Efficacy and safety of intraoperative dexmedetomidine for acute postoperative pain in children: a meta-analysis of randomized controlled trials

Anesthetic-sparing effect of dexmedetomidine during total intravenous anesthesia for children undergoing dental surgery: A randomized controlled trial

BACKGROUND

Dexmedetomidine, an α2-adrenergic agonist, reduces propofol and remifentanil requirements when used as an adjunct to total intravenous anesthesia in adults, but studies in a pediatric population are sparse. This study investigates the magnitude of dose-sparing effects of a postinduction dexmedetomidine bolus on propofol and remifentanil requirements during pediatric surgery.

METHODS

In this randomized, double-blind, controlled trial, children aged 2-10 years undergoing elective dental surgery were assigned to one of four groups: placebo, 0.25 mcg/kg dexmedetomidine, 0.5 mcg/kg dexmedetomidine, and 1 mcg/kg dexmedetomidine. Maintenance with fixed-ratio propofol and remifentanil total intravenous anesthesia followed a bispectral index (BIS)-guided algorithm designed to maintain a stable depth of anesthesia. The primary outcomes were time-averaged maintenance infusion rates of propofol and remifentanil. Secondary outcomes in the postanesthetic care unit included sedation scores, pain scores, and time to discharge.

RESULTS

Data from 67 patients were available for analysis. The median [interquartile range] propofol infusion rate was lower in the 1 mcg/kg dexmedetomidine group (180 [164-185] mcg/kg/min) versus placebo (200 [178-220] mcg/kg/min): percent change -10.0%; 95% CI -2.4 to -19.8; p = 0.013. The remifentanil infusion rate was also lower in the 1 mcg/kg dexmedetomidine group (0.089 [0.080, 0.095] mcg/kg/min) versus placebo (0.103 [0.095, 0.106] mcg/kg/min): percent change, -13.7%; 95% CI -5.47 to -21.0; p = .022. However, neither propofol nor remifentanil infusion rates were significantly different in the 0.25 or 0.5 mcg/kg dexmedetomidine groups. In the postanesthesia care unit, there were no differences in pain or sedation scores, and time to discharge was not significantly prolonged in any dexmedetomidine group.

CONCLUSION

Dexmedetomidine 1 mcg/kg reduced the propofol and remifentanil requirements during maintenance of anesthesia in children when administered as a postinduction bolus.

TRIALS REGISTRATION

ClinicalTrials.gov: NCT03422978, date of registration 2018-02-06.

Systematic review and meta-analysis comparing the efficacy of dexmedetomidine to midazolam as premedication and a sedative agent in pediatric patients undergoing dental procedures

INTRODUCTION

Pediatric dental surgeries are associated with the emotions of fear, anxiety, and other behavioral disturbances of children that need to be managed. Sedation using drugs like dexmedetomidine (DEX) and midazolam (MID) is a common pharmacological behavior managing technique. We conducted this meta-analysis to evaluate the efficacy of both these drugs in current literature.

METHODOLOGY

A thorough literature search was conducted on PubMed, MEDLINE, Google Scholar, and Cochrane's database for randomized studies that compared sedative efficacy of dexmedetomidine with midazolam in children of 0-15 years of age undergoing dental surgeries. Sedation in children during dental procedure, when used as a premedication, at the time of separation from parents and at the time of mask induction, onset time, duration of anesthesia, and surgery were evaluated. The mean differences (MDs), odds ratio (OR), and their 95% confidence intervals (CIs) were calculated both for continuous and dichotomous outcome data using random-effects model.

RESULTS

Seven studies met out inclusion criteria and were analyzed. Results of premedication with DEX was associated with more anxiolysis (OR=0.29, 95% CI: 0.17-0.52, p=0.0001; I2=0%) and at the time of separation from parents (OR=0.36, 95% CI: 0.19-0.69, p=0.002; I2=52%) in comparison to MID. No significant differences in results were seen at mask induction (OR=0.63, 95% CI: 0.34-1.18, p=0.15; I2=47%) and for sedation in children during dental procedures (OR=0.52, 95% CI: 0.07-3.70, p=0.51; I2=72%). Also, there were no significant differences in onset time, duration of anesthesia, and surgery between the two agents.

CONCLUSION

DEX proved to be a better premedicant than MID for pediatric patients. No significant difference in efficacy of both sedative agents was observed in children undergoing dental treatment. More clinical trials need to be conducted to see its efficacy in dental surgeries in children of standardized ages and with standard doses.

A comparative evaluation of intranasal α2-adrenoceptor agonists and intranasal midazolam as premedication in pediatric sedation: A meta-analysis of randomized controlled trials

BACKGROUND

Midazolam and α2-adrenoceptor agonists have been widely used off-label as intranasal sedatives for children. The present meta-analysis aimed to evaluate the effects of two interventions in pediatric sedation.

METHODS

PubMed, Embase, and Cochrane Library were searched from inception to April 2022. All randomized controlled trials used intranasal α2-adrenoceptor agonists and midazolam as sedatives in children were enrolled. Parental separation, anesthesia induction or facemask acceptance, sedation level, different hemodynamic parameters and adverse events were considered as outcomes.

RESULTS

Totally 21 studies with 1,495 patients were included. Only one study reported comparison between midazolam and clonidine met the inclusion criteria, and patients in clonidine group had significantly better mask acceptance compared to midazolam group. Compared with midazolam, using of dexmedetomidine was associated with higher rate of satisfactory parental separation (52.88% vs 75.18%, RR = 0.70, with 95%CI [0.55, 0.90]), anesthesia induction or facemask acceptance (60.92% vs 81.47%, RR = 0.76, 95% CI [0.68, 0.84]) and less incidence of postoperative pain and nasal irritation.

CONCLUSION

Compared with midazolam, dexmedetomidine should be considered as the preferred intranasal sedative option for pediatric patients, since it provides more satisfactory sedative level with less incidence of several side effects. But insufficient evidences about effects of intranasal clonidine and overall low and moderate quality evidences evaluated by GRADE system indicate that superiority of intranasal α2-adrenoceptor agonists in pediatric sedation needs to be validated by more studies with high quality and large sample size in future.

Dexmedetomidine and perioperative analgesia in children

Dexmedetomidine (DEX) is an anaesthetic agent that mimics natural deep sleep and produces minimal cardiorespiratory depression. As such, it is a very valuable option in the management of such a challenging population as paediatric patients. The main objective of this mini review was to evaluate the role of DEX as a perioperative analgesic in children receiving anaesthesia. We searched Google, Pubmed, Embase and the Cochrane Library for articles published between 2010 and 2021, and reviewed various of aspects of DEX, such as pharmacology, effectiveness, safety, and the most recent evidence on its clinical use as an analgesic in paediatric anaesthesia. We also include a cost estimate of perioperative analgesia with DEX.

