmedetomidine during the study period were included in the DEX group (8 males, age 42 ± 13 years, BMI 45 ± 8), and 15 other patients were included in the N-DEX group (8 males, age 62 ± 13 years, BMI 26 ± 6). Patients who underwent bariatric, abdominal, or plastic surgery were enrolled. At least 3 pupillary evaluations were taken for each patient. PPI ≤ 3 was observed in 97% of patients in the DEX group and 53% in the N-DEX group. Additionally, the DEX group received less than half the remifentanil dose than the N-DEX group (0.13 ± 0.07 vs 0.3 ± 0.11 mcg kg-1 min-1). The average dose of dexmedetomidine administered was 0.17 ± 0.08 mcg kg-1 h-1.

CONCLUSION

The feasibility of applying the protocol was verified. An OSA strategy involving dexmedetomidine may be associated with improved analgesic stability: a randomized controlled trial is necessary to verify this hypothesis.

TRIAL REGISTRATION

Trial.gov registration number: NCT05785273.

Effect of dexmedetomidine on postoperative nausea and vomiting in patients under general anaesthesia: an updated meta-analysis of randomised controlled trials

OBJECTIVES

To explore the effect of dexmedetomidine (DEX) on postoperative nausea and vomiting (PONV) in adult patients after general anaesthesia.

DESIGN

Systematic review and meta-analysis.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials (RCTs) comparing the efficacy of DEX with placebo or a single drug on PONV in adult patients after general anaesthesia.

DATA SOURCES

We searched the PubMed, the Web of Science, the Cochrane Library and Embase (1 January 2000 to 30 June 2022) to select the relevant RCTs.

DATA ANALYSIS

All the relevant data were analysed by using RevMan V.5.4. Heterogeneity was tested for each outcome, and random-effect or fixed-effect models was selected according to the level of heterogeneity. The primary outcome was the incidence of PONV. The secondary outcomes were the incidence of bradycardia, perioperative opioid consumption, extubation time and the length of hospitalisation.

RESULTS

A total of 18 trials involving 2018 patients were included in this meta-analysis. Notably, 15 updated studies were not involved in the previous meta-analysis. The incidence of PONV in DEX group was lower than that in the control group (OR=0.49, 95% CI: 0.36 to 0.67) and the perioperative opioid consumption in DEX group was also decreased significantly (standard mean difference (SMD)=-1.04, 95% CI: -1.53 to -0.54). Moreover, the length of hospitalisation (SMD=-2.29, 95% CI: -4.31 to -0.28) and the extubation time (SMD=-0.75, 95% CI: -1.26 to -0.25) in DEX group were shorter. Whereas, more number of patients receiving DEX might increase the occurrence of bradycardia (OR=1.60, 95% CI: 1.13 to 2.27).

CONCLUSIONS

DEX could decrease the occurrence of PONV in adult patients under general anaesthesia and promote the recovery after surgery. However, DEX might increase the occurrence of bradycardia.

PROSPERO REGISTRATION NUMBER

CRD 42022341548.

Pharmacological interventions for preventing opioid-induced hyperalgesia in adults after opioid-based anesthesia: a systematic review and network meta-analysis

Background: Opioid-induced hyperalgesia (OIH) is an adverse event of prolonged opioid use that increases pain intensity. The optimal drug to prevent these adverse effects is still unknown. We aimed to conduct a network meta-analysis to compare different pharmacological interventions for preventing the increase in postoperative pain intensity caused by OIH. Methods: Several databases were searched independently for randomized controlled trials (RCTs) comparing various pharmacological interventions to prevent OIH. The primary outcomes were postoperative pain intensity at rest after 24 h and the incidence of postoperative nausea and vomiting (PONV). Secondary outcomes included pain threshold at 24 h after surgery, total morphine consumption over 24 h, time to first postoperative analgesic requirement, and shivering incidence. Results: In total, 33 RCTs with 1711 patients were identified. In terms of postoperative pain intensity, amantadine, magnesium sulphate, pregabalin, dexmedetomidine, ibuprofen, flurbiprofen plus dexmedetomidine, parecoxib, parecoxib plus dexmedetomidine, and S (+)-ketamine plus methadone were all associated with milder pain intensity than placebo, with amantadine being the most effective (SUCRA values = 96.2). Regarding PONV incidence, intervention with dexmedetomidine or flurbiprofen plus dexmedetomidine resulted in a lower incidence than placebo, with dexmedetomidine showing the best result (SUCRA values = 90.3). Conclusion: Amantadine was identified as the best in controlling postoperative pain intensity and non-inferior to placebo in the incidence of PONV. Dexmedetomidine was the only intervention that outperformed placebo in all indicators. Clinical Trial Registration: https://www.crd.york.ac. uk/prospero/display_record.php?, CRD42021225361.

The effect of intranasal dexmedetomidine administration on emergence agitation or delirium in pediatric patients after general anesthesia: A meta-analysis of randomized controlled trials

BACKGROUND

Emergence agitation or delirium can occur in pediatric patients after anesthesia. Dexmedetomidine is known to reduce the impairment of postoperative cognitive function.

AIMS

This study aimed to identify the role of intranasal administration of dexmedetomidine in lowering the development of emergence agitation or emergence delirium in pediatric patients after general anesthesia.

METHODS

Electronic databases, including PubMed, EMBASE, CENTRAL, Scopus, and Web of Science, were searched to identify studies. The primary outcome was the proportion of patients who underwent emergence agitation or emergence delirium after the surgery. Secondary outcomes included emergence time and incidence of postoperative nausea and/or vomiting. We estimated the odds ratio and mean difference with 95% confidence intervals for the determination of effect size using a random-effects model.

RESULTS

In total, 2103 pediatric patients from 20 randomized controlled trials were included in the final analysis. The incidence of emergence agitation or emergence delirium was 13.6% in the dexmedetomidine group and 33.2% in the control group. The pooled effect size revealed that intranasal dexmedetomidine administration significantly reduced the incidence of postoperative emergence agitation or emergence delirium in pediatric patients undergoing surgery under general anesthesia (odds ratio 0.25, 95% confidence interval 0.18-0.34; p = .0000; I²  = 37.74%). Additionally, significant difference was observed in emergence time between the two groups (mean difference 2.42, 95% confidence interval 0.37-4.46; p = .021; I²  = 98.40%). Children in the dexmedetomidine group had a significantly lower incidence of postoperative nausea and/or vomiting than those in the control group (odds ratio 0.39, 95% confidence interval 0.24-0.64; p = .0002; I²  = 0.00%).

CONCLUSIONS

Intranasal dexmedetomidine reduced the incidence of emergence agitation or emergence delirium in pediatric patients after general anesthesia.

Impact of Bilateral Quadratus Lumborum Block Using Different Doses of Dexmedetomidine for Postoperative Analgesia in Laparoscopic Myomectomy: A Randomized Controlled Trial

OBJECTIVES

The optimal dosage of dexmedetomidine (DEX) for postoperative analgesia of quadratus lumborum block (QLB) after laparoscopic myomectomy is not clear. Our study evaluated the analgesic and adverse effects of different doses of locally administered DEX.

MATERIALS AND METHODS

Patients underwent laparoscopic myomectomy were enrolled in this randomized controlled trial. Transmuscular bilateral QLB was conducted postoperatively using local anesthetic plus different doses of DEX, as an adjuvant, per side. Numeric rating scales (NRS) of pain score and heart rate (HR) were assessed after performing QLB. Additional analgesics through patient-controlled analgesia pump, recovery time to first flatus, hospital stay, and other outcomes were also compared.

RESULTS

A total of 150 participants were randomly divided into 3 groups (DEX1 group: 0.1 μg/kg; DEX2 group: 0.3 μg/kg; DEX3 group: 0.5 μg/kg), 50 for each group. Compared with the DEX1 group, NRS pain scores were lower in groups DEX2 and DEX3 ( P <0.017) 20 minutes after QLB and the significance lasted for 24 hours. Patients in groups DEX2 and DEX3 needed fewer additional analgesics than the group DEX1 ( P <0.017). HR in groups DEX2 and DEX3 was lower than the group DEX1 10 minutes and 20 minutes after QLB, respectively ( P <0.017). Sixty minutes after QLB, HR in the DEX3 group was still lower than the other groups. More patients in the DEX3 group were found bradycardia. Satisfaction score of postoperative analgesia was higher in groups DEX2 and DEX3 than the DEX1 group ( P <0.017).

DISCUSSION

The results suggest that solution of DEX 0.3 μg/kg in ropivacaine 0.25% for QLB is recommended to relieve postoperative pain after laparoscopic myomectomy effectively and safely.

The Effect of Two Different Dexmedetomidine Doses on the Prevention of Nausea and Vomiting in Discectomy Surgery under Spinal Anesthesia

Background

Considering the preventative effect of various medications on such complications after surgery, the present study evaluated the effect of two different dexmedetomidine doses on the prevention of nausea and vomiting in discectomy surgery.

Materials and Methods

The present controlled, double-blind clinical trial was performed on 135 patients that were candidates for discectomy surgery under spinal anesthesia, which were randomly allocated into three groups. Two different dexmedetomidine doses of 0.2 and 0.5 mcg/kg/h were intravenously administered using an infusion pump for 10 min in the first (DEX-0.2 group) and second (DEX-0.5 group) groups, respectively, with the third placebo group being used as a control group. Hemodynamic parameters, the severity of nausea and vomiting, and the incidence of complications were evaluated and recorded up to 24 h after surgery.

Results

The results of the present study revealed that, 20 min after the intervention, the severity of nausea and vomiting in the control group (with the mean of 1.95 ± 1.58) was significantly higher than that of the DEX-0.2 and DEX-0.5 groups with the means of 1.52 ± 1.11 and 1.27 ± 0.99, respectively (P = 0.010). In addition, no significant difference was found between the two dexmedetomidine doses in terms of the severity of nausea and vomiting (P > 0.05).

Conclusion

According to the results of the present study, a low dose of dexmedetomidine may be a more preferable choice as a preventive drug in the incidence of nausea and vomiting in discectomy surgery due to its lower complications, further reduction of nausea and vomiting, and more desirable hemodynamic stability.

Framework, component, and implementation of enhanced recovery pathways

The introduction of enhanced recovery pathways (ERPs) has led to a considerable paradigm shift towards evidence-based, multidisciplinary perioperative care. Such pathways are now widely implemented in a variety of surgical specialties, with largely positive results. In this narrative review, we summarize the principles, components and implementation of ERPs, focusing on recent developments in the field. We also discuss ‘special cases’ in ERPs, including: surgery in frail patients; emergency procedures; and patients with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2/COVID-19).

The Optimal Dose of Intraoperative Dexmedetomidine for Antiemetic Effects of Post-operative Nausea and Vomiting in Patients Undergoing Elective Thoracic Surgery: A Retrospective Cohort Study

Background

Dexmedetomidine (DEX) administration decreases post-operative nausea and vomiting (PONV), but it is a lack of large-scale retrospective cohort study and is unclear whether there is a dose-relationship and optimal dose for antiemetic effects between DEX and PONV. We performed a large-scale retrospective cohort study to explore the optimal dose of intraoperative DEX for antiemetic effects of PONV.

Methods

A total of 5,310 patients aged ≥18 who underwent elective thoracic surgery from January 2016 to March 2020 under total intravenous anesthesia (TIVA) or combined intravenous and inhalation anesthesia in Henan Provincial People's Hospital. Patients were divided into two groups, those who received DEX intraoperatively and those who did not receive DEX. Patients who received DEX after surgery were excluded. Our primary outcomes were the association, the dose-response relationship, and the optimal dose for antiemetic effects between intraoperative DEX and PONV.

Results

Among the 3,878 patients enrolled, 2,553 patients received DEX and 1,325 patients did not receive DEX. The incidence of PONV in patients who received DEX was 21.3%, and the incidence of PONV in patients who did not receive DEX was 46.5% (P = 0.001). After the matched-pairs cohort consisted of 1,325 patients, the incidence of PONV in patients who received DEX was 23.6%, and the incidence of PONV in patients who did not receive DEX was 46.5% (P = 0.001). We analyzed three different models after propensity matching to validate the stability of the prediction model between intraoperative DEX and PONV. A dose-response relationship between intraoperative DEX and PONV was observed. The optimal dose range of intraoperative DEX for antiemetic effects of PONV is 50–100 μg in elective thoracic surgery.

Conclusions

Intraoperative DEX was associated with a decreased incidence of PONV in the large-scale retrospective cohort study. A dose-response relationship between intraoperative DEX and PONV was observed. The optimal dose range of intraoperative DEX for antiemetic effects of PONV is 50–100 μg in elective thoracic surgery.

The efficacy and safety of dexmedetomidine in preventing emergence delirium in paediatric patients following ophthalmic surgery: a systematic review and meta-analysis of randomised controlled trials

Background

The leading cause of emergence delirium (ED) in children postoperatively is the exposure to inhalational anaesthetics. ED can occur immediately after waking from anaesthesia, making patients generally uncooperative and agitated. Dexmedetomidine has sedative and analgesic effects and helps to reduce agitation and delirium and improve hemodynamic stability and the recovery of respiratory function; in addition to decreasing pain intensity, it is also well known for helping reduce nausea and vomiting.

Objectives

This updated systematic review meta-analysis investigate and summarise currently available evidence on the use of dexmedetomidine to prevent ED, reduce postoperative nausea and vomiting (PONV) and decrease the need for rescue analgesia in paediatric patients undergoing ophthalmic surgery.

Methods

The medical databases EMBASE, PubMed and Cochrane Library were searched for randomised controlled trials published between January 2020 and August 2022 that used Dexmedetomidine in paediatric patients undergoing ophthalmic surgery. The protocol was prospectively registered with PROSPERO (CRD42022343622). The review was accomplished according to the ‘Preferred Reporting Items for Systematic Reviews and Meta-Analyses’, and the meta-analysis was conducted by using RevMan5.4. These studies examine the efficacy of dexmedetomidine in preventing ED in children undergo ophthalmic surgery. The Cochrane ROB-1 was used to assess risk of bias (ROB).

Results

Eight studies comprised of 629 participants, of which 315 received dexmedetomidine and 314 placebos were examined. PAED score identified ED following surgery. A review and meta-analysis indicated that dexmedetomidine reduces ED incidence (RR = 0.39; 95% CI 0.25–0.62). Similarly, it reduces the use of rescue analgesia (RR = 0.38; 95% CI 0.25–0.57). However, dexmedetomidine did not help prevent PONV since no difference was found between groups (RR = 0.33; 95% CI 0.21–0.54).

Conclusion

This review showed that dexmedetomidine helped to reduce ED incidence in paediatric patients after ophthalmic surgery and reduced the need for rescue analgesia compared to placebo or other medications.

Effect of Dexmedetomidine in Sub-Tenon's Block on Emergence Agitation in Pediatric Strabismus Surgery under Sevoflurane Anesthesia

Background

Numerous unfavorable complications may occur with strabismus surgery as emergency agitation (EA), oculocardiac reflex (OCR), postoperative pain, and postoperative nausea and vomiting (PONV).

Aims

This study was designed to evaluate the dexmedetomidine effect in sub-Tenon's block on EA in strabismus surgery in the pediatric population under sevoflurane anesthesia.

Design

This was a prospective randomized double-blind clinical trial.

Patients and Methods

Eighty American Society of Anesthesiologists (ASA) Physical Status Class I and II pediatric patients, in an age group ranging from 2 to 8 years of either sex, had strabismus surgery under sevoflurane anesthesia using laryngeal mask airway. Patients were divided randomly into two groups (each = 40). Sub-Tenon's block is performed in the operated eye with 0.5% bupivacaine (0.08 mL.kg-1) alone in Group B (bupivacaine group), and with 0.5% bupivacaine (0.08 mL.kg-1) and dexmedetomidine (0.5 μg.kg-1) in Group D (dexmedetomidine group). Hemodynamics were monitored, and OCR was recorded. Furthermore, postoperative EA (Pediatric Anesthesia Emergence Delirium and Cravero Scales), pain (Face, Legs, Activity, Cry, and Consolability), and incidence of PONV were recorded as well.

Statistical Analysis

A prospective analysis of the collected data was performed using the SPSS program for Windows (version 26).

Results

The dexmedetomidine group exhibited a lower EA incidence, pain, and PONV as compared to the bupivacaine group. No statistically significant differences regarding hemodynamics, OCR, or emergence time were found between both the groups.

Conclusion

The addition of dexmedetomidine to bupivacaine in sub-Tenon's block can alleviate postoperative EA and nausea and vomiting with better pain management and hemodynamic stability in pediatric strabismus surgery under sevoflurane anesthesia.

The therapeutic antiemetic and hemodynamic effects of dexmedetomidine, ephedrine, and dexamethasone in combination with midazolam on laparoscopic cholecystectomy patients: A randomised clinical trial

Objective:

The objective was to compare the hemodynamic and antiemetic effects of the combination of midazolam with ephedrine, dexamethasone, and dexmedetomidine in laparoscopic cholecystectomy surgical patients.

