Intravenous infusion of dexmedetomidine amplifies thoracic epidural analgesic effect after open thoracotomy: A prospective, double-blind, randomized controlled trial

Update on guidelines and recommendations for enhanced recovery after thoracic surgery

PURPOSE OF REVIEW

Enhanced recovery after thoracic surgery (ERATS) has continued its growth in popularity over the past few years, and evidence for its utility is catching up to other specialties. This review will present and examine some of that accumulated evidence since guidelines sponsored by the Enhanced Recovery after Surgery (ERAS) Society and the European Society of Thoracic Surgeons (ESTS) were first published in 2019.

RECENT FINDINGS

The ERAS/ESTS guidelines published in 2019 have not been updated, but new studies have been done and new data has been published regarding some of the individual components of the guidelines as they relate to thoracic and lung resection surgery. While there is still not a consensus on many of these issues, the volume of available evidence is becoming more robust, some of which will be incorporated into this review.

SUMMARY

The continued accumulation of data and evidence for the benefits of enhanced recovery techniques in thoracic and lung resection surgery will provide the thoracic anesthesiologist with guidance on how to best care for these patients before, during, and after surgery. The data from these studies will also help to elucidate which components of ERAS protocols are the most beneficial, and which components perhaps do not provide as much benefit as previously thought.

The Effect of Epidural Infusion of Dexmedetomidine on Postoperative Analgesia After Thoracotomy: A Randomized Clinical Trial

Background

The unique analgesic properties of dexmedetomidine have led anesthesiologists to use it as an alternative to relieve pain after major surgeries.

Objectives

We aimed to evaluate the effect of continuous injection of thoracic epidural dexmedetomidine on analgesia after thoracotomy.

Methods

In this randomized, double-blind clinical trial, 46 patients (18 to 70 years old) who were candidates for thoracotomy surgery were randomly assigned to receive ropivacaine alone or combined with dexmedetomidine after epidural anesthesia as postoperative epidural anesthesia. The postoperative sedation rate, pain score, and opioid use were assessed within 48 hours after surgery and compared between the 2 groups.

Results

Comparing the mean postoperative sedation scores indicated no difference between the 2 study groups. The pain score assessment showed a lower pain score 6 to 36 hours after surgery in the group receiving concurrent ropivacaine and dexmedetomidine than in the group receiving ropivacaine alone. In the 2 groups receiving ropivacaine with and without dexmedetomidine, the rate of morphine administration after surgery was 43.4% and 65.2%, respectively, indicating no difference. However, the first group received significantly lower doses of morphine after the end of surgery (3.26 ± 0.90 mg vs. 7.04 ± 1.48 mg; P = 0.035).

Conclusions

A combination of ropivacaine and dexmedetomidine as epidural analgesia can lead to lower postoperative pain scores and reduced doses of opioids required.

Effects of Different Doses of Dexmedetomidine Combined with Thoracic Paravertebral Nerve Block Anesthesia on Agitation and Hemodynamics in Patients Undergoing Thoracotomy during Recovery

Objective

To investigate the effect of different doses of dexmedetomidine combined with thoracic paravertebral nerve block anesthesia on agitation and hemodynamics in patients undergoing thoracotomy during recovery.

Methods

One hundred patients who underwent thoracotomy in our hospital from August 2018 to April 2021 were enrolled and assigned (1 : 1 : 1 : 1) into 4 groups via the random number table method. The patients in the control group were treated with double-lumen tube general anesthesia + ropivacaine for thoracic paravertebral nerve block anesthesia; patients in experimental group A received double-lumen general anesthesia +0.5 μg·kg^-1 dexmedetomidine + ropivacaine for thoracic paravertebral nerve block anesthesia; patients in experimental group B received thoracic paravertebral nerve block anesthesia with double-lumen general anesthesia +1.0 μg·kg^-1 dexmedetomidine + ropivacaine; patients in experimental group C received thoracic paravertebral nerve block anesthesia with double-lumen general anesthesia +1.5 μg·kg^-1 dexmedetomidine + ropivacaine. The postoperative recovery time and visual analog scale (VAS), level of hemodynamics (heart rate (HR), mean arterial pressure (MAP)), agitation during the recovery period, and complications were compared amongst the 4 groups of patients at different time points.

Results

The postoperative VAS scores of patients in groups B2 and B3 were slightly lower than those of patients in groups A and B1, but a one-way analysis of variance revealed no statistical difference in the postoperative recovery time and VAS pain scores of the four groups (P > 0.05), and the recovery time of patients in experimental group C was slightly higher than that of patients in group B2. At T0 and T1, there was no significant difference in the levels of HR and MAP among the four groups (P > 0.05). The levels of HR and MAP of the patients in groups B2 and B3 were significantly different from the patients in the control group and experimental group A at T2 and T3 (P < 0.05). The patients in experimental group B and experimental group C showed better outcomes than those in the control group and experimental group A in the assessment of agitation during the recovery period (P < 0.05). There was no significant difference in the incidence of complications among the four groups (P > 0.05).

Conclusion

In line with the principle of preference for a small anesthesia dose, 1.0 μg·kg^-1 dose of dexmedetomidine combined with ropivacaine produces a pronounced efficacy in patients undergoing thoracotomy. It effectively controls the occurrence of agitation during the recovery period and maintains the stability of the patient's hemodynamics, with a high clinical safety profile.