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Xu H, Wang L, Zhu W, Ren C, Liu G, Liu Y. Comparison of the Safety and Efficacy of Remimazolam Besylate versus Dexmedetomidine for Patients Undergoing Fiberoptic Bronchoscopy: A Prospective, Randomized Controlled Trial. Drug Des Devel Ther 2024; 18:2317-2327. [PMID: 38915861 PMCID: PMC11194170 DOI: 10.2147/dddt.s460949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 06/11/2024] [Indexed: 06/26/2024] Open
Abstract
Objective Remimazolam besylate is a novel ultra-short-acting benzodiazepine that is rapidly hydrolyzed to zolpidem propionic acid by tissue lipases. We designed this study to compare the safety and efficacy of remimazolam besylate alfentanil versus dexmedetomidine-alfentanil for fiberoptic bronchoscopy (FB). Methods One hundred and twenty patients undergoing FB into this prospective randomized controlled trial were divided into two groups. The anesthesia induction consisted of 6 mg/kg/h of remimazolam besylate in the RA group and 0.5 μg/kg of dexmedetomidine in the DA group. 1-2 mg/kg/h of remimazolam besylate or 0.2-0.7 µg/kg/h of dexmedetomidine were administered to maintain during FB. The lowest oxygen saturation, success rate of FB, hemodynamics, time metrics, bronchoscopy feasibility, drug dose requirements, patient and bronchoscopist satisfaction scores, occurrence of intraoperative awareness, number of patients willing to repeat FB with the same sedation regimen, and occurrence and severity of adverse events. Results The lowest oxygen saturation during the FB was significantly higher in the RA group (P = 0.001). Compared with the variables in the DA group, peripheral oxygen saturation, systolic blood pressure, and diastolic blood pressure were significantly lower at T2 and T3 in the RA group (P < 0.05). Heart rates were significantly higher from T2 to T4 in the DA group (P < 0.05). More patients experienced bradycardia in the DA group (P = 0.041). Compared with time metrics in the DA group, the induction time, fully-alert time, and recovery room-leaving time were all significantly shorter in the RA group (P < 0.05). The bronchoscopy feasibility scores in the RA group were significantly lower at T2, whereas they were lower at T3 in the DA group (P < 0.05). Conclusion Remimazolam besylate is superior to dexmedetomidine when combined with alfentanil during FB, promoting faster patients' recovery, better operative conditions and respiratory stability with similar rates of occurrence and severity of adverse events.
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Affiliation(s)
- Huiying Xu
- Department of Anaesthesiology, Liaocheng People’s Hospital, Liaocheng, People’s Republic of China
| | - Lizhen Wang
- Department of Tuberculosis, Liaocheng Infectious Disease Hospital, Liaocheng, People’s Republic of China
| | - Wenchao Zhu
- Department of Anaesthesiology, Liaocheng People’s Hospital, Liaocheng, People’s Republic of China
| | - Chunguang Ren
- Department of Anaesthesiology, Liaocheng People’s Hospital, Liaocheng, People’s Republic of China
| | - Guoying Liu
- Department of Anaesthesiology, Liaocheng People’s Hospital, Liaocheng, People’s Republic of China
| | - Yanchao Liu
- Department of Anaesthesiology, Liaocheng People’s Hospital, Liaocheng, People’s Republic of China
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Maagaard M, Funder KS, Schou NK, Penny JØ, Toquer P, Laigaard J, Stormholt ER, Nørskov AK, Jæger P, Andersen JH, Mathiesen O. Combined Dexamethasone and Dexmedetomidine as Adjuncts to Popliteal and Saphenous Nerve Blocks in Patients Undergoing Surgery of the Foot or Ankle: A Randomized, Blinded, Placebo-controlled Clinical Trial. Anesthesiology 2024; 140:1165-1175. [PMID: 38489226 DOI: 10.1097/aln.0000000000004977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2024]
Abstract