Materials and Methods:

This randomised, parallel-group, double-blind clinical trial was conducted by enrollment of 96 patients who were referred for laparoscopic cholecystectomy. Patients assigned into three equal-sized intervention arms having received anaesthesia induction with midazolam-ephedrine, midazolam-dexamethasone, and midazolam-dexmedetomidine using a block randomisation method. Frequency and severity of nausea and vomiting were observed from recovery to 24 h later, adverse events, and sedation on Ramsay sedation scale at recovery, 1, 2, and 4 h postoperatively. Data were recorded and analysed at a significance level lower than 0.05 in SPSS software.

Results:

The clinical parameters including mean blood pressure at all times and heart rate in 60–90 min were lower in the dexmedetomidine group when compared with other groups. The lowest severity of postsurgery nausea occurrence was observed in the midazolam-dexamethasone group and those receiving midazolam-dexmedetomidine from 4 to 24 h. In addition, vomiting scores were lower throughout recovery up to postoperative 4 h in the dexamethasone and dexmedetomidine groups (all P < 0.05). The highest sedation score was observed in the dexmedetomidine group during recovery up to 2 h (P = 0.001), reflecting a more clinically superior effect than dexamethasone (P = 0.01).

Conclusions:

A positive implication of dexmedetomidine was observed in attenuating postoperative nausea and vomiting and potentiating sedation. Nevertheless, it is providing a drop in the blood pressure and heart rate. Lending support to the potent adjuvant efficacy of dexamethasone following dexmedetomidine, consequently, a hypothesis can be put forward, stating that the dexmedetomidine and dexamethasone as adjuvants to midazolam are expected to bring the advantages of avoiding the adverse events and improving postoperative sedation.

Combination of Dexmedetomidine and Butorphanol Optimized Sedation in Drug-Induced Sleep Endoscopy: A Randomized, Double-Blind Trial

OBJECTIVE

Drug-induced sleep endoscopy (DISE) allows for the evaluation of dynamic airway collapse in patients with obstructive sleep apnea. However, a standardized sedation regimen for DISE is not yet available. This study aimed to investigate the safety profiles and efficacies of dexmedetomidine combined with butorphanol for DISE.

METHODS

Sixty patients with obstructive sleep apnea scheduled to undergo DISE were randomly divided into Group D and Group DB. All recipients were initially given intravenous butorphanol (1 mg) (Group DB) or saline (Group D). Subsequently, both groups were sedated using a loading dose of 1.0 µg/kg/h of dexmedetomidine. Hemodynamic and respiratory parameters, the time to attain sufficient sedation, wakeup time, and adverse events during DISE were recorded.

RESULTS

Compared with Group D, the time until sufficient sedation and wakeup time in Group DB were significantly reduced. A higher performer satisfaction level was achieved in Group DB. Patients in Group DB showed a higher incidence of bradycardia compared with Group D. However, the bradycardia resolved spontaneously in both groups without any treatment. There was no instance of cough, hypotension, arrhythmia, nausea or vomiting in either group.

CONCLUSION

Compared to dexmedetomidine alone, a small dose of butorphanol infusion (1 mg) as an adjunct treatment to dexmedetomidine during DISE can reduce the dosage of dexmedetomidine, shorten the time until sufficient sedation and enhance the performer satisfaction level. This synergistic combination could be a promising sedation regimen for DISE in terms of procedural convenience and patient safety.

Preoperative Anxiety and Postoperative Pain in Patients With Laparoscopic Hysterectomy

Objective: This study was designed to investigate preoperative anxiety situations and postoperative pain degree in Chinese patients undergoing laparoscopic hysterectomy and to analyze the related factors of preoperative anxiety and the correlation between preoperative anxiety and postoperative pain to provide a reference for effective postoperative analgesia management.

Methods: A total of 100 female patients undergoing laparoscopic hysterectomy were enrolled in this study and randomly divided into two groups (n = 50, each). In group A, the patients were treated with dexmedetomidine and sufentanil for postoperative analgesia. In group B, the patients were treated with sufentanil alone for postoperative analgesia. All patients were evaluated with a self-rating anxiety scale (SAS) 1 day before the operation. The patients’ pain was evaluated using the numerical rating scale (NRS) 1 day after the operation, and data were recorded.

Results: In these 100 patients, the highest preoperative SAS score was 48, and the average score was 40.99 ± 4.55 points, which is higher than the norm in China. There were significant differences in preoperative SAS scores among patients with different occupations and previous surgical experience (P < 0.05). There was no significant difference in SAS scores among patients with different education levels (P > 0.05). The postoperative NRS score of group A was significantly higher than that of group B, and the difference was statistically significant (P < 0.05). The correlation coefficients between SAS scores and NRS scores in groups A and B were 0.836 and 0.870, respectively, presenting with a significantly positive correlation.

Conclusion: Preoperative anxiety is an important predictor of postoperative pain. Patients undergoing laparoscopic hysterectomy have preoperative anxiety. The degree of anxiety is influenced by the occupation and previous operation experience of the patients, and patients with higher preoperative anxiety have greater postoperative pain. In addition, we should not neglect the management of postoperative pain because of the small trauma of laparoscopic surgery, and dexmedetomidine combined with sufentanil can improve the postoperative analgesic effect.

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 dexmedetomidine on opioid consumption and pain control after laparoscopic cholecystectomy: a meta-analysis of randomized controlled trials

Introduction

The clinical evidence on dexmedetomidine (DEX) for postoperative pain scores and opioid consumption remains unclear in laparoscopic cholecystectomy (LC).

Aim

To evaluate whether DEX could reduce opioid consumption and pain control after LC.

Material and methods

A meta-analysis search of EMBASE, PubMed and Cochrane CENTRAL databases was performed and randomized controlled trials (RCTs) comparing DEX with control for adult patients undergoing LC were searched. The primary outcome was opioid consumption in the first 24 h after the operation. The secondary outcomes were the time of first request of analgesia, visual analogue scale (VAS) scores 24 h after the operation, the incidence of patients’ need for rescue analgesics, opioid-related adverse effects, DEX-related adverse effects and other complications.

Results

There were fourteen aspects of twelve trials and 967 patients included in the analysis. DEX use significantly reduced the opioid consumption in the first 24 h after the operation (weighted mean difference (WMD), –19.17; 95% confidence interval (CI), –30.29 to –8.04; p = 0.0007), lengthened the time of first request of analgesia (WMD = 38.90; 95% CI: 0.88–76.93; p = 0.04) and lowered post-operative nausea or vomiting (PONV) (odds ratio (OR) = 0.49; 95% CI: 0.27–0.89; p = 0.02).

Conclusions

Intravenous DEX infusion significantly improved the duration of the analgesic effect and reduced postoperative opioid consumption. Moreover, lower incidence of post-operative nausea or vomiting was found in the DEX group.

An Opioid-free Anesthesia Protocol for Pediatric Strabismus Surgery: A Quality Improvement Project

Introduction:

This quality improvement (QI) project tracks a series of 2 Plan-Do-Study-Act (PDSA) cycles as we standardized and refined an ambulatory pediatric anesthesia strabismus protocol. We aimed to provide effective pain relief, reduce postoperative nausea and vomiting (PONV) rates, and be cost-efficient while minimizing perioperative opioids over 5 years.

Methods:

We used statistical process control (SPC) charts to analyze real-world data captured from the medical record. We chose the following outcome and process measures to evaluate effectiveness: postoperative morphine rescue rate, maximum pain score in the postanesthesia care unit (PACU), and PONV rescue rate. We also used 2 balancing measures: postoperative length of stay (LOS) and total anesthesia time. We standardized our anesthesia protocol for our first PDSA cycle (April 2017) by removing intraoperative intravenous acetaminophen and utilizing fentanyl only. For the second PDSA cycle (January 2019), we replaced intraoperative fentanyl with dexmedetomidine.

Results:

There was a total of 325 pediatric strabismus repair surgeries performed between April 2015 and July 2020. There was no special cause variation detected in the SPC charts for the family of measures chosen to measure effectiveness: postoperative morphine rescue rate, maximum pain score in the PACU, or the PONV rescue rate. The PONV rescue rate was 0 with the removal of opioids. Also, there was no special cause variation for the balancing measures: postoperative LOS or total anesthesia time.

Conclusions:

Throughout 2 PDSA cycles, this QI project enabled our team to standardize an opioid-free and cost-efficient anesthesia protocol for pediatric strabismus surgery over 5 years.

Effects of lidocaine, dexmedetomidine, and their combination infusion on postoperative nausea and vomiting following laparoscopic hysterectomy: a randomized controlled trial

Background

A few studies have reported that administration of lidocaine and dexmedetomidine relieves the incidence of postoperative nausea and vomiting (PONV). We explored whether combined infusion of lidocaine plus dexmedetomidine had lower occurrence of PONV undergoing laparoscopic hysterectomy with general anesthesia.

