The impact of dexmedetomidine added to ropivicaine for transversus abdominis plane block on stress response in laparoscopic surgery: a randomized controlled trial

Comparative Study of Levobupivacaine Versus Levobupivacaine With Dexmedetomidine as an Adjuvant in Transversus Abdominis Block for Postoperative Pain Relief in Abdominal Hysterectomy Patients: A Randomized, Double-Blind Study

Background Adjuvants have been discovered to prolong the analgesic impact of local anesthetics (LA), while the transversus abdominis plane (TAP) block offers sufficient postoperative pain relief after various abdominal procedures. Nevertheless, the impact of the given LA will determine the duration of the TAP block. Thus, in this investigation, we aimed to estimate the analgesic impact of combining dexmedetomidine (DEX) with levobupivacaine in the TAP block for patients having an infraumbilical incision for an abdominal hysterectomy while under spinal anesthetic. Aim This study aimed to determine the analgesic effect of DEX (0.5 mcg/kg) to 20 ml of 0.25% levobupivacaine on each side in the TAP block in patients undergoing total abdominal hysterectomy (TAH). Materials and methods Two groups of 30 patients each, with ASA grades 1 and 2, were randomly selected from patients. Group N, comprising 30 patients, had a bilateral TAP block using 2 mL of normal saline and 20 mL of 0.25% levobupivacaine. Group D (n = 30 patients) was given DEX at a dose of 0.5 mcg/kg (2 mL) in addition to 20 mL of 0.25% levobupivacaine given bilaterally. The TAP block was administered just after skin closure. Time of the initial analgesic dose administration; total fentanyl doses utilized as rescue analgesia; pain scores (numerical rating scale (NRS)) at 2, 4, 6, 8, 12, and 24 hours; and pre- and postoperative cortisol levels were also noted. For each group, 1 gram IV paracetamol was administered every eight hours. Drugs used for rescue analgesia (RA) were diclofenac 75 mg IV stat and fentanyl 1 mcg/kg. Results and discussion In addition to Group N having lower NRS scores at rest, Group D had a considerably longer time for initial rescue analgesia than Group N. There was also a significant decrease in the total fentanyl consumption and postoperative serum cortisol levels in Group D in contrast to Group N. Conclusion Potential adjuvant DEX prolongs postoperative analgesia in patients experiencing abdominal hysterectomy when used alongside LA in TAP.

The impact of the transversus abdominis plane block (TAP) on stress response measured through the complete blood- derived inflammatory markers

This study aims to evaluate the effect of the transversus abdominis plane (TAP) block on the blood cells and the inflammatory markers neutrophil- to- lymphocyte ratio (NLR), platelet- to- lymphocyte ratio (PLR), and systemic immune- inflammation index (SII) after the laparoscopic ovariectomy (LapOV) in dogs. 72 healthy bitches undergoing LapOV were randomly allocated to the no- TAP group of dogs under inhaled anesthesia (IA), the TAP- S group (IA and TAP with saline), and the TAP- B group (IA and TAP with bupivacaine). The NLR, PLR, and SII were calculated 1 h before ovariectomy (T0) and at 2-3 h (T1), 6-8 h (T2), and 20-24 h (T3) post- surgery. The number of dogs requiring postoperative analgesic rescue with buprenorphine and the doses administered in each group were recorded. Significant changes were observed in all groups' postoperative NLR, PLR, and SII over time. Between groups, no differences were observed in any of the ratios at any control point (NLR at T0-T3: p = 0.17, 0.36, 0.80, and 0.95; PLR at T0-T3: p = 0.70, 0.62, 0.21, 0.87; SII at T0-T3: p = 0.29, 0.65, 0.09, and 0.34). A significantly lower number of dogs required analgesic rescue in the TAP-B group (p = 0.0001) and a lower number of doses were administered (p = 0.001). There is no difference in the inflammatory response measured through the complete blood- derived inflammatory markers after the LapOV in dogs when the postoperative pain is managed entirely with opioids or with the TAP block with bupivacaine. The hydrodissection associated with the TAP block technique does not increase the inflammatory response.

Levobupivacaine versus levobupivacaine plus dexmedetomidine in transversus abdominis plane block in patients undergoing abdominal aortic surgery

Background:

Severe postoperative pain is a major dilemma for patients undergoing abdominal aortic surgery. Transversus abdominis plane (TAP) block has been described a successful pain management technique after major abdominal surgery. Dexmedetomidine was proved to enhance the analgesic action of local anesthetics.

Aim:

This study was aimed to assess the impact of adding dexmedetomidine to levobupivacaine during TAP block in patients undergoing abdominal aortic operations.

Patients and Methods:

We included 114 patients in this prospective trial, and they were enrolled into two groups; the L group received levobupivacaine only, and the LD group received levobupivacaine plus dexmedetomidine. The block was performed before anesthetic induction. Postoperative pain score was our main outcome.

Statistical Analysis:

The collected data were tabulated and analyzed through the SPSS software program IBM's Statistical Package for the Social Sciences (SPSS) statistics for Windows (version 25, 2017) (IBM Corporation, Armonk, NY, USA). The categorical data were expressed as numbers and percentages and then compared using the Chi-square test. The continuous data were expressed as mean and standard deviation if normally distributed, or median and range if abnormally distributed. The former data were compared through the one-way ANOVA, while the latter were compared through the Kruskal–Wallis test. Any P < 0.05 was considered statistically significant.

Results:

Group LD showed significantly earlier sensory blocks compared to the other group. Postoperative pain scores were comparable between the two groups for the initial 4 h following the surgery. Adjuvant dexmedetomidine was associated with better pain scores for the subsequent 12 h compared to Group L. The duration till the first analgesic request showed a significant increase in the LD group (13.3 vs. 11.09 h in Group L). In addition, the same group showed a significant decline in their opioid consumption after the operation (48.95 μg vs. 72.63 μg in the other group). Postoperative nