Pooled analysis of the efficacy and safety of intraoperative dexmedetomidine on postoperative catheter-related bladder discomfort

Successful Second Awake Craniotomy Reoperation With Dexmedetomidine After an Initial Abandonment Case Due to Restlessness

Awake craniotomy (AC) is sometimes aborted due to poor arousal and restlessness. Dexmedetomidine (DEX), an α2-adrenoreceptor agonist, has sedative, analgesic, and anesthetic-sparing effects, with a low risk of respiratory depression, making it effective for intraoperative pain and agitation during the awake phase. We report a case in which AC was successfully performed in combination with low-dose continuous administration of DEX during reoperation in a patient who experienced poor arousal and restlessness during their first surgery, leading to the abandonment of AC. The patient is a 48-year-old male who is scheduled for AC reoperation. Two years ago, the first AC was scheduled and performed under anesthesia with propofol and remifentanil. However, AC was abandoned due to poor intraoperative arousal and restlessness. At reoperation, general anesthesia was induced with propofol and continuous administration of remifentanil (0.1 µg/kg/min); following anesthesia induction (continuous infusion of propofol, remifentanil, and a bolus infusion of fentanyl), DEX was also administered (0.2 µg/kg/hour). We performed a scalp nerve block. Before the awake phase, the propofol dose was decreased as was DEX to 0.1 µg/kg/hour, and propofol and remifentanil were discontinued. The patient gradually awoke without any agitation and restlessness 24 min after stopping propofol and remifentanil and could perform language tasks without any complications. In this case, AC was successfully performed in combination with continuous low-dose administration of DEX at the time of reoperation in a patient who experienced poor arousal and restlessness during their first operation and had to discontinue AC.

Determination of the 90% Effective Dose of Dexmedetomidine for Treating Postoperative Catheter‑related Bladder Discomfort During Recovery: An Open-label, Single-group Study

PURPOSE

Catheter-related bladder discomfort (CRBD) is an unpleasant experience for patients during postoperative recovery. Dexmedetomidine is an effective therapy for CRBD; however, little is known about dexmedetomidine administration for treating CRBD during recovery. This study was conducted to determine the 90% effective dose (ED90) of dexmedetomidine to provide adequate treatment for CRBD during recovery.

DESIGN

Prospective, single-blind dose-finding study.

METHODS

This open-label, single-group trial included severe postoperative CRBD patients aged 18 to 80 years and the American Society of Anesthesiologists' physical status class I or II in the postanesthesia care unit. All patients were assigned to receive intravenous dexmedetomidine. The dose of dexmedetomidine was determined using the modified Dixon's up-and-down method. The first patient was treated with 0.4 mcg/kg dexmedetomidine. An increment or decrement of 0.05 mcg/kg dexmedetomidine was used based on the response of the previous patient. A successful treatment was defined as the transition from severe CRBD to mild CRBD. Probit regression was applied to calculate the ED90 of dexmedetomidine.

FINDINGS

A total of 29 patients were recruited, of whom 14 patients (48.3%) underwent successful treatment. The ED90 of dexmedetomidine required for successfully treating postoperative CRBD was 0.55 mcg/kg (95% confidence interval: 0.49-1.54 mcg/kg).

CONCLUSIONS

The ED90 of dexmedetomidine for the successful treatment of severe postoperative CRBD during recovery is 0.55 mcg/kg.

Different interventions for preventing postoperative catheter-related bladder discomfort: a systematic review and meta-analysis

OBJECTIVE

Catheter-related bladder discomfort (CRBD) is a common complication of intraoperative urinary catheterization. Various studies have evaluated the efficacy of different interventions in postoperative CRBD. The present review was performed to assess the efficacy of these interventions.

METHODS

PubMed, Embase, and CENTRAL (Cochrane Central Register of Controlled Trials) databases were systematically searched to identify randomized controlled trials (RCTs) investigating the efficacy of different drugs for the prevention of postoperative CRBD. This review evaluated the incidence and severity of CRBD after different interventions at 0, 1, 2, and 6 h postoperatively.

RESULTS

Forty-five studies including 31 different drugs were analyzed. Eleven drugs were investigated in more than two RCTs, of which dexmedetomidine, gabapentin, tolterodine, tramadol, ketamine, nefopam, oxybutynin, pregabalin, and pudendal nerve block (PNB) generally showed significantly higher efficacy than controls postoperatively. Solifenacin only showed significant efficacy compared with the control at 0 h, and intravenous lidocaine only showed significant efficacy compared with the control at 6 h. There were insufficient trials to draw conclusions regarding atropine, butylscopolamine, chlorpheniramine, clonidine, darifenacin, diphenhydramine, glycopyrrolate, intravesical bupivacaine, ketamine-haloperidol, pethidine-haloperidol, ketorolac, lidocaine-prilocaine cream, magnesium, hyoscine n-butyl bromide, oxycodone, paracetamol, parecoxib, trospium, resiniferatoxin, or amikacin. However, all but pethidine-haloperidol and chlorpheniramine showed some efficacy at various time points compared with controls.

CONCLUSION

This review suggests that dexmedetomidine, gabapentin, tolterodine, tramadol, ketamine, nefopam, oxybutynin, pregabalin, and PNB are effective in preventing postoperative CRBD. Considering the efficacy and adverse effects of all drugs, dexmedetomidine and gabapentin were ranked best.

Effects of various catheter fix sites on catheter-associated lower urinary tract symptoms

The present study aimed to compare the effects of various catheter fix sites on catheter-associated lower urinary tract symptoms (CALUTS) in 450 patients who underwent surgical removal of upper urinary calculi 24 h earlier. All patients had 16 French Foley catheters inserted and the balloons were filled. In group A, the catheters were fixed on the top one-third of the thigh. In group B, the catheters were fixed on the abdominal wall. Patients in whom the catheters were neither fixed on the thigh nor abdominal wall were designated as controls. There were 150 patients in each group. CALUTS, such as frequency, urgency, burning during micturition, odynuria, bladder pain and other symptoms, including urethral discharge, a red and swollen external urethral orifice, catheter traction or blockage and catheter-associated discomfort were recorded. Patients in group A compared with the control group had a significantly lower incidence of frequency, urgency, odynuria, urethral discharge, catheter traction and catheter-associated discomfort (P<0.05). Patients in group B were observed to have a significantly lower incidence of urgency, urethral discharge, catheter traction and catheter-associated discomfort compared with the control group (P<0.05), but a higher incidence of odynuria, urethral pain, urethral discharge and a red and swollen external urethral orifice compared with group A (P<0.05). An additional catheter fixation site for bedridden patients was necessary and an additional fix site on the thigh was preferred to the abdominal wall, which may further reduce catheter-associated lower urinary tract symptoms.