BACKGROUND Both dexamethasone and dexmedetomidine increase the duration of analgesia of peripheral nerve blocks. The authors hypothesized that combined intravenous dexamethasone and intravenous dexmedetomidine would result in a greater duration of analgesia when compared with intravenous dexamethasone alone and placebo. METHODS The authors randomly allocated participants undergoing surgery of the foot or ankle under general anesthesia and with a combined popliteal (sciatic) and saphenous nerve block to a combination of 12 mg dexamethasone and 1 µg/kg dexmedetomidine, 12 mg dexamethasone, or placebo (saline). The primary outcome was the duration of analgesia measured as the time from block performance until the first sensation of pain in the surgical area as reported by the participant. The authors predefined a 33% difference in the duration of analgesia as clinically relevant. RESULTS A total of 120 participants from two centers were randomized and 119 analyzed for the primary outcome. The median [interquartile range] duration of analgesia was 1,572 min [1,259 to 1,715] with combined dexamethasone and dexmedetomidine, 1,400 min [1,133 to 1,750] with dexamethasone alone, and 870 min [748 to 1,138] with placebo. Compared with placebo, the duration was greater with combined dexamethasone and dexmedetomidine (difference, 564 min; 98.33% CI, 301 to 794; P < 0.001) and with dexamethasone (difference, 489 min; 98.33% CI, 265 to 706; P < 0.001). The prolongations exceeded the authors' predefined clinically relevant difference. The duration was similar when combined dexamethasone and dexmedetomidine was compared with dexamethasone alone (difference, 61 min; 98.33% CI, -222 to 331; P = 0.614). CONCLUSIONS Dexamethasone with or without dexmedetomidine increased the duration of analgesia in patients undergoing surgery of the foot or ankle with a popliteal (sciatic) and saphenous nerve block. Combined dexamethasone and dexmedetomidine did not increase the duration of analgesia when compared with dexamethasone. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Mathias Maagaard
- Centre for Anaesthesiological Research, Department of Anesthesiology, Zealand University Hospital, Køge, Denmark
| | - Kamilia S Funder
- Department of Anesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Nikolaj K Schou
- Centre for Anaesthesiological Research, Department of Anesthesiology, Zealand University Hospital, Køge, Denmark
| | - Jeannette Ø Penny
- Department of Orthopedic Surgery and Traumatology, Zealand University Hospital, Køge, Denmark
| | - Peter Toquer
- Department of Orthopedic Surgery and Traumatology, Zealand University Hospital, Køge, Denmark
| | - Jens Laigaard
- Department of Orthopedic Surgery, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Emma R Stormholt
- Centre for Anaesthesiological Research, Department of Anesthesiology, Zealand University Hospital, Køge, Denmark
| | - Anders K Nørskov
- Centre for Anaesthesiological Research, Department of Anesthesiology, Zealand University Hospital, Køge, Denmark; Department of Anesthesiology, Copenhagen University Hospital-North-Zealand, Hillerød, Denmark
| | - Pia Jæger
- Department of Anesthesiology, The Juliane Marie Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jakob H Andersen
- Centre for Anaesthesiological Research, Department of Anesthesiology, Zealand University Hospital, Køge, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Ole Mathiesen
- Centre for Anaesthesiological Research, Department of Anesthesiology, Zealand University Hospital, Køge, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Maagaard M, Andersen JH, Jaeger P, Mathiesen O. Effects of combined dexamethasone and dexmedetomidine as adjuncts to peripheral nerve blocks: a systematic review with meta-analysis and trial sequential analysis. Reg Anesth Pain Med 2024:rapm-2023-105098. [PMID: 38253609 DOI: 10.1136/rapm-2023-105098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 01/02/2024] [Indexed: 01/24/2024]
Abstract