Methods

A total of 248 women undergoing elective laparoscopic hysterectomy were allocated into the following four groups: the control group (group C, n = 62) received an equal volume of saline, the lidocaine group (group L, n = 62) received intravenous lidocaine (bolus infusion of 1.5 mg/kg over 10 min, 1.5 mg/kg/h continuous infusion), the dexmedetomidine group (group D, n = 62) received dexmedetomidine administration (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, n = 62) received combination of lidocaine (bolus infusion of 1.5 mg/kg over 10 min, 1.5 mg/kg/h continuous infusion) and dexmedetomidine administration (bolus infusion of 0.5 µg/kg over 10 min, 0.4 µg/kg/h continuous infusion). The primary outcome was the incidence of nausea, vomiting, and PONV during the first 48 h after surgery. The secondary outcomes included the incidence of total 24 h PONV after surgery, intraoperative remifentanil requirement, postoperative pain visual analogue scale (VAS) scores and fentanyl consumption, the incidence of bradycardia, agitation, shivering, and mouth dry during post-anesthesia care unit (PACU) stay period.

Results

The occurrence of nausea and PONV in group LD (5.0 and 8.3%) at 0–2 h after operation was lower than group C (21.7 and 28.3%) (P < 0.05). There was no statistically significant difference with respect to occurrence of nausea and PONV in groups L (13.3 and 20.0%) and D (8.3 and 13.3%) at 0–2 h after operation compared to group C (21.7 and 28.3%). The incidence of nausea, vomiting, and PONV at 2–24 and 24–48 h after surgery in all four groups was not statistically significant. The incidence of total 24 h PONV in group LD (33.3%) was significantly decreased compared to group C (60.0%) (P < 0.05). The cumulative consumption of fentanyl at 6 and 12 h after surgery was significantly reduced in group LD compared to other three groups (P < 0.05). The pain VAS scores were significantly decreased at 2, 6, and 12 h after operation in group LD compared to other three groups (P < 0.05). Remifentanil dose in the intraoperative period was significantly lower in groups LD and D compared with groups C and L (P < 0.05). The number of mouth dry, bradycardia, and over sedation during the PACU stay period was markedly increased in group LD (28.3, 30.0, and 35.0%, respectively) compared with groups C (1.7, 1.7, and 3.3%, respectively) and L (3.3, 5.0, and 6.7%, respectively) (P < 0.05).

Conclusions

Lidocaine combined with dexmedetomidine infusion markedly decreased the occurrence of nausea and PONV at 0–2 h as well as the total 24 h PONV. However, it significantly increased the incidence of mouth dry, bradycardia, and over sedation during the PACU stay period after laparoscopic hysterectomy with general anesthesia.

Trial registration

ClinicalTrials.gov (NCT03809923), registered on January 18, 2019.

Crucial involvement of catecholamine neurotransmission in postoperative nausea and vomiting: Whole-transcriptome profiling in the rat nucleus of the solitary tract

The genetic mechanisms of postoperative nausea and vomiting (PONV) and the involvement of the catecholamine system in the brain have not been elucidated. Eating kaolin clay as a type of pica has been examined as an alternative behavior to emesis. Here, we evaluated changes in whole-transcriptome analysis in the nucleus of the solitary tract (NTS) in a rat pica model as a surrogate behavior of PONV to elucidate the molecular genetic mechanisms of the development of PONV and the involvement of the catecholamine system in the NTS. First, kaolin pica behaviors were investigated in 71 female Wistar rats following isoflurane anesthesia, surgical insult or morphine administration. Multiple linear regression analysis showed that 3 mg/kg morphine increased kaolin intake by 2.8 g (P = 0.0002). Next, total RNA and protein were extracted from the dissected NTS, and whole-transcriptome sequencing (RNA-seq) was performed to identify PONV-associated genes and to verify the involvement of the catecholamine system. The gene expression levels of tyrosine hydroxylase and dopamine beta-hydroxylase in the catecholamine biosynthesis pathway decreased significantly in the PONV model. Release of noradrenaline, a catecholamine pathway end product, may have increased at the synaptic terminal of the NTS neuron after pica behavior. Systematic administration of α2 adrenergic receptor agonists after surgery reduced kaolin intake from 3.2 g (control) to 1.0 g (P = 0.0014). These results indicated that catecholamine neurotransmission was involved in the development of PONV in the NTS.

Risk factors for postoperative nausea and vomiting after thoracoscopic pulmonary wedge resection: pitfalls of an increased fentanyl dose

Background

Thoracoscopic pulmonary wedge resection (TPWR) is a surgical procedure that can maintain lung function and is less physically invasive to a patient. However, the risk factors for postoperative nausea and vomiting (PONV) following TPWR remain unknown. We aimed to evaluate multiple risk factors of PONV after TPWR and the impact of PONV on postoperative outcomes.

Methods

We retrospectively reviewed consecutive patients who underwent TPWR for malignant pulmonary tumors at our institution between October 2017 and March 2020. We assessed the differences in the clinical and perioperative parameters between the PONV and non-PONV groups.

Results

We reviewed 160 patients, of whom 27 (16.9%) had PONV. Sixteen (59.3%) patients with PONV required postoperative antiemetics. Failed mobilization was associated with PONV requiring postoperative antiemetics (P=0.048). In the multivariate analysis, increased fentanyl dose was an independent risk factor for PONV (P=0.022). Using the receiver operating characteristic curve, the optimal cut-off value for PONV was 3.58 µg/kg/hr (area under the curve =0.665; sensitivity =85.2%; specificity =53.4%; 95% confidence interval: 0.562–0.768; P=0.007). For example, in a case of a 50-kg patient who underwent a 70-min operation (our median operative time), the total dose of fentanyl within 208 µg was the cut-off value for preventing PONV.

Conclusions

An increased dose of fentanyl/kg/h was the strongest risk factor for PONV during TPWR. The optimal cut-off value for PONV was 3.58 µg/kg/hr. It is important to avoid the inadvertent administration of intraoperative fentanyl.

Effects of dexmedetomidine sedation for magnetic resonance imaging in children: a systematic review and meta-analysis

PURPOSE

Pediatric sedation is commonly required to obtain high-quality images in magnetic resonance imaging (MRI). We performed a systematic review and meta-analysis to assess the effects of dexmedetomidine sedation for MRI in children.

METHODS

A systematic review was conducted to find all randomized controlled trials concerning dexmedetomidine sedation for MRI in children. We searched databases using the Ovid platform in the Cochrane Controlled Trials Register, MEDLINE, and EMBASE. This study was registered in the PROSPERO database: CRD42020198368.

RESULTS

Seven studies and 753 participants were included. Dexmedetomidine sedation showed a significantly delayed onset time [weighted mean differences (WMD) = 8.13 min, 95% confidence interval (CI) 4.64 to 11.63, I² = 98%] and recovery time (WMD = 5.22 min, 95% CI 0.35 to 10.09, I² = 92%) compared to propofol, ketamine, and midazolam sedation. There was no difference in quality of sedation [risk ratio (RR) = 1.25, 95% CI 0.92 to 1.69, I² = 89%], or incidence of sedation failure (RR = 1.39, 95% CI 0.53 to 3.66, I² = 83%) between groups. Although a significantly decreased heart rate (WMD = - 17.34 beats/minute, 95% CI - 22.42 to - 12.26, I² = 96%) was observed, bradycardia that required treatment was not increased (RR = 8.00, 95% CI 1.02 to 62.64, I² = 0%). Dexmedetomidine sedation had a lower incidence of desaturation events (RR = 0.42, 95% CI 0.20 to 0.86, I² = 4%). However, there was no difference in incidence of postoperative vomiting (RR = 0.42, 95% CI 0.15 to 1.17, I² = 17%) between groups.

CONCLUSIONS

Dexmedetomidine sedation provided a similar sedation quality with a reduced incidence of desaturation events. However, the delayed onset and recovery times were drawbacks. The clinical significance of bradycardia is considered to be low. GRADE assessment revealed the quality of the evidence in this meta-analysis ranged from very low to moderate.

Perioperative dexmedetomidine reduces emergence agitation without increasing the oculocardiac reflex in children: A systematic review and meta-analysis

BACKGROUND

Intravenous dexmedetomidine (DEX) has been used to prevent emergence agitation (EA) in children. The aim of this meta-analysis was to evaluate whether DEX decreases EA incidence without augmenting oculocardiac reflex (OCR) in pediatric patients undergoing strabismus surgery.