Applications of Dexmedetomidine in Palliative and Hospice Care

Although the use of dexmedetomidine is currently approved by the US Food and Drug Administration in the adult population for monitored anesthesia care and sedation during mechanical ventilation, clinical experience suggests the potential application of dexmedetomidine in the palliative care arena. The medication can provide sedation with lower risk of delirium, control or minimize the adverse effects of other medications, and augment analgesia from opioids. We conducted a computerized bibliographic search of the literature regarding dexmedetomidine use for the treatment of pain and provision of sedation during palliative and hospice care in adult and pediatric patients. The objective was to provide a general descriptive account of the physiologic effects of dexmedetomidine and review its potential applications in the field of palliative and hospice care in adult and pediatric patients. The sedative and analgesic effects of dexmedetomidine have been well studied in animal and human models. Published experience from both single case reports and small case series has demonstrated the potential therapeutic applications of dexmedetomidine in palliative and hospice care. In addition to intravenous administration, case reports have demonstrated its successful use by both the intranasal and subcutaneous routes. Although these experiences have suggested its safety and efficacy, larger series and additional clinical experience with prospective comparison to other agents are needed to further define its efficacy and role in palliative and hospice care.

Comparison of the Effect of Ketamine and Dexmedetomidine Combined with Total Intravenous Anesthesia in Laparoscopic Cholecystectomy Procedures: A Prospective Randomized Controlled Study

This randomized prospective clinical study aimed to investigate the effects of dexmedetomidine or ketamine administration to total intravenous anesthesia (TIVA) on postoperative analgesia in subjects undergoing elective laparoscopic cholecystectomy procedures. 90 adults, American Society of Anesthesiologists (ASA) physical status 1 and II patients, who underwent elective laparoscopic cholecystectomy procedures were included in the study and randomized into three groups equally. Remifentanil, propofol, and rocuronium infusions were used for TIVA guided by the bispectral index. In group KETA, 10 μg/kg/min ketamine was added to TIVA before surgery, and in group DEX, 0.5 μg/kg/h dexmedetomidine was added to TIVA before surgery. Normal saline infusions were infused in the control group. Postoperative analgesia was provided with intravenous patient-controlled analgesia (PCA) morphine (1 mg bolus morphine, 5 min lockout time). Hemodynamic parameters, scores of visual analogue scale (VAS) for pain, rescue morphine requirements, and side effects such as sedation, nausea, and vomiting were recorded for 48 hours after surgery. Postoperative first analgesic requirement time was longer in group KETA (P < 0.001), and it was longer in group DEX than in the control group (P < 0.001). Pain scores were lower in group KETA and group DEX than in the control group at all corresponding times throughout the 48 h period of observation. Intravenous PCA morphine consumptions were higher in the control group than in group KETA (P < 0.001 for all followed-up times), and they were higher in group DEX than in group KETA (P < 0.001 for all followed-up times). It is concluded that the use of dexmedetomidine or ketamine infusions can be suitable as an additive for TIVA in the intraoperative period. Furthermore, the addition of both drugs to the TIVA protocol may improve postoperative pain relief and decrease opioid consumption.

Reducing Benzodiazepine Exposure by Instituting a Guideline for Dexmedetomidine Usage in the NICU

BACKGROUND

Midazolam is a benzodiazepine sedative used in NICUs. Because benzodiazepine's effects include respiratory depression and potential detrimental developmental effects, minimizing exposure could benefit neonates. Dexmedetomidine is routinely used for sedation in older pediatric populations. We implemented a quality improvement initiative with the aim of decreasing midazolam infusions by 20% through use of dexmedetomidine.

METHODS

A multidisciplinary committee created a sedation guideline that included standardized dexmedetomidine dosing escalation and weaning. Baseline data collection occurred from January 2015 to February 2018, with intervention from March 2018 to December 2019. Percentage of sedation episodes with dexmedetomidine initiated was followed as a process measure. Outcomes measures were percentage of eligible infants receiving midazolam infusions and midazolam-free days per sedation episode. Bradycardia with dexmedetomidine, unplanned extubation rates, and morphine dosage were monitored as balancing measures.

RESULTS

Our study included 434 episodes of sedation in 386 patients. Dexmedetomidine initiation increased from 18% to 49%. The intervention was associated with a significant reduction in midazolam initiation by 30%, from 95% to 65%, with special cause variation on statistical process control chart analysis. Midazolam-free days per sedation episode increased from 0.3 to 2.2 days, and patients receiving dexmedetomidine had lower midazolam doses (1.3 mg/kg per day versus 2.2 mg/kg per day, P = 5.97 × 10-04). Bradycardia requiring discontinuation of dexmedetomidine, unplanned extubation rates, and morphine doses were unchanged.

CONCLUSIONS

Implementation of a quality improvement initiative was successful in reducing the percentage of patients receiving midazolam infusions and increased midazolam-free days per sedation episode, revealing an overall reduction in benzodiazepine exposure while maintaining adequate sedation.

Dexmedetomidine & perioperative analgesia in children

Dexmedetomidine (DEX) is an anaesthetic agent that mimics natural deep sleep and produces minimal cardiorespiratory depression. As such, it is a very valuable option in the management of such a challenging population as paediatric patients. The main objective of this mini review was to evaluate the role of DEX as a perioperative analgesic in children receiving anaesthesia. We searched Google, Pubmed, Embase and the Cochrane Library for articles published between 2010 and 2021, and reviewed various of aspects of DEX, such as pharmacology, effectiveness, safety, and the most recent evidence on its clinical use as an analgesic in paediatric anaesthesia. We also include a cost estimate of perioperative analgesia with DEX.

PROSPECT guideline for tonsillectomy: systematic review and procedure-specific postoperative pain management recommendations

Tonsillectomy is one of the most frequently performed surgical procedures; however, pain management remains challenging. Procedure‐specific efficacy as well as specific risks of treatment options should guide selection of pain management protocols based on evidence and should optimise analgesia without harm. The aims of this systematic review were to evaluate the available literature and develop recommendations for optimal pain management after tonsillectomy. A systematic review utilising preferred reporting items for systematic reviews and meta‐analysis guidelines with procedure‐specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials published in the English language up to November 2019 assessing postoperative pain using analgesic, anaesthetic or surgical interventions were identified. Out of the 719 potentially eligible studies identified, 226 randomised controlled trials met the inclusion criteria, excluding the studies examining surgical techniques. Pre‐operative and intra‐operative interventions that improved postoperative pain were paracetamol; non‐steroidal anti‐inflammatory drugs; intravenous dexamethasone; ketamine (only assessed in children); gabapentinoids; dexmedetomidine; honey; and acupuncture. Inconsistent evidence was found for local anaesthetic infiltration; antibiotics; and magnesium sulphate. Limited evidence was found for clonidine. The analgesic regimen for tonsillectomy should include paracetamol; non‐steroidal anti‐inflammatory drugs; and intravenous dexamethasone, with opioids as rescue analgesics. Analgesic adjuncts such as intra‐operative and postoperative acupuncture as well as postoperative honey are also recommended. Ketamine (only for children); dexmedetomidine; or gabapentinoids may be considered when some of the first‐line analgesics are contra‐indicated. Further randomised controlled trials are required to define risk and combination of drugs most effective for postoperative pain relief after tonsillectomy.