BACKGROUND/IMPORTANCE The effects of combining dexamethasone and dexmedetomidine on block duration are unclear. OBJECTIVE To investigate the effects of combining dexamethasone and dexmedetomidine on block duration. EVIDENCE REVIEW Systematic review of randomized controlled trials (RCTs) from Medline, Embase, CENTRAL, CINAHL, the Web of Science, and BIOSIS until June 8, 2023. RCTs with adults undergoing surgery with a peripheral nerve block randomized to combined dexamethasone and dexmedetomidine versus placebo or other adjuncts were eligible. Primary outcome was duration of analgesia. We performed meta-analysis, trial sequential analysis, risk of bias-2, and Grading Recommendations Assessment, Development, and Evaluation assessment. FINDINGS We included 9 RCTs with 14 eligible comparisons. The combination of dexamethasone and dexmedetomidine was compared with placebo in three RCTs (173 participants), dexamethasone in seven (569 participants), and dexmedetomidine in four (281 participants). The duration of analgesia was likely increased with the combination versus placebo (mean difference 460 min, 95% CI 249 to 671) and versus dexmedetomidine (mean difference 388 min, 95% CI 211 to 565). The duration was likely similar with the combination versus dexamethasone (mean difference 50 min, 95% CI -140 to 239). The certainty of the evidence was moderate because most trials were at high risk of bias. CONCLUSIONS Combined dexamethasone and dexmedetomidine likely increased the duration of analgesia when compared with placebo and dexmedetomidine. The combination likely provided a similar duration of analgesia as dexamethasone. Based on this systematic review, it seems reasonable to use dexamethasone as the sole adjunct if the goal is to increase the duration of analgesia.
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Affiliation(s)
| | | | - Pia Jaeger
- Department of Anaesthesia, the Juliane Marie Centre, Copenhagen University Hospital, Kobenhavn, Denmark
| | - Ole Mathiesen
- Anaesthesiology, Zealand University Hospital, Koge, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Desai N, Albrecht E. Local anaesthetic adjuncts for peripheral nerve blockade. Curr Opin Anaesthesiol 2023; 36:533-540. [PMID: 37314172 DOI: 10.1097/aco.0000000000001272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
PURPOSE OF REVIEW Moderate-to-severe pain is common and remains a significant problem. Compared with opioid analgesia alone, single-shot peripheral nerve blockade has been associated with improved pain relief and the potential of decreased side effects. Single-shot nerve blockade, however, is limited by its relatively short duration of action. In this review, we aim to summarize the evidence related to local anaesthetic adjuncts for peripheral nerve blockade. RECENT FINDINGS Dexamethasone and dexmedetomidine exhibit characteristics that most closely resemble the ideal local anaesthetic adjunct. In upper limb block, dexamethasone has been demonstrated to be superior to dexmedetomidine regardless of administration route for the duration of sensory and motor blockade as well as the duration of analgesia. No clinically significant differences between intravenous and perineural dexamethasone were found. Perineural and intravenous dexamethasone have the potential to prolong sensory blockade to a greater extent than motor blockade. The evidence indicates that the mechanism of action of perineural dexamethasone in upper limb block is systemic in nature. Unlike perineural dexmedetomidine, intravenous dexmedetomidine has not been shown to result in differences in the characteristics of regional blockade compared with local anaesthetic alone. SUMMARY Intravenous dexamethasone is the local anaesthetic adjunct of choice, increasing the duration of sensory and motor blockade as well as the duration of analgesia by 477, 289 and 478 min, respectively. In view of this, we recommend consideration of the intravenous administration of dexamethasone at a dose of 0.1-0.2 mg/kg for all patients undergoing surgery whatever the level of postoperative pain, mild, moderate or severe. Further research should focus on the potential synergism of action between intravenous dexamethasone and perineural dexmedetomidine.
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Affiliation(s)
- Neel Desai
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust
- King's College London, London, United Kingdom
| | - Eric Albrecht
- Department of Anaesthesia, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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