Comparison of the effects of dexmedetomidine and remifentanil on perioperative hemodynamics and recovery profile of patients undergoing laryngeal microsurgery: A prospective randomized double-blinded study

Superior Laryngeal Nerve Block for Microlaryngoscopic Surgery: A Systematic Review and Meta-Analysis

OBJECTIVES

To assess the safety and efficacy of superior laryngeal nerve block (SLNB) for microlaryngoscopic surgery (MLS).

DATA SOURCES

PubMed, Embase, Web of Science, Ovid Medline, Cochrane Library, CNKI database, VIP database, Wanfang database, and trial registry databases.

METHODS

PICOS principles were performed: adults undergoing MLS receiving SLNB compared with no-SLNB in randomized controlled trials were included. Primary outcome included the incidence of severe postoperative sore throat (POST). Secondary outcomes included perioperative mean arterial pressure (MAP) and heart rate (HR), incidence of severe postoperative cough, and anesthesia recovery time.

RESULTS

Eleven articles with 728 patients were included. Results indicated that SLNB provides lower incidence of severe POST in post-extubation 30 min (relative ratio [RR] = 0.13; 95% confidence intervals [CIs]: 0.05 ~ 0.34), 2 h (RR = 0.09; 95% CI: 0.02 ~ 0.36), 4-6 h (RR = 0.11; 95% CI: 0.03 ~ 0.41), and 24 h (RR = 0.15; 95% CI: 0.03 ~ 0.83); lower MAP (tracheal intubation: standardized mean difference [SMD] = -1.59; 95% CI: -1.69 to -0.42); suspension laryngoscope insertion: (SMD = -0.98; 95% CI: -1.49 to -0.46); tracheal extubation: (SMD = -0.78; 95% CI:-1.24 to -0.31); post-extubation 5 min: (SMD = -0.95; 95% CI: -1.41 to -0.49); lower HR (tracheal intubation: mean difference [MD] = -9.71; 95% CI: -17.16 to -2.27); suspension laryngoscope insertion: (MD = -8.64; 95% CI: -16.79 to -0.49); tracheal extubation: (MD = -10.13; 95% CI: -17.86 to -2.39); post-extubation 5 min: (MD = -13.44; 95% CI: -22.53 to -4.35); lower incidence of severe postoperative cough in post-extubation 30 min (RR = 0.18; 95% CI: 0.06 ~ 0.57) and 2 h (RR = 0.13; 95% CI: 0.02 ~ 0.69); and shorter anesthesia recovery time (MD = -5.34; 95% CI: -8.81 to -1.86) compared to controls.

CONCLUSIONS

SLNB could provide lower incidence of severe POST, more stable perioperative MAP and HR, lower incidence of severe postoperative cough, and shorter anesthesia recovery time for MLS.

LEVEL OF EVIDENCE

I Laryngoscope, 134:3437-3446, 2024.

Esketamine versus Sufentanil Applied Prior to Placement of Suspension Laryngoscope

OBJECTIVE

In laryngeal microsurgery, the insertion of the suspension laryngoscope is a strong stimulus that may cause hemodynamic fluctuations and adverse cardiovascular events. The purpose of this study was to compare the effect of preemptive treatment with esketamine and sufentanil on maintaining hemodynamics and reducing the occurrence of adverse cardiovascular events during the insertion of suspension laryngoscope.

METHODS

In this double-blind randomized controlled trial, patients undergoing general anesthesia for laryngeal microsurgery were randomly assigned (1:1) to esketamine 0.5 mg kg-1 (esketamine group) and sufentanyl 0.125 μg kg-1 (sufentanil group) before inserting the laryngoscope, respectively.

RESULTS

During the insertion of suspension laryngoscope, the incidence of bradycardia (HR < 60 beats/min) was 39.3% (22/56) in esketamine group, lower than 60.0% (33/55) in sufentanil group (odds ratio [OR], 2.32 [95% CI, 1.11-5.08]; p = 0.029). The incidence of hypotension (MAP <65 mmHg) was 33.9% (19/56) in esketamine group, lower than 56.4% (31/55) in sufentanil group (odds ratio [OR], 2.52 [95% CI, 1.91-5.27]; p = 0.018). The frequency of hypotension in esketamine group was lower than that in sufentanil group (0.36 ± 0.52 vs. 0.56 ± 0.50, p = 0.035). The time-weighted average of HR dropping above 30% of baseline was smaller in esketamine group than in sufentanil group (0.52 ± 2.06 vs. 1.08 ± 2.77, p = 0.006).