The Opioid Wars-CON: The Risks of Opioids for Pain Management Outweigh the Benefits

The entire field of medicine, not just anesthesiology, has grown comfortable with the risks posed by opioids; but these risks are unacceptably high. It is time for a dramatic paradigm shift. If used at all for acute or chronic pain management, they should be used only after consideration and maximizing the use of nonopioid pharmacologic agents, regional analgesia techniques, and nonpharmacologic methods. Opioids poorly control pain, their intraoperative use may increase the risk of recurrence of some types of cancer, and they have a large number of both minor and serious side effects. Furthermore, there are a myriad of alternative analgesic strategies that provide superior analgesia, decrease recovery time, and have fewer side effects and risks associated with their use. In this article the negative consequences of opioid use for pain, appropriate alternatives to opioids for analgesia, and the available evidence in pediatric populations for both are described.

Association Between Race and Ethnicity with Intraoperative Analgesic Administration and Initial Recovery Room Pain Scores in Pediatric Patients: a Single-Center Study of 21,229 Surgeries

INTRODUCTION

Perioperative pain may have deleterious effects for all patients. We aim to examine disparities in pain management for children in the perioperative period to understand whether any racial and ethnic groups are at increased risk of poor pain control.

METHODS

Medical records from children ≤ 18 years of age who underwent surgery from May 2014 to May 2018 were reviewed. The primary outcome was total intraoperative morphine equivalents. The secondary outcomes were intraoperative non-opioid analgesic administration and first conscious pain score. The exposure was race and ethnicity. The associations of race and ethnicity with outcomes of interest were modeled using linear or logistic regression, adjusted for preselected confounders and covariates. Bonferroni corrections were made for multiple comparisons.

RESULTS

A total of 21,229 anesthetics were included in analyses. In the adjusted analysis, no racial and ethnic group received significantly more or less opioids intraoperatively than non-Hispanic (NH) whites. Asians, Hispanics, and Pacific Islanders were estimated to have significantly lower odds of receiving non-opioid analgesics than NH whites: odds ratio (OR) = 0.83 (95% confidence interval (CI): 0.70, 0.97); OR = 0.84 (95% CI: 0.74, 0.97), and OR = 0.53 (95% CI: 0.33, 0.84) respectively. Asians were estimated to have significantly lower odds of reporting moderate-to-severe pain on awakening than NH whites: OR = 0.80 (95% CI: 0.66, 0.99).

CONCLUSIONS

Although children of all races and ethnicities investigated received similar total intraoperative opioid doses, some were less likely to receive non-opioid analgesics intraoperatively. Asians were less likely to report moderate-severe pain upon awakening. Further investigation may delineate how these differences lead to disparate patient outcomes and are influenced by patient, provider, and system factors.

A comparative evaluation of dexmedetomidine and midazolam in pediatric sedation: A meta-analysis of randomized controlled trials with trial sequential analysis

Background

The present study with trial sequential analysis (TSA) was conducted to evaluate comprehensively the efficacy and safety of dexmedetomidine and midazolam in pediatric sedation, and to investigate whether the outcomes achieved the required information size to draw the conclusions.

Methods

PubMed, Embase, and Cochrane Library were searched from inception to October 2019. All randomized controlled trials used dexmedetomidine and midazolam in pediatric sedation were enrolled. Sedative efficacy, postoperative analgesic effect, and incidence of emergence agitation were considered as the co‐primary outcomes. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was applied to rate the quality of evidences.

Results

We acquired data from 34 studies involving 2281 pediatric patients. The results indicated that administration of dexmedetomidine was associated with less incidence of emergence agitation (RR = 0.78, with 95% CI [0.65, 0.92]) and more satisfactory sedation at parental separation (RR = 0.31, with 95% CI [0.24, 0.41]) compared to midazolam, and the current sample sizes were sufficient with unnecessary further trials. Two groups did not differ significantly in sedation level at mask induction (RR = 0.86, with 95% CI [0.74, 1.00]). And using of dexmedetomidine was associated with less incidence of postoperative analgesic rescue (RR = 0.57, with 95% CI [0.35, 0.93]), but the number of patients was too few to achieve the required information size and to draw reliable conclusions. Premedication of dexmedetomidine was associated with significant less value of SBP, heart rate, increased incidence of bradycardia, and a lower rate of shivering. And there were no differences about onset of sedation and recovery time between two groups.

Conclusions

Given that more satisfactory sedation at separation from parents and less incidence of emergence agitation, dexmedetomidine is preferred for pediatric sedation. However, compared with midazolam, the superiority of dexmedetomidine in providing adequate sedation at mask induction and postoperative analgesic effects has not yet been defined.

Volatiles or TIVA: Which is the standard of care for pediatric airway procedures? A pro-con discussion

Anesthesia for pediatric airway procedures constitutes a true art form that requires training and experience. Communication between anesthetist and surgeon to establish procedure goals is essential in determining the most appropriate anesthetic management. But does the mode of anesthesia have an impact? Traditionally, inhalational anesthesia was the most common anesthesia technique used during airway surgery. Introduction of agents used for total intravenous anesthesia (TIVA) such as propofol, short-acting opioids, midazolam, and dexmedetomidine has driven change in practice. Ongoing debates abound as to the advantages and disadvantages of volatile-based anesthesia versus TIVA. This pro-con discussion examines both volatiles and TIVA, from the perspective of effectiveness, safety, cost, and environmental impact, in an endeavor to justify which technique is the best specifically for pediatric airway procedures.

Dexmedetomidine Improves Cardiovascular and Ventilatory Outcomes in Critically Ill Patients: Basic and Clinical Approaches

Dexmedetomidine (DEX) is a highly selective α2-adrenergic agonist with sedative and analgesic properties, with minimal respiratory effects. It is used as a sedative in the intensive care unit and the operating room. The opioid-sparing effect and the absence of respiratory effects make dexmedetomidine an attractive adjuvant drug for anesthesia in obese patients who are at an increased risk for postoperative respiratory complications. The pharmacodynamic effects on the cardiovascular system are known; however the mechanisms that induce cardioprotection are still under study. Regarding the pharmacokinetics properties, this drug is extensively metabolized in the liver by the uridine diphosphate glucuronosyltransferases. It has a relatively high hepatic extraction ratio, and therefore, its metabolism is dependent on liver blood flow. This review shows, from a basic clinical approach, the evidence supporting the use of dexmedetomidine in different settings, from its use in animal models of ischemia-reperfusion, and cardioprotective signaling pathways. In addition, pharmacokinetics and pharmacodynamics studies in obese subjects and the management of patients subjected to mechanical ventilation are described. Moreover, the clinical efficacy of delirium incidence in patients with indication of non-invasive ventilation is shown. Finally, the available evidence from DEX is described by a group of Chilean pharmacologists and clinicians who have worked for more than 10 years on DEX.