METHODS

We searched PubMed, EMBASE, Chinese National Knowledge Infrastructure (CNKI), Wan Fang, and the Cochrane Library to collect the randomized controlled trials (RCTs) investigating the effects of intraoperative DEX in children undergoing strabismus surgery from inception to October 2019. Postoperative Pediatric Agitation and Emergence Delirium (PAED) score, postoperative EA, extubation or laryngeal mask airway (LMA) removal time, postanesthetic care unit (PACU) stay time, OCR, and postoperative vomiting (POV) were evaluated.

RESULTS

11 RCTs including 801 patients were included in this study. Compared with control group, intravenous DEX significantly reduced postoperative PAED score (WMD, 3.05; 95% CI: -3.82 to -2.27, P = .017) and incidences of postoperative EA 69% (RR, 0.31; 95% CI: 0.17 to 0.55, P < .00) and POV (RR, 0.28; 95% CI: 0.13 to 0.61, P = .001). Furthermore, the use of DEX significantly delayed extubation or LMA removal time (WMD, 2.11; 95% CI: 0.25 to 3.97, P < .001). No significant difference was found in the incidence of ORC and PACU stay time.

CONCLUSION

Intravenous DEX reduced the incidences of EA without increasing OCR in pediatric patients undergoing strabismus surgery. Meanwhile, DEX infusion decreased the incidence of POV in children.

Comparison of the prophylactic effect of dexamethasone and dexmedetomidine and their combination in reducing postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy

Nausea and vomiting are some of the most common complaints of patients after any anesthesia, which is often associated with postoperative pain. The double-blind clinical trial study aimed to compare the prophylactic effect of dexamethasone and dexmedetomidine and their combination in reducing postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy. One hundred sixty-two patients undergoing laparoscopic cholecystectomy were enrolled in the study. In the first group of patients, 25 mg of dexmedetomidine were administered slowly. In comparison, the patients in the second group received dexamethasone (4 ml/2 mg) with 0.1 mg/kg of normal saline solution. The third group received a combination of dexmedetomidine and dexamethasone. Hemodynamic changes were recorded during surgery and after surgery, and the patients were admitted to recovery. Nausea and vomiting scores were recorded 2 and 4 hours after surgery. Blood pressure and heart rate were lower in the dexmedetomidine group at all times (P<0.05). Two hours after surgery, the dexamethasone and dexmedetomidine combination group had less vomiting (P=0.012). The incidence of nausea 2 and 4 hours after surgery was lower in the dexamethasone and dexmedetomidine combination group (P<0.05). Blood pressure and heart rate were lower in the dexmedetomidine group at all times. The dexmedetomidine and dexamethasone combination decreased postoperative nausea and vomiting in patients. Therefore, we recommend using a dexmedetomidine and dexamethasone combination for reducing postoperative nausea and vomiting.

Effect of different administration and dosage of dexmedetomidine in the reduction of emergence agitation in children: a meta-analysis of randomized controlled trials with sequential trial analysis

BACKGROUND

Beneficial effects of dexmedetomidine (DEX) against emergence agitation (EA) in children remain controversial. We performed a more comprehensive meta-analysis to evaluate the protective effect of different administration routes, timing, patterns, and doses of DEX on EA in children.

METHODS

The randomized controlled trials about DEX preventing EA in children were searched in PubMed, Cochrane Library, Embase, and Web of Sciences up to October 7, 2020. The traditional meta-analysis and subgroup analysis were performed to study the influence of DEX on EA in children. The sequential trial analysis (TSA) further analyzed the pooled results to evaluate meta-analyses' robustness. Grading of recommendation, assessment, development, and evaluation (GRADE) was used to assess evidence quality.

RESULTS

Sixty-seven studies with 5,688 pediatric patients were included. DEX significantly decreased EA in children compared to placebo [RR 0.29, 95% confidence intervals (CI): 0.25-0.34] and midazolam (RR 0.34, 95% CI: 0.25-0.45), with firm evidence from TSA. Notably, using DEX significantly reduced severe EA incidence (RR 0.23, 95% CI: 0.16-0.32), with firm evidence by TSA and high quality of GRADE. Pre-specified subgroup analyses revealed firm and high-quality evidence for a reduction of EA, only if the perineural route administers DEX (RR 0.24, 95% CI: 0.14-0.41), as premedication (RR 0.27, 95% CI: 0.20-0.36), as continuous dosage (RR 0.25, 95% CI: 0.18-0.33), at high dose (RR 0.24, 95% CI: 0.18-0.31). The pooled results also showed that DEX reduced the incidence of PONV compared to placebo (RR 0.43, 95% CI: 0.33-0.55). Evidence for DEX's influence on other secondary outcomes (emergence time, time in PACU, rescue analgesia, hypotension, and bradycardia) is insufficient to draw any conclusion.

CONCLUSIONS

Our findings confirm the beneficial effects of DEX on EA, severe EA, and PONV in children. There was firm and high-quality evidence for the efficacy of DEX in preventing EA in children when perineural routes administered DEX, as premedication, as continuous dosage, and at a high dose. The best dose, route, patterns, and timing of DEX and influence on other outcomes call for further studies.

Dexmedetomidine for hyperactive delirium at the end of life: An open-label single arm pilot study with dose escalation in adult patients admitted to an inpatient palliative care unit

BACKGROUND

Terminal delirium, specifically the hyperactive delirium subtype at the end of life, is common in palliative care patients. Standard care often involves sedation to alleviate distress. The alpha₂-adrenoreceptor agonist dexmedetomidine may have promise in terminal delirium, due to its properties of decreasing delirium and permitting rousable sedation.

AIM

This study aimed to describe the effect of dexmedetomidine on delirium and sedation, when delivered via continuous subcutaneous infusion (CSCI) in patients with terminal delirium.

DESIGN

The trial was prospectively registered in the ANZCTR database (ACTRN12618000658213) and conducted in accordance with CONSORT (pilot study extension). Twenty-two adult patients were treated with a CSCI of dexmedetomidine with a two-tier dose schedule, low and high dose. Delirium severity was measured by the Memorial Delirium Assessment Scale (MDAS, target <13), and sedation by the Richmond Agitation-Sedation Scale, Palliative Version (RASS-PAL, target -1 to -3).

RESULTS

All patients had a response to dexmedetomidine as measured by decrease in MDAS after initiation; 59% required escalation to high dose to maintain control of delirium. All responses to high dose were sustained. RASS-PAL scores showed significant variability, however mean scores remained within target range on both doses, and the majority of patients were rousable. Fifty percent of patients treated crossed over to standard care; no patients who crossed over were experiencing moderate-severe delirium. Predominant reason for crossover was family request for deeper sedation.

CONCLUSION

Dexmedetomidine shows potential for the management of terminal delirium with improved interactivity. Further research is needed to determine efficacy compared to current standard care.

Off-label use of dexmedetomidine in paediatric anaesthesiology: an international survey of 791 (paediatric) anaesthesiologists

PURPOSE

The purpose of this international study was to investigate prescribing practices of dexmedetomidine by paediatric anaesthesiologists.

METHODS

We performed an online survey on the prescription rate of dexmedetomidine, route of administration and dosage, adverse drug reactions, education on the drug and overall experience. Members of specialist paediatric anaesthesia societies of Europe (ESPA), New Zealand and Australia (SPANZA), Great Britain and Ireland (APAGBI) and the USA (SPA) were consulted. Responses were collected in July and August 2019.

RESULTS

Data from 791 responders (17% of 5171 invitees) were included in the analyses. Dexmedetomidine was prescribed by 70% of the respondents (ESPA 53%; SPANZA 69%; APAGBI 34% and SPA 96%), mostly for procedural sedation (68%), premedication (46%) and/or ICU sedation (46%). Seventy-three percent had access to local or national protocols, although lack of education was the main reason cited by 26% of the respondents not to prescribe dexmedetomidine. The main difference in dexmedetomidine use concerned the age of patients (SPA primarily < 1 year, others primarily > 1 year). The dosage varied widely ranging from 0.2-5 μg kg-1 for nasal premedication, 0.2-8 μg kg-1 for nasal procedural sedation and 0-4 μg kg-1 intravenously as adjuvant for anaesthesia. Only ESPA members (61%) had noted an adverse drug reaction, namely bradycardia.

CONCLUSION

The majority of anaesthesiologists use dexmedetomidine in paediatrics for premedication, procedural sedation, ICU sedation and anaesthesia, despite the off-label use and sparse evidence. The large intercontinental differences in prescribing dexmedetomidine call for consensus and worldwide education on the optimal use in paediatric practice.

Efficacy of Electroacupuncture Combined with Tropisetron in Treating Carboprost Tromethamine-Induced Nausea and Vomiting during Cesarean Section under Lumbar Anesthesia

OBJECTIVE

We evaluated the efficacy of electroacupuncture combined with tropisetron in treating carboprost tromethamine-induced nausea and vomiting during cesarean section under lumbar anesthesia.