CONCLUSIONS

These findings showed that compared with preemptive treatment of sufentanil (0.125 μg kg-1 ), esketamine (0.5 mg kg-1 ) was effective in reducing the incidence of cardiovascular adverse events, including bradycardia and hypotension induced by the insertion of suspension laryngoscope during the laryngeal microsurgery.

LEVEL OF EVIDENCE

2 Laryngoscope, 133:3021-3027, 2023.

Efficacy of a propofol bolus against placebo to prevent cough at emergence from general anesthesia with desflurane: a randomized controlled trial

PURPOSE

Emergence from anesthesia is a critical period and cough can result in adverse effects. Propofol inhibits airway reflexes and when infused it reduces cough more than inhalation anesthesia does. We evaluated the effect of a propofol bolus given at emergence on the incidence of coughing following a desflurane-based anesthesia.

METHODS

One hundred and fifty-four patients scheduled for elective surgery were prospectively randomized to propofol (0.5 mg·kg-1) or normal saline (NS) administered at the end of the surgery at 1 minimum alveolar concentration (MAC) of desflurane. A "no touch" emergence technique was used until extubation. The primary outcome was the incidence of cough at the discontinuation of desflurane (T0) and reaching a MAC adjusted for age (MACage) of 0.15. Secondary outcomes included incidence and severity of cough until five minutes postextubation (T0-T5), time to extubation, nausea and vomiting, sedation, hemodynamic variations, postoperative hypoventilation, hypoxemia, and sore throat.

RESULTS

We could not draw inferences on the incidence of cough between T0 and MACage of 0.15 because only 27/68 (40%) patients in the NS group and 13/73 (18%) patients in the propofol group regained consciousness before reaching a MACage of 0.15. There were no significant differences between the groups in coughing incidence and severity between T0 and T5 (NS group, 57/68 [84%] vs propofol group, 70/73 [96%] ). The mean time to extubation in the propofol group was prolonged by 3 min 27 sec (95% confidence interval, 1 min 7 sec to 4 min 47 sec; P < 0.001) and more vasopressors were used at emergence (P = 0.02). The incidence of respiratory complications, nausea and vomiting, agitation, and sedation were not different between groups.

CONCLUSION

In the present trial, a propofol bolus administered at emergence did not reduce the incidence of cough occurring between T0 and T5 following a desflurane-based general anesthesia compared with placebo.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT02932397); registered 13 October 2016.

Comparison of dexmedetomidine and remifentanil on reducing coughing during emergence from anesthesia with tracheal intubation: A meta-analysis

Background: Dexmedetomidine and remifentanil are well known to suppress airway reflex during emergence from anesthesia, but which one is more effective is unclear. We conducted a meta-analysis to compare the effect of dexmedetomidine and remifentanil on reducing the occurrence of coughing.

Methods: We systematically searched PubMed, Embase, and Cochrane Library for randomized controlled trials (published between 1 January 1950, and 30 December 2021; no language restrictions) comparing dexmedetomidine infusion with remifentanil infusion. The primary endpoint was the incidence of moderate to severe coughing during the recovery period. The secondary endpoints were the time of recovery and extubation, and residual sedation. We assessed pooled data by using a random-effects model.

Results: Eight studies with 502 participants were included. The meta-analysis showed no statistically difference between dexmedetomidine and remifentanil in the occurrence of moderate to severe coughing during emergence from anesthesia (OR 1.45,95%CI 0.62–3.38), the extubation time (MD 0.93 min, 95%CI -0.28–2.14), and the residual sedation (OR 2.52, 95%CI 0.92–6.91). Compared with dexmedetomidine, the average recovery time of remifentanil was shorter (MD 3.88 min, 95%CI 1.01–6.75).

Conclusion: Dexmedetomidine and remifentanil infusion had no difference in the occurrence of moderate to severe coughing during emergence from anesthesia.

Clinical Trial Registration:https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42021239710