Perioperative Dexmedetomidine Infusion, as Opioid-Sparing Strategy, in Patients Undergoing General Anesthesia: A Systematic Review Protocol

Introduction:

Although there are multiple analgesia techniques, opioids remain the most widely used drug for pain control. Postoperative Nausea and Vomiting (PONV), sleepiness, respiratory, and gastrointestinal disorder are common complications of postoperative opioid use, which makes the decrease in opioid demand, through combination with non-opioid agents, desirable. Dexmedetomidine (DEX) is an alpha2-adrenergic agonist with sedative and anxiolytic effects. Recently, some studies proved the evidence of its notable opioid-sparing effect. Furthermore DEX, compared to opioids, seems to have the advantage of not inhibiting spontaneous breathing.

Aim:

This systematic review protocol aims to define the analgesic effect of perioperative DEX infusion and the cumulative opioid consumption of patients undergoing general anesthesia.

Methods:

The review will be conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta- Analysis Protocols (PRISMA- P) statement and the Cochrane recommendations for Systematic Reviews of Interventions.

Results:

The primary outcomes will be 1) The effect of DEX infusion, on pain control, compared to placebo or other treatments and 2) The opioid-sparing effect of DEX infusion compared to placebo or other treatments. The secondary outcome will be a) Respiratory depression, b) Hypotension requiring fluid infusion and/or amine, c) Bradycardia requiring vasoactive drugs, d) Needing of prolonged hospital stay, e) PONV and gastrointestinal disorders.

Conclusion:

A sub-analysis is planned for i) The type of surgery performed, ii) Patient’s gender, iii) Patients age. If possible, a meta- analysis (including sub-analysis and sensitivity analysis for all assessed outcomes) will be performed. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach will be followed to create a Summary of Findings.

The Registration Number for this Systematic Review is CRD42018086687.

Effect of Intravenous Dexmedetomidine During General Anesthesia on Acute Postoperative Pain in Adults: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Dexmedetomidine has been shown to have an analgesic effect. However, no consensus was reached in previous studies.

METHODS

Electronic databases such as PubMed, Embase, and Cochrane Central were searched for relevant randomized controlled trials. The relative risk and weighted mean difference (WMD) were used to analyze the outcomes. Random-effects model was used for meta-analysis.

RESULTS

Compared with the normal saline group, patients using DEX showed a significantly decreased pain intensity within 6 hours [WMD=-0.93; 95% confidence interval (CI), -1.34 to -0.53) and at 24 hours after surgery (WMD=-0.47; 95% CI, -0.83 to -0.11). DEX usage significantly reduced the cumulative opioids consumption at 24 hours after surgery (WMD=-6.76; 95% CI, -10.16 to -3.35), decreased the rescue opioids consumption in postanesthesia care unit (WMD=-3.11; 95% CI, -5.20 to -1.03), reduced the risk of rescue analgesics (relative risk=0.49; 95% CI, 0.33-0.71), and the interval to first rescue analgesia was prolonged (WMD=34.93; 95% CI, 20.27-49.59).

CONCLUSIONS

Intravenous DEX effectively relieved the pain intensity, extended the pain-free period, and decreased the consumption of opioids during postoperative recovery of adults in general anesthesia.

Analgesics and Sedatives in Critically Ill Newborns and Infants: The Impact on Long-Term Neurodevelopment

Inadequate pain and/or stress management in preterm- and term-born infants has been associated with increased morbidity and even mortality. However, exposure to analgosedatives during early infancy may also be one of the risk factors for subsequent neurodevelopmental impairment, at least in animal studies. Because infants admitted to neonatal or pediatric intensive care units may receive high amounts of these drugs for prolonged periods of time and the majority of these infants nowadays survive to discharge, this is of major concern. A balanced approach that incorporates the assessment and quantification of both wanted effects as well as unwanted side effects is therefore needed. In this article, the optimal dose determination of commonly used analgosedative drugs as well as their potential long-term effects on the developing human brain and neuropsychological functioning are reviewed.

Identification of novel analgesics through a drug repurposing strategy

The identification of new indications for approved or failed drugs is a process called drug repositioning or drug repurposing. The motivation includes overcoming the productivity gap that exists in drug development, which is a high-cost–high-risk process. Repositioning also includes rescuing drugs that have safely entered the market but have failed to demonstrate sufficient efficiency for the initial clinical indication. Considering the high prevalence of chronic pain, the lack of sufficient efficacy and the safety issues of current analgesics, repositioning seems to be an attractive approach. This review presents example of drugs that already have been repositioned and highlights new technologies that are available for the identification of additional compounds to stimulate the curiosity of readers for further exploration.

Spinal α2 -adrenoceptors and neuropathic pain modulation; therapeutic target

Neuropathic pain can arise from disease or damage to the nervous system. The most common symptoms of neuropathic pain include spontaneous pain, allodynia, and hyperalgesia. There is still limited knowledge about the factors that initiate and maintain neuropathic pain. However, ample evidence has proved the antinociceptive role of spinal α-adrenoceptors following nerve injury. It is well-documented that noradrenergic descending pathways from supraspinal loci exert an inhibitory influence on the spinal cord nociceptive neurons, mostly through the activation of spinal α₂ -adrenoceptors. This, in turn, suppresses transmission of pain input and the hyperexcitability of spinal dorsal horn neurons. There is considerable evidence demonstrating that spinal application of α₂ -adrenoceptor agonists leads to analgesic effects in animal models of neuropathic pain. Today, despite the recent rapid development of neuroscience and drug discovery, effective drugs with clear basic mechanisms have remained a mystery. Here, we give an overview of the cellular mechanisms through which brainstem adrenergic descending inhibitory processing can alter spinal pain transmission to the higher centres, and how these pathways change in neuropathic pain conditions focusing on the role of spinal α₂ -adrenoceptors in the spinal dorsal horn. We then suggest that α₂ -adrenoceptor agonist may be useful to treat neuropathic pain. LINKED ARTICLES: This article is part of a themed section on Adrenoceptors-New Roles for Old Players. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v176.14/issuetoc.

Caudal and intravenous dexmedetomidine similarly prolong the duration of caudal analgesia in children: A randomized controlled trial

BACKGROUND

Dexmedetomidine can prolong the duration of action of a local anesthetic agent, but the route of administration that is the most beneficial remains unclear. The purpose of this study was to compare the clinical effectiveness of caudal or intravenous dexmedetomidine administration on postoperative analgesia in children undergoing inguinal hernia repair given caudal levobupivacaine.