METHODS

A total of 264 patients aged 22-40 years were enrolled, who received carboprost tromethamine and suffered nausea and vomiting during cesarean section under lumbar anesthesia. The patients were divided randomly into the control group, electroacupuncture group, tropisetron group, and electroacupuncture + tropisetron group.

RESULTS

Compared to the control group, the nausea and vomiting scores decreased at T3 in both the electroacupuncture and electroacupuncture + tropisetron groups, and decreased at T4 in the electroacupuncture group, tropisetron group, and electroacupuncture + tropisetron group; the motilin, gastrin, and 5-hydroxytryptamine (5-HT) levels decreased at T5 in the other 3 groups. Compared to the electroacupuncture + tropisetron group, the nausea and vomiting scores increased at T3 in the control and tropisetron groups, and increased at T4 in the other 3 groups; the motilin, gastrin, and 5-HT levels increased at T5.

CONCLUSIONS

Our study suggested that electroacupuncture combined with tropisetron could effectively relieve carboprost tromethamine-induced nausea and vomiting during cesarean section under lumbar anesthesia. The effect was better than its single application, and the reduced 5-HT, motilin, and gastrin levels might be involved in the underlying mechanism.

In Pursuit of an Opioid-Free Pediatric Ambulatory Surgery Center: A Quality Improvement Initiative

BACKGROUND

Opioids have been a central component of routine adult and pediatric anesthesia for decades. However, the long-term effects of perioperative opioids are concerning. Recent studies show a 4.8%-6.5% incidence of persistent opioid use after surgery in older children and adults. This means that >2 million of the 50 million patients undergoing elective surgeries in the United States each year are likely to develop persistent opioid use. With this in mind, anesthesiologists at Bellevue Clinic and Surgery Center assembled an interdisciplinary quality improvement team focused on 2 goals: (1) develop effective anesthesia protocols that minimize perioperative opioids and (2) add value to clinical services by maintaining or improving perioperative outcomes while reducing costs. This article describes our project and findings but does not attempt to make inferences or generalizations about populations outside our facility.

METHODS

We performed a large-scale implementation of opioid-sparing protocols at our standalone pediatric clinic and ambulatory surgery facility, based in part on the prior success of our previously published tonsillectomy and adenoidectomy protocol. Multiple Plan-Do-Study-Act cycles were performed using data captured from the electronic medical record. The percentage of surgical patients receiving intraoperative opioids and postoperative morphine preintervention and postintervention were compared. The following measures were evaluated using statistical process control charts: maximum postoperative pain score, postoperative morphine rescue rate, total postanesthesia care unit minutes, total anesthesia minutes, and postoperative nausea and vomiting rescue rate. Intraoperative analgesic costs were calculated.

RESULTS

Between January 2017 and June 2019, 10,948 surgeries were performed at Bellevue, with 10,733 cases included in the analyses. Between December 2017 and June 2019, intraoperative opioid administration at our institution decreased from 84% to 8%, and postoperative morphine administration declined from 11% to 6% using analgesics such as dexmedetomidine, nonsteroidal anti-inflammatory drugs, and regional anesthesia. Postoperative nausea and vomiting rescue rate decreased, while maximum postoperative pain scores, total anesthesia minutes, and total postanesthesia care unit minutes remained stable per control chart analyses. Costs improved.

CONCLUSIONS

By utilizing dexmedetomidine, nonsteroidal anti-inflammatory drugs, and regional anesthesia for pediatric ambulatory surgeries at our facility, perioperative opioids were minimized without compromising patient outcomes or value.

Intranasal Dexmedetomidine Reduces Postoperative Opioid Requirement in Patients Undergoing Total Knee Arthroplasty Under General Anesthesia

BACKGROUND

Total knee arthroplasty (TKA) causes severe pain, and strong opioids are commonly used in postoperative analgesia. Dexmedetomidine is a novel alpha-2-adrenoceptor-activating drug indicated for procedural sedation, but previous studies have shown clinically relevant analgesic and antiemetic effects. We evaluated retrospectively the effect of intranasal dexmedetomidine on the postoperative opioid requirement in patients undergoing TKA.

METHODS

One hundred and fifty patients with ASA status 1-2, age between 35 and 80 years, and scheduled for unilateral primary TKA under total intravenous anesthesia were included in the study. Half of the patients received 100 μg of intranasal dexmedetomidine after anesthesia induction, while the rest were treated conventionally. The postoperative opioid requirement was calculated as morphine equivalent doses for both groups. The effect of dexmedetomidine on postoperative hemodynamics, length of stay (LOS), and incidence of postoperative nausea and vomiting (PONV), was evaluated.

RESULTS

The cumulative postoperative opioid consumption was significantly reduced in the dexmedetomidine group compared to the control group (-28.5 mg, 95% CI 12-47 mg P < .001). The reduction in cumulative opioid dose was significantly different between the groups already at 2, 12, 24, and 36 h postoperatively (P < .001). LOS was shorter in the dexmedetomidine group (P < .001), and the dexmedetomidine group had lower postoperative mean arterial pressure and heart rates were lower compared to the control group (P < .001). The incidence of PONV did not differ between the groups (P = .64).

CONCLUSION

Intraoperatively administered intranasal dexmedetomidine reduces postoperative opioid consumption and may be associated with a shorter hospital stay in patients undergoing TKA under general anesthesia.

The Effects of Propofol or Dexmedetomidine Sedation on Postoperative Recovery in Elderly Patients Receiving Lower Limb Surgery under Spinal Anesthesia: A Retrospective Propensity Score-Matched Analysis

Propofol and dexmedetomidine are the two most popular intravenous sedatives during anesthesia. However, data comparing the effects of these two sedatives during spinal anesthesia on postoperative recovery are still insufficient. We retrospectively analyzed the medical records of patients aged ≥65 years who underwent orthopedic surgery under spinal anesthesia between March 2012 and February 2017. The patients were allocated into two groups according to the intraoperative sedatives: the propofol group and dexmedetomidine group. We analyzed the incidence of postoperative delirium, analgesic requirement, and rescue anti-emetic treatment. A total of 1045 patients were included in the analysis. After propensity score matching with the propofol group, the dexmedetomidine group showed a lower incidence of postoperative delirium (odds ratio, 0.19; 95% CI, 0.07–0.56; p = 0.011). Postoperative analgesic and anti-emetic requirement were not significantly different between the two groups (p = 0.156 and 0.245, respectively). Multivariate logistic regression analysis revealed that intraoperative sedation, age, preoperative albumin level, and hip surgery were significantly associated with the incidence of postoperative delirium. This study showed that intraoperative dexmedetomidine sedation under spinal anesthesia during lower limb surgery is associated with a lower incidence of postoperative delirium compared with propofol sedation.

Prevention and Treatment of Postoperative Nausea and Vomiting (PONV): A Review of Current Recommendations and Emerging Therapies

Postoperative nausea and vomiting is one of the most frequent adverse events after surgery and anesthesia. It is distressing for the patient and can lead to other postoperative complications. Management of PONV involves a framework of risk assessment, multimodal risk reduction, and prophylactic measures, as well as prompt rescue treatment. There has been a significant paradigm shift in the approach towards PONV prevention. There have also been several emerging therapeutic options for PONV prophylaxis and treatment. In this review, we will discuss the up-to-date PONV management guidelines and highlight novel therapeutic options which have emerged in the last few years.

Dexmedetomidine use in pediatric strabismus surgery: A systematic review and meta-analysis

BACKGROUND

Common complications of pediatric strabismus surgery, including emergence agitation (EA), postoperative nausea and vomiting (PONV), and postoperative pain, may be prevented using dexmedetomidine, which is an anxiolytic and analgesic. This systematic review and meta-analysis assessed the effects of dexmedetomidine in patients who had undergone pediatric strabismus surgery.

METHOD

Five databases were searched for randomized controlled trials published from database inception to April 2020 that compared dexmedetomidine use with placebo or active comparator use and evaluated EA, PONV, or postoperative pain incidence (main outcomes) in patients who had undergone pediatric strabismus surgery. Oculocardiac reflex (OCR) incidence and postanesthesia care unit (PACU) stay duration were considered as safety outcomes. All meta-analyses were performed using a random-effects model.