METHODS

This was a prospective, randomized, double-blinded, placebo-controlled trial. Ninety ASA I subjects, aged 2-5 year, undergoing unilateral inguinal hernia repair were enrolled. The children were randomized in a double-blind fashion to three groups. The L-Dcau group received 1 mL/kg of caudal 0.25% levobupivacaine plus 1 μg/kg dexmedetomidine and IV 20 mL saline. The L-Div group received 1 mL/kg of caudal 0.25% levobupivacaine and IV 1 μg/kg dexmedetomidine in 20 mL saline. The L group received 1 mL/kg of caudal 0.25% levobupivacaine and IV 20 mL saline. The primary outcome was the duration of analgesia, which was defined as the time from the caudal block to a Postoperative Pain Scale (CHIPPS) score ≥4. Secondary outcomes were the number of patients requiring rescue analgesia, pain intensity, the incidence of emergence agitation, intraoperative hemodynamic variations, residual motor block, and adverse effects.

RESULTS

The median duration of analgesia in the L-Dcau group was 14.2 hour compared to 6 hour in the L group with a median difference of 8.5 hour [95% CI (6.5, 10.5), P < 0.001]. The median duration of analgesia in the L-Div group was 12.4 hour compared to 6 hour in the L group with a median difference of 6.4 hour [95% CI (4, 8.5), P < 0.001]. Fewer patients in the L-Dcau and L-Div groups required rescue analgesia in the first 24 hour postoperatively compared to the L group, although there was no significant difference between the L-Dcau and L-Div groups for these outcomes. Both dexmedetomidine routes reduced the pain and the incidence of emergence agitation. No bradycardia, hypotension, or motor block was observed in any of the three groups.

CONCLUSION

Caudal and IV dexmedetomidine similarly prolong the duration of analgesia produced by caudal levobupivacaine.

Pain Management in Pediatric Burn Patients: Review of Recent Literature and Future Directions

Childhood burns are a profoundly traumatic and painful experience. Despite recognition of the prevalence of burn injuries in children and the severity of the associated pain, burn pain remains undertreated. At the same time, more evidence is emerging to suggest that undertreated pain has serious long-term medical and psychiatric consequences, many of which can be ameliorated with improved pain control. Pain in burn patients is, however, notoriously difficult to treat, perhaps because there is a chronic pain aspect underlying the acute pain that accompanies wound care and procedures. This difficulty is compounded by the fact that there are little data to guide decision making in these patients. This article aims to identify the best strategies to guide clinical practice through a review of the past 10 years' development in pediatric burn pain management. However, because clinical investigations remain limited in burned children, we also aim to draw attention to those areas where the data do not identify an optimal approach and further work is needed. Overall, in addition to just the traditional pharmacological approaches to pain, such as acetaminophen, benzodiazepines, and opioids, there is growing evidence to support more widespread use of regional anesthesia and novel technologies such as virtual reality. Starting with an improved understanding of the current state of the literature, we can identify areas of research and important questions whose answers will ultimately improve care and reduce suffering for this unfortunate population of children.

Does dexmedetomidine given as a premedication or intraoperatively reduce post-hospitalisation behaviour change in children? A study protocol for a randomised controlled trial in a tertiary paediatric hospital

INTRODUCTION

It has been reported that post-hospitalisation behaviour change (PHBC) occurs in over 50% of children undergoing a general anaesthetic and manifests as behaviours such as sleep and eating disorders, defiance of authority, nightmares, enuresis and temper tantrums. The effect is usually short-lived (2-4 weeks); however, in 5-10% of children, these behaviours can last up to 12 months. The risk factors for developing PHBC include underlying anxiety in the child or parent, a previous bad hospital experience, emergence delirium and preschool age. A recent meta-analysis of alpha-2 agonists (including dexmedetomidine) found that they effectively reduce the incidence of emergence delirium but none of the studies looked at longer term outcomes, such as PHBC.

METHODS AND ANALYSIS

Two-year-old to seven-year-old children requiring general anaesthesia for common day-case procedures will be randomly assigned to one of three groups: a dexmedetomidine pre medication group, an intraoperative dexmedetomidine group and a control group. Baseline anxiety levels of the parent will be recorded and the anxiety of the child during induction of anaesthesia will also be recorded using validated tools. The primary outcome will be negative behaviours after hospitalisation and these will be measured using the Post Hospitalisation Behaviour Questionnaire for Ambulatory Surgery and the Strengths and Difficulties Questionnaire. These questionnaires will be administered by a blinded researcher at days 3, 14 and 28 post surgery.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the Children's Health Queensland human research ethics committee (HREC/15/QRCH/248) and the University of Queensland human research ethics office (#2016001715). Any amendments to this protocol will be submitted to the ethics committees for approval.

TRIAL REGISTRATION NUMBER

ANZCTR:12616000096459; Pre-results.

Non-intubated thoracoscopic bullectomy under sedation is safe and comfortable in the perioperative period

Background

Non-intubated thoracoscopic surgery can be performed under sedation using adjuvant regional anesthesia, however, the benefits of non-intubated thoracoscopic surgery under sedation have not yet been completely verified. In this study, we compare the perioperative safety and pain complaints of sedation without intubation in thoracoscopic bullectomy with that of conventional general anesthesia with double-lumen intubation and mechanical ventilation.

Methods

Forty-one patients with primary spontaneous pneumothorax who were scheduled for thoracoscopic bullectomy were enrolled in this study. Twenty-one patients were under sedation anesthesia (SA group) and 20 patients were under general anesthesia (GA group). In SA group, sedation was done with dexmedetomidine (a loading dose of 1 µg/kg for 10 min and then maintained in dosages of 0.3-1 µg/kg/h) and ketamine (2-4 mg/kg/h intraoperatively). Meanwhile, in GA group, induction with propofol and rocuronium, intubation with double lumen endotracheal tube and maintenance with 1.0-2.5% sevoflurane was done. In both groups, thoracoscopic bullectomy was performed in the same manner and all operations were conducted by single surgeon. Time for anesthesia [including emergence time and post-anesthesia care unit (PACU) recovery time] and operation, postoperative pain, sore throat, hoarseness, adverse events (nausea, vomiting, hypotension and bradycardia), dose of rescue analgesic drug used for 24 hours post-operatively and perioperative arterial blood gas analysis were recorded.

Results

The times for anesthesia, operation and emergence were significantly shorter in SA than GA. Incidence of sore throat were significantly lower in SA. The difference of other adverse events in the two groups was not significant.

Conclusions

Our study demonstrated that compared to double-lumen intubation with general anesthesia, non-intubation with sedation for bullectomy for primary spontaneous pneumothorax was safe and efficient to reduce perioperative time.

Effect of single-dose dexmedetomidine on postoperative recovery after ambulatory ureteroscopy and ureteric stenting: a double blind randomized controlled study

BACKGROUND

Ambulatory surgery has recently gain popularity, as it is a good method of optimizinghospital resources utilization. To support ambulatory surgery, anaesthetic goals nowrevolve around patients' early recovery with minimal pain and nausea, expedientdischarge home and prompt resumption of activities of daily living. In this study, weevaluated the effect of a single pre-induction dose of dexmedetomidine on anaestheticrequirements, postoperative pain and clinical recovery after ambulatory ureteroscopy andureteric stenting under general anaesthesia.

METHODS

Sixty patients were randomised to receive IV dexmedetomidine 0.5 μg.kg-¹ (Group DEX, n = 30) or IV saline (Group P, n = 30). General anaesthesia was maintained with Sevoflurane: oxygen: air, titrated to BIS 40-60. Pain intensity, sedation, rescue analgesics, nausea/vomiting and resumption of daily activities were recorded at 1 h, and postoperative day (POD) 1-5.

RESULTS

Group DEX patients had significant reduction in sevoflurane minimum alveolar concentration (MAC), mean (SD) DEX vs. Placebo 0.6 (0.2) vs. 0.9 (0.1), p = 0.037; reduced postoperative resting pain at 1 h (VAS 0-10) (mean (SD) 1.00 (1.84) vs. 2.63 (2.78), p = 0.004), POD 1 (mean (SD) 1.50 (1.48) vs. 2.87 (2.72), p = 0.002), POD 2 (0.53 (0.97) vs. 1.73 (1.96), p = 0.001) and POD 3 (0.30 (0.75) vs. 0.89 (1.49), p = 0.001). DEX patients also had less pain on movement POD 1 (3.00 (2.12) vs. 4.30 (3.10), p = 0.043) and POD 2 (2.10 (1.98) vs. 3.10 (2.46), p = 0.040), with higher resumption of daily activities by 48 h compared to placebo, 87% vs. 63%, p = 0.04.

CONCLUSIONS

We conclude that a single dose of dexmedetomidine was a useful adjuvant in reducing MAC and postoperative pain (at 1 h and POD 1-3), facilitating faster return to daily activities by 48 h.

TRIAL REGISTRATION

The Australian New Zealand Clinical Trials Registry (ANZCTR), ACTRN12617001120369 , 31st July 2017, retrospectively registered.

Interventions for postoperative pain in children: An overview of systematic reviews

The aim of this study was to conduct an overview of systematic reviews that summarizes the results about efficacy and safety from randomized controlled trials involving the various strategies used for postoperative pain management in children. We searched the Cochrane Database of Systematic Reviews, CINAHL, Database of Reviews of Effect, Embase, MEDLINE, and PsycINFO from the earliest date to January 24, 2016. This overview included 45 systematic reviews that evaluated interventions for postoperative pain in children. Out of 45 systematic reviews that investigated various interventions for postoperative pain in children, 19 systematic reviews (42%) presented conclusive evidence of efficacy. Positive conclusive evidence was reported in 18 systematic reviews (40%) for the efficacy of diclofenac, ketamine, caudal analgesia, dexmedetomidine, music therapy, corticosteroid, epidural analgesia, paracetamol, and/or nonsteroidal anti-inflammatory drugs and transversus abdominis plane block. Only one systematic review reported conclusive evidence of equal efficacy that involved a comparison of dexmedetomidine vs morphine and fentanyl. Safety of interventions was reported as conclusive in 14 systematic reviews (31%), with positive conclusive evidence for dexmedetomidine, corticosteroid, epidural analgesia, transversus abdominis plane block, and clonidine. Seven systematic reviews reported equal conclusive safety for epidural infusion, diclofenac intravenous vs ketamine added to opioid analgesia, bupivacaine, ketamine, paracetamol, and dexmedetomidine vs intravenous infusions of various opioid analgesics, oral suspension and suppository of diclofenac, only opioid, normal saline, no treatment, placebo, and midazolam. Negative conclusive statement for safety was reported in one systematic review for caudal analgesia vs noncaudal regional analgesia. More than half of systematic reviews included in this overview were rated as having medium methodological quality. Of 45 included systematic reviews, 10 were Cochrane reviews and they had higher methodological quality than non-Cochrane reviews. As evidence concerning efficacy and safety is inconclusive for most of the analyzed interventions, our review points out the need for more rigorous trials concerning pain management in children.

Breaking barriers to novel analgesic drug development

Acute and chronic pain complaints, although common, are generally poorly served by existing therapies. This unmet clinical need reflects a failure to develop novel classes of analgesics with superior efficacy, diminished adverse effects and a lower abuse liability than those currently available. Reasons for this include the heterogeneity of clinical pain conditions, the complexity and diversity of underlying pathophysiological mechanisms, and the unreliability of some preclinical pain models. However, recent advances in our understanding of the neurobiology of pain are beginning to offer opportunities for developing novel therapeutic strategies and revisiting existing targets, including modulating ion channels, enzymes and G-protein-coupled receptors.

Dexmedetomidine sedation combined with caudal anesthesia for lower abdominal and extremity surgery in ex-preterm and full-term infants

BACKGROUND

Awake caudal anesthesia is a potentially attractive option, because the administration of general anesthesia is associated with a high rate of respiratory complications and hemodynamic disturbances and potential neurotoxic effects. To facilitate the caudal puncture and subsequent surgical intervention, additional sedatives are commonly administered.

AIM

We aimed to establish a new, safe, and effective anesthetic procedure for very young children with comorbidities.

METHODS

We retrospectively analyzed 23 children who underwent lower abdominal or lower extremity surgery with dexmedetomidine sedation and caudal anesthesia from January 2015 to August 2015. Dexmedetomidine was initiated with a total bolus infusion of 0.7-1.1 μg·kg^-1 followed by a continuous infusion of 1 μg·kg^-1 ·h^-1 . Bupivacaine (2.5 mg·kg^-1 ) was supplemented with 5-10 μg·kg^-1 epinephrine to strengthen and prolong motor block. According to maturity at birth, two groups were defined: ex-preterm and full-term infants.

RESULTS

There were 12 ex-preterm and 10 full-term infants available for analysis. The median postmenstrual age was 44 (38-52) weeks in ex-preterm and 46.5 (40-72) weeks in full-term infants. Without any additional intervention, surgery was successfully accomplished in 82% of all cases. While respiratory complications were not a problem, hemodynamic disturbances commonly occurred. Maximum decreases in heart rate (HR) of 30% were accompanied by maximum decreases in mean arterial pressure (MAP) of 38%. No infant had a heart rate below 100 bpm. MAP declined in one ex-preterm infant to a minimum value of 32 mmHg.

CONCLUSION

Caudal anesthesia combined with dexmedetomidine sedation is an effective anesthetic technique for lower abdominal and extremity surgery in ex-preterm and full-term infants with severe comorbidities.

Impact of Dexmedetomidine on Pediatric Agitation in the Postanesthesia Care Unit

PURPOSE

This study aims to investigate the impacts of dexmedetomidine (DEX) on agitation in the postanesthesia care unit (PACU) for pediatric patients undergoing tonsillectomy.

DESIGN

Eighty-two pediatric patients with elective tonsillectomy were randomly divided into the DEX group (group D) and the control group (group C). All patients' surgery in the two study groups were completed under tracheal cannula-based general anesthesia. Group D was infused 0.2 mcg/kg/hour DEX. The operation time, extubation time, PACU time, number of cases with nausea and vomiting, hemodynamic changes, and doses of rescue fentanyl, as well as every 10-minute observational pain scoring, and emergence agitation score in PACU, of the two groups were recorded.