RESULTS

In the nine studies meeting our inclusion criteria, compared with placebo use, dexmedetomidine use reduced EA incidence [risk ratio (RR): 0.39; 95% confidence interval (CI): 0.25-0.62, I2 = 66%], severe EA incidence (RR: 0.27, 95% CI: 0.17-0.43, I2 = 0%), PONV incidence (RR: 0.33, 95% CI: 0.21-0.54, I2 = 0%), analgesia requirement (RR: 0.38, 95% CI: 0.25-0.57, I2 = 0%), and pain scores (standardized mean difference: -1.02, 95% CI: -1.44 to -0.61, I2 = 75%). Dexmedetomidine also led to lower EA incidence in the sevoflurane group than in the desflurane group (RR: 0.26 for sevoflurane vs. 0.45 for desflurane). Continuous dexmedetomidine infusion (RR: 0.19) led to better EA incidence reduction than did bolus dexmedetomidine infusion at the end of surgery (RR: 0.26) or during the peri-induction period (RR: 0.36). Compared with placebo use, dexmedetomidine use reduced OCR incidence (RR: 0.63; I2 = 40%). No significant between-group differences were noted for PACU stay duration.

CONCLUSION

In patients who have undergone pediatric strabismus surgery, dexmedetomidine use may alleviate EA, PONV, and postoperative pain and reduce OCR incidence. Moreover, dexmedetomidine use does not affect the PACU stay duration.

Optimizing Perioperative Use of Opioids: A Multimodal Approach

Purpose of Review

The main purpose of this article is to review recent literature regarding multimodal analgesia medications, citing their recommended doses, efficacy, and side effects. The second part of this report will provide a description of drugs in different stages of development which have novel mechanisms with less side effects such as tolerance and addiction.

Recent Findings

Multimodal analgesia is a technique that facilitates perioperative pain management by employing two or more systemic analgesics along with regional anesthesia, when possible. Even though opioids and non-opioid analgesics remain the most common medication used for acute pain management after surgery, they have many undesirable side effects including the potential for misuse. Newer analgesics including peripheral acting opioids, nitric oxide inhibitors, calcitonin gene-related peptide receptor antagonists, interleukin-6 receptor antagonists and gene therapy are under intensive investigation.

Summary

A patient's first exposure to opioids is often in the perioperative setting, a vulnerable time when multimodal therapy can play a large role in decreasing opioid exposure. Additionally, the current shift towards faster recovery times, fewer post-operative complications and improved cost-effectiveness during the perioperative period has made multimodal analgesia a central pillar of Enhanced Recovery After Surgery (ERAS) protocols.

Influence of Epidural Ropivacaine with or without Dexmedetomidine on Postoperative Analgesia and Patient Satisfaction after Thoraco-Lumbar Spine Instrumentation: A Randomized, Comparative, and Double-Blind Study

Study Design

This was a prospective, randomized, and double-blind study.

Purpose

Thoraco-lumbar spine surgery is associated with severe postoperative pain and can cause chronic pain. We aimed to compare the impact of epidural ropivacaine with and without dexmedetomidine on postoperative analgesia after thoracolumbar spine instrumentation wherein an epidural catheter was placed by the surgeon intraoperatively.

Overview of Literature

Very few studies have reported the use of epidural dexmedetomidine in spine surgeries. When used via the epidural route, dexmedetomidine is safe and efficacious and is associated with reduced rescue analgesia consumption, increased duration of analgesia, reduced pain scores, but not with major hemodynamic adverse effects.

Methods

Total 60 American Society of Anesthesiologists I–III adult patients aged 18–65 years who were scheduled to undergo thoraco-lumbar spine instrumentation were randomly allocated into group RD (epidural ropivacaine+dexmedetomidine) or group R (epidural ropivacaine plus saline). We aimed to compare the total rescue analgesic consumption on postoperative day 0, 1, and 2. Moreover, we studied the time to first rescue analgesia with visual analogue scale score <4 and the overall patient satisfaction scores.

Results

There was no difference between the demographic characteristics of the two groups. The mean value of total rescue analgesia consumption was 162.5±68.4 mg in the RD group and 247.5±48.8 mg in the R group. The mean time to first rescue analgesia was 594.6±83.0 minutes in the RD group and 103.6±53.2 minutes in the R group. The mean patient satisfaction score was 4.2±0.7 in the RD group and 3.2±0.6 in the R group. No patient had any respiratory depression or prolonged motor blockade during the postoperative period.

Conclusions

This study demonstrated the superior efficacy, in terms of postoperative analgesia and patient satisfaction scores, of epidural ropivacaine plus dexmedetomidine over that of ropivacaine alone in patients undergoing surgery for thoraco-lumbar spine.

Management strategies for the treatment and prevention of postoperative/postdischarge nausea and vomiting: an updated review

Postoperative nausea and vomiting (PONV) and postdischarge nausea and vomiting (PDNV) remain common and distressing complications following surgery. The routine use of opioid analgesics for perioperative pain management is a major contributing factor to both PONV and PDNV after surgery. PONV and PDNV can delay discharge from the hospital or surgicenter, delay the return to normal activities of daily living after discharge home, and increase medical costs. The high incidence of PONV and PDNV has persisted despite the introduction of many new antiemetic drugs (and more aggressive use of antiemetic prophylaxis) over the last two decades as a result of growth in minimally invasive ambulatory surgery and the increased emphasis on earlier mobilization and discharge after both minor and major surgical procedures (e.g. enhanced recovery protocols). Pharmacologic management of PONV should be tailored to the patient’s risk level using the validated PONV and PDNV risk-scoring systems to encourage cost-effective practices and minimize the potential for adverse side effects due to drug interactions in the perioperative period. A combination of prophylactic antiemetic drugs with different mechanisms of action should be administered to patients with moderate to high risk of developing PONV. In addition to utilizing prophylactic antiemetic drugs, the management of perioperative pain using opioid-sparing multimodal analgesic techniques is critically important for achieving an enhanced recovery after surgery. In conclusion, the utilization of strategies to reduce the baseline risk of PONV (e.g. adequate hydration and the use of nonpharmacologic antiemetic and opioid-sparing analgesic techniques) and implementing multimodal antiemetic and analgesic regimens will reduce the likelihood of patients developing PONV and PDNV after surgery.

Dexmedetomidine as an Opioid-Sparing Agent in Pediatric Craniofacial Surgery

Pediatric craniofacial reconstruction surgery is associated with significant perioperative analgesic requirements. As dexmedetomidine mediates central nervous system sympathetic activity and pain modulation, its intraoperative use could be beneficial in craniofacial surgery. We hypothesized that intraoperative administration of dexmedetomidine in children undergoing craniofacial reconstructive surgery would result in reduced opioid requirements, pain, sedation scores, and opioid-induced side effects compared to patients who did not receive dexmedetomidine. All patients who underwent craniofacial reconstructive surgery at our institution from July 2013 to June 2017 were retrospectively evaluated. The primary outcome measure was mean postoperative morphine equivalent requirements. Secondary outcome measures included incidence of opioid-related side effects, pain scores, and hospital length of stay. Thirty-nine patients received dexmedetomidine intraoperatively while 41 patients did not. There was no difference in postoperative opioid requirements or pain scores between the two cohorts. However, patients who received higher doses of dexmedetomidine (4.7 mcg/kg) intraoperatively exhibited significantly lower rescue medication requirements for nausea and vomiting postoperatively. Contrary to the hypothesis, dexmedetomidine was not associated with reduced postoperative opioid requirements or pain scores in children undergoing craniofacial reconstructive surgery. However, our findings do suggest that dexmedetomidine may be beneficial in reducing side effects such as postoperative nausea and vomiting. A randomized controlled trial would be necessary to verify these findings.

A Comparison of Dexmedetomidine and Midazolam for the Prevention of Postoperative Nausea and Vomiting Caused by Hemabate in Cesarean Delivery: A Randomized Controlled Trial

Objective

To compare the efficacy of dexmedetomidine and midazolam in the prevention of postoperative nausea and vomiting (PONV) caused by hemabate in postpartum hemorrhage during cesarean delivery.

Methods

One hundred and five parturients with American Society of Anesthesiology (ASA) physical status I and II, aged 20–40 years, undergoing elective cesarean delivery under epidural anesthesia were randomly allocated into dexmedetomidine group (group D, n=35), midazolam group (group M, n=35) and control group (group C, n=35). Patients received an intrauterine injection of 250 μg hemabate and continuous intravenous infusion of 5 units oxytocin immediately following the delivery of the infant. At the same time, patients in group D received 1μg/kg intravenous dexmedetomidine, group M received 0.02 mg/kg intravenous midazolam and group C received 20 mL intravenous saline. Parameters such as the PONV, other adverse reactions (chest distress, flush, etc.) caused by hemabate, patient satisfaction, the sedation (OAA/S) scores, and the hemodynamic parameters were recorded in both groups.