METHODS

Chi-square and Fischer exact tests were applied for categorical variables.

FINDINGS

The maximum observational pain scoring and emergence agitation score of group D at 0, 10, and 20 minutes in PACU were significantly lower than group C (P < .01); the rescue doses of fentanyl and incidence of severe agitation in PACU in group D were significantly reduced than group C (P < .01). Group D showed significantly less cases with nausea and vomiting than group C (P < .05).

CONCLUSIONS

Low-dose DEX could significantly reduce the delirium and agitation in the PACU stage of pediatric tonsillectomy, and there were no untoward hemodynamic events in this study of 80 patients.

[Postoperative pain therapy in Germany. Status quo]

A great deal of progress has been made in the field of postoperative pain therapy in the last 20 years. Beginning from clinical trials on the effectiveness of individual procedures, such as epidural anesthesia and patient-controlled analgesia, a wide range of healthcare services research as well as basic research with human and animal experiments has been established. Whereas health services research in the 1980s and 1990s focused more on the implementation of acute pain services, outcome-oriented research approaches are nowadays the center of attention. Acute pain registries and pain certification projects initiated in Germany have to be mentioned particularly in this respect. Basic research papers from recent years increasingly address specific aspects of acute postoperative pain and have provided translational approaches that are applied around the world for studying neurobiological mechanisms of postoperative pain. At the same time, interdisciplinary cooperation in research projects has led to a better understanding of complex correlations regarding predictors and mechanisms (including psychosocial aspects) of acute and in recent times also chronic pain after surgery. In parallel, evidence-based medicine has found its way into acute pain medicine in Germany. In 2007, clinical acute pain therapy in Germany was enhanced by S3 level guidelines for the first time; however, the implementation is still incomplete. In future, questions concerning mechanism-based therapy of acute pain need to be equally in the center of attention of research, such as prevention of persisting pain after surgery and acute pain of different origins.

Adjuncts to local anaesthetics in tonsillectomy: a systematic review and meta-analysis

The infiltration of local anaesthetic agents has been shown to reduce post-tonsillectomy pain. A number of recent studies have shown that the addition of agents such as clonidine and dexamethasone improve the efficacy of nerve blocks and spinal anaesthesia. The aim of this review was to determine whether additives to local anaesthetic agents improve post-tonsillectomy outcomes. Four major databases were systematically searched for all relevant studies published up to August 2016. All study designs with a control group receiving local anaesthetic infiltration and an intervention receiving the same infiltration with an added agent were included in this review. These studies were then assessed for level of evidence and risk of bias. The data were then analysed both qualitatively and where appropriate by meta-analysis. We reviewed 11 randomised controlled trial (RCTs) that included 854 patients. Due to inconsistencies in the methods used to report outcomes, both quantitative and qualitative comparisons were required to analyse the extracted data. Overall, we found that dexamethasone, magnesium, pethidine and tramadol reduce post-operative pain and analgesia use, with dexamethasone in particular significantly reducing post-operative nausea and vomiting and magnesium infiltration significantly reducing the incidence of laryngospasm. This systematic review of RCTs provides strong evidence that the use of dexamethasone and magnesium as additives to local anaesthetics reduces post-tonsillectomy pain and analgesia requirement. There is limited evidence that pethidine and tramadol have a similar effect on pain and analgesia requirement. The studies in this pooled analysis are sufficiently strong to make a level one recommendation that the addition of magnesium to local anaesthetics reduces the incidence of laryngospasm, a potentially lethal post-operative complication. Review level of evidence: 1.

Efficacy of Intraoperative Dexmedetomidine Compared with Placebo for Postoperative Pain Management: A Meta-Analysis of Published Studies

Introduction

Dexmedetomidine (Dex) has sedative, analgesic, and anesthetic-sparing effects. This meta-analysis examines demonstrated intraoperative and postoperative effects of intraoperative Dex administration during pediatric surgery.

Methods

A search for randomized placebo-controlled trials was conducted to identify clinical trials examining intraoperative Dex use in children, infants, and neonates. Primary outcome was postoperative opioid consumption; secondary outcomes were: postoperative pain intensity and postoperative nausea and vomiting (PONV).

Results

Fourteen randomized controlled trials performed during painful procedures were analyzed. Intraoperative Dex administration was associated with significantly reduced postoperative opioid consumption in the postanesthesia care unit [PACU; risk ratio (RR) = 0.31 (0.17, 0.59), I² = 76%, p < 0.0001 and cumulative z score using trial sequential analysis], decreased pain intensity in PACU [standardized mean difference (SMD) = −1.18 (−1.88, −0.48), I² = 91%, p < 0.0001] but had no effect upon PONV incidence [RR = 0.67 (0.41, 1.08), I² = 0%, p = 0.48]. Subgroup analyses found administering Dex during adenotonsillectomy and using a bolus <0.5 µg/kg (irrespective to the use of a continuous administration) without effects on studies outcomes. Heterogeneity was high among results and a high suspicion of publication bias was present for all analyzed outcomes.

Conclusions

This meta-analysis shows that intraoperative Dex administration in children reduces postoperative opioids consumption and postoperative pain in PACU. According to our results, optimal bolus dose was found to be ≥0.5 µg/kg. Future studies have to explore this particular point and the postoperative analgesic effects of Dex during longer periods.

Anaesthesia for the paediatric outpatient

PURPOSE OF REVIEW

The aim of this review was to discuss recent developments in paediatric anaesthesia, which are particularly relevant to the practitioner involved in paediatric outpatient anaesthesia.

RECENT FINDINGS

The use of a pharmacological premedication is still a matter of debate. Several publications are focussing on nasal dexmedetomidine; however, its exact place has not yet been defined. Both inhalational and intravenous anaesthesia techniques still have their advocates; for diagnostic imaging, however, propofol is emerging as the agent of choice. The disappearance of codeine has left a breach for an oral opioid and has probably worsened postoperative analgesia following tonsillectomy. In recent years, a large body of evidence for the prevention of postoperative agitation has appeared. Alpha-2-agonists as well as the transition to propofol play an important role. There is now some consensus that for reasons of practicability prophylactic antiemetics should be administered to all and not only to selected high-risk patients.

SUMMARY

Perfect organization of the whole process is a prerequisite for successful paediatric outpatient anaesthesia. In addition, the skilled practitioner is able to provide a smooth anaesthetic, minimizing complications, and, finally, he has a clear concept for avoiding postoperative pain, agitation and vomiting.

Effectiveness of dexmedetomidine for emergence agitation in infants undergoing palatoplasty: a randomized controlled trial

OBJECTIVES

In infants, there is a high incidence of emergence agitation (EA) after sevoflurane (Sev) anesthesia. This study aimed to test the hypothesis that dexmedetomidine (Dex) administration would reduce the incidence and severity of EA after Sev-based anesthesia in infants undergoing palatoplasty.

METHODS

A prospective randomized clinical trial was conducted with 70 patients undergoing palatoplasty, aged 10-14 months. Infants were randomly allocated into two groups: Dex (n=35) and saline (n=35). In the Dex group, Dex (6 μg/kg/h) was administered approximately 10 min before the end of the surgery for 10 min, followed by 0.4 μg/kg/h until 5 min after extubation. In the saline group, an equivalent amount of saline was administered in a similar manner. After the surgery, patients were transferred to the postanesthetic care unit (PACU). The infant's behavior and pain were assessed with scoring system for EA (5-point rating scale) and pain scale (PS; 10-point rating scale), respectively. EA and PS were estimated at six time points (after extubation, leaving the operating room, 0, 30, 60, and 120 min after arrival in PACU).

RESULTS

EA and PS scores were significantly lower in the Dex group than in the saline group from extubation to 120 min after arrival in PACU.

CONCLUSIONS

Dex administration has the advantage of a reduced EA and PS without any adverse effects. Dex provided satisfactory recovery in infants undergoing palatoplasty.

Effect of Intraoperative Dexmedetomidine on Post-Craniotomy Pain

PURPOSE

Pain management for patients who have undergone a craniotomy remains challenging. This study aimed to determine whether intraoperative dexmedetomidine could reduce postoperative pain, analgesic consumption, and possible adverse events in patients after craniotomy.

METHODS

Eighty patients scheduled for elective supratentorial craniotomy under sevoflurane-fentanyl anesthesia were randomly allocated into two equal groups, to receive a continuous dexmedetomidine infusion of 0.5 µg/kg/h or placebo, beginning after induction and continuing until the start of skin closure. Intravenous tramadol (0.5 mg/kg) was administered to achieve an 11-point verbal rating scale (a discrete 0-10 scale) score of 4 or less in the postanesthesia care unit and, thereafter, on the ward. Pain scores, tramadol consumption, sedation scores, postoperative nausea and vomiting (PONV) scores, and other adverse events were recorded in the first 24 hours postoperatively.

FINDINGS

Seventy-six patients were included in the analyses. Demographic data, surgical characteristics, and sedation levels were similar between the groups. Dexmedetomidine reduced pain scores (30 minutes, P = 0.041; 2 hours, P = 0.021) and tramadol consumption (0-2 hours, P = 0.043; 0-6 hours, P = 0.006; 0-12 hours, P = 0.023; 0-24 hours, P = 0.040) postoperatively. Dexmedetomidine also reduced PONV scores at 20, 60, 90, 120, and 240 minutes (P = 0.038, 0.022, 0.018, 0.037, 0.016, respectively). The dexmedetomidine group exhibited fewer PONV events that required treatment (P = 0.005).

IMPLICATIONS

Intraoperative dexmedetomidine infusion was effective for reducing pain and analgesic consumption after craniotomy. In addition, dexmedetomidine may help to reduce PONV in patients after craniotomy treated with tramadol postoperatively. Chinese Clinical Trial Register identifier: ChiCTR-TRC-13003598.

Dexmedetomidine and hydromorphone: a novel pain management strategy for the oncology ward setting during anti-GD2 immunotherapy for high-risk neuroblastoma in children

BACKGROUND

Treatment of neuroblastoma with targeted immunotherapy using chimeric anti-GD2 monoclonal antibodies (ch14.18) is associated with significant pain requiring management with a high-dose opioid infusion. We present a case series of six children, for whom dexmedetomidine and hydromorphone infusions safely and effectively reduced the pain of ch14.18 therapy in the oncology ward setting.

PROCEDURE

The ch14.18 infusion is administered for ≥ 10 hr over four consecutive days in each of 5 cycles. Hydromorphone (2-8 mcg.kg(-1) .hr(-1) ) and dexmedetomidine (0.1-0.6 mcg.kg(-1) .hr(-1) ) infusions were commenced 1 hr before starting ch14.18 immunotherapy and titrated to optimal clinical effect. One hour after stopping the ch14.18 infusion, dexmedetomidine was discontinued and hydromorphone weaned as tolerated. This strategy was supervised by the Acute Pain Service with strict monitoring and nursing policies. Patient charts were reviewed for evidence of side effects and quality of analgesia.

RESULTS

Data from six patients, with median (range) age of 3.5 (2-12) years are reported. Median (range) utilization of hydromorphone was 2.9 (2.0-4.7) mcg.kg(-1) .hr(-1) , and of dexmedetomidine was 0.17 (0.10-0.20) mcg.kg(-1) .hr(-1) . A drop in mean arterial pressure ≥ 30% below baseline was identified during 30% of treatment days, but only prompted interrupting or reducing the ch14.18 infusion on 7% of treatment days; only one episode of grade 3 hypotension was recorded during this series. Hypoxemia occurred during 8% and bradycardia during 4% of treatment days.

CONCLUSIONS

Dexmedetomidine infusion may be an effective and safe pain management adjunct to opioid therapy for the pain of ch14.18 infusion.

Total intravenous anesthesia will supercede inhalational anesthesia in pediatric anesthetic practice

Inhalational anesthesia has dominated the practice of pediatric anesthesia. However, as the introduction of agents such as propofol, short-acting opioids, midazolam, and dexmedetomidine a monumental change has occurred. With increasing use, the overwhelming advantages of total intravenous anesthesia (TIVA) have emerged and driven change in practice. These advantages, outlined in this review, will justify why TIVA will supercede inhalational anesthesia in future pediatric anesthetic practice.

Premedication with dexmedetomidine in pediatric patients: a systematic review and meta-analysis

Premedication is important in pediatric anesthesia. This meta-analysis aimed to investigate the role of dexmedetomidine as a premedicant for pediatric patients. A systematic literature search was conducted to identify randomized controlled trials comparing dexmedetomidine premedication with midazolam or ketamine premedication or placebo in children. Two reviewers independently performed the study selection, quality assessment and data extraction. The original data were pooled for the meta-analysis with Review Manager 5. The main parameters investigated included satisfactory separation from parents, satisfactory mask induction, postoperative rescue analgesia, emergence agitation and postoperative nausea and vomiting. Thirteen randomized controlled trials involving 1190 patients were included. When compared with midazolam, premedication with dexmedetomidine resulted in an increase in satisfactory separation from parents (RD = 0.18, 95% CI: 0.06 to 0.30, p = 0.003) and a decrease in the use of postoperative rescue analgesia (RD = -0.19, 95% CI: -0.29 to -0.09, p = 0.0003). Children treated with dexmedetomidine had a lower heart rate before induction. The incidence of satisfactory mask induction, emergence agitation and PONV did not differ between the groups. Dexmedetomidine was superior in providing satisfactory intravenous cannulation compared to placebo. This meta-analysis suggests that dexmedetomidine is superior to midazolam premedication because it resulted in enhanced preoperative sedation and decreased postoperative pain. Additional studies are needed to evaluate the dosing schemes and long-term outcomes of dexmedetomidine premedication in pediatric anesthesia.