Results

The PONV incidence in group D and group M was significantly lower compared with group C (6%, 17%, and 71% for group D, group M, and group C, respectively, P<0.05). The sedation (OAA/S) scores in group D and group M was significantly higher compared with group C (1.62±0.28, 1.75±0.31, and 1.00±0.00 for group D, group M, and group C, respectively, P<0.05). The patient satisfaction in group D and group M was significantly higher compared with group C (94%, 69%, and 46% for group D, group M, and group C, respectively, P<0.05). Furthermore, there were more patients satisfied with group D than group M (94% vs.69%, P<0.05).

Conclusion

Intravenous dexmedetomidine (1 μg/kg) and midazolam (0.02 mg/kg) were equally effective in preventing PONV introduced by hemabate and dexmedetomidine is superior to midazolam in patient satisfaction.

Comparison of the Effects of Haloperidol, Metoclopramide, Dexmedetomidine and Ginger on Postoperative Nausea and Vomiting After Laparoscopic Cholecystectomy

Nausea is a mental sensation of unease and discomfort before vomiting. Vomiting refers to the return of the contents of the upper gastrointestinal tract to the mouth caused by contractions of chest and abdomen muscles. Postoperative nausea and vomiting is an unpleasant experience with high treatment costs. Therefore, this study aimed to compare the effects of haloperidol, metoclopramide, dexmedetomidine, and ginger on postoperative nausea and vomiting after laparoscopy. This double-blind clinical trial was performed on all laparoscopy candidates at Valiasr hospital, Arak, Iran. The patients were randomly divided into four groups (haloperidol, metoclopramide, dexmedetomidine and ginger), and all patients underwent general anesthesia using fentanyl, midazolam, atracurium, and propofol. After intubation, tube fixation, and stable hemodynamic conditions, the patients received four ginger capsules with a hint of lemon. A group of patients received 25 μg of dexmedetomidine. In the Plasil group, 10 mg of metoclopramide was given 30 minutes before the completion of surgery. In addition, 0.5 cc of haloperidol (5 mg) was administered to a group of patients. Heart rate, blood pressure, and oxygen saturation were recorded from the beginning of surgery, every 15 minutes until the end of the surgery. Furthermore, the occurrence of nausea and vomiting was recorded during recovery, 2 and 4 hours after surgery. Data were then analyzed using the SPSS software v.23. Eighty-eight patients were enrolled in the study. The youngest and the oldest were 30 years and 70 years old, respectively, and the mean age was 48.02 ± 9.31 years. Moreover, the number of women in the four groups was higher than that of men. Blood pressure in the dexmedetomidine group was lower than the other four groups (P <0.05). The lowest heart rate was observed in the haloperidol group, while the highest heart rate was seen in the plasil group (P <0.05). The occurrence of vomiting and nausea was not significantly different between the four groups (P <0.05). Our results showed no significant difference in postoperative nausea and vomiting between the four drugs. Due to the hemodynamic changes induced by each drug, it is best to use these drugs based on the patient's condition. Ginger is also a herbal remedy that has fewer side effects, and this drug can be a good option for patients when there is no contraindication.

[Risk factors for nausea and vomiting after adolescent idiopathic scoliosis surgery]

OBJECTIVE

To explore risk factors for postoperative nausea and vomiting (PONV) that requires intervention with medications during adolescent idiopathic scoliosis (AIS) surgery.

METHODS

We analyzed the data of 986 patients with AIS (including 156 male and 830 female patients) undergoing scoliosis surgery through a posterior approach between December, 2012 and January, 2016 in Nanjing Drum Tower Hospital. The data were collected from the patients including ASA grade, body mass index (BMI), Cobb angle, preoperative respiratory and cardiovascular diseases, operation time, type of anesthesia, quantity of intraoperative liquid infusion, blood loss, urine volume, the lowest MAP and CVP, intraoperative fentanyl consumption, and intraoperative administration of dexmedetomidine, dexamethasone, ondansetran and droperidol. The incidence of PONV in 48 h following the surgery, hemoglobin variation after operation (ΔHb), postoperative analgesia, times of use and types of antiemetic drugs, and postoperative hospital stay were recorded for all the patients. The potential risk factors of PONV within 48 h were analyzed using univariate analysis and multivariate logistic regression.

RESULTS

Of the 986 patients analyzed, 151 (15.3%) experienced PONV within 48 h following surgeries for AIS. Multivariate logistic regression analysis suggested that an high intraoperative fentanyl dose (> 0.65 mg; OR=9.303, 95% CI: 2.373-8.622, P < 0.001), an obvious ΔHb (> 28.5 g/L; OR=1.107, 95% CI: 1.060-1.157, P < 0.001), and postoperative analgesia with fentanyl (OR=11.671, 95% CI: 2.381-11.284, P < 0.001) were risk factors for PONV. Intraoperative administration of dexmedetomidine (OR=0.027, 95% CI: 0.006-0.123, P=0.002) and dexamethasone combined with ondansetron (OR=0.241, 95%CI: 0.066-0.886, P=0.032) were protective factors against PONV.

CONCLUSIONS

A high-dose intraoperative fentanyl consumption, a marked ΔHb, and postoperative analgesia with fentanyl are risk factors for PONV while intraoperative administration of dexmedetomidine and dexamethasone combined with ondansetron are protective factors against PONV following surgeries for AIS.

Effectiveness and safety of intravenous application of dexmedetomidine for cesarean section under general anesthesia: a meta-analysis of randomized trials

Objective

The meta-analysis was conducted to assess the effectiveness and safety of intravenous administration of dexmedetomidine for cesarean section under general anesthesia, as well as neonatal outcomes.

Materials and methods

We searched PubMed, Embase, Cochrane Central Register of Controlled Trials and the China National Knowledge Infrastructure database for relevant randomized controlled trials (RCTs) about the application of intravenous dexmedetomidine under general anesthesia for cesarean section. RevMan 5.3 was used to conduct the meta-analysis of the outcomes of interest.

Results

Eight RCTs involved 376 participants were included in this study. The meta-analysis showed that the mean blood pressure at the time of intubation (weighted mean difference [WMD]: -15.67, 95% CI: -21.21, -10.13, P<0.00001), skin incision (WMD: -12.83, 95% CI -20.53, -5.14, P=0.001), and delivery (WMD: -11.65, 95% CI -17.18, -6.13, P<0.0001) in dexmedetomidine group were significantly lower than that in the control group. The heart rate (HR) at the time of intubation (WMD: -31.41, 95% CI -35.01, -27.81, P<0.00001), skin incision (WMD: -22.32, 95% CI -34.55, -10.10, P=0.0003), and delivery (WMD: -19.07, 95% CI -22.09, -16.04, P<0.00001) were also lower than that in control group. For neonatal parameters, no differences existed in umbilical blood gases at delivery, and Apgar scores at 1 minute (WMD: -0.12, 95% CI -0.37, 0.12, P=0.33) and 5 minutes (WMD: -0.17, 95% CI -0.13, 0.46, P=0.27) among two groups.

Conclusion

Intravenous administration of dexmedetomidine could efficiently attenuate the maternal cardiovascular response during cesarean section, without affecting Apgar score of the neonate.

Sedation with dexmedetomidine prolongs the analgesic duration of brachial plexus block: a randomised controlled trial

PURPOSE

Dexmedetomidine, an alpha 2 receptor agonist, prolongs nerve block duration when administered in conjunction with peripheral nerve blocks. We hypothesised that sedation with dexmedetomidine could also significantly prolong the analgesic duration of brachial plexus block (BPB) during orthopaedic surgery on the upper extremities.

MATERIALS AND METHODS

One hundred and two patients received upper extremity surgery under BPB. The patients were randomly sedated with dexmedetomidine (D group) or midazolam (M group) following BPB using 25 mL of local anaesthetics (1:1 mixture of 1% lidocaine and 0.75% ropivacaine). Adequate sedation was evaluated with the modified Ramsay Sedation Scale. Primary outcome was measured as the time the patient first requested analgesic via a patient-controlled analgesia device. Total opioid consumption during the first 24 post-operative hours was also measured as secondary outcomes.

RESULTS

Time to first request for analgesia (mean ± standard deviation) was significantly longer in the D group (616.9 ± 158.2 min) than in the M group (443.7 ± 127.2 min) (P < 0.001, Mean difference [95% CI] 173.2 [114.8-231.5] min). Total opioid consumption were significantly lower in the D group (fentanyl equivalent, 280.0 μg [171.3;374.0] vs. 363.9 μg [208.3;570.1], P = 0.01). Although patients in the D group showed deeper sedation over time (P < 0.001), PACU stay time was only slightly extended in D group (5.2 [1.2-9.2] min). Perioperative complications did not differ in the two groups.

CONCLUSION

Sedation with dexmedetomidine not only prolongs analgesic duration of BPB, but also reduces total opioid consumption during the first 24 post-operative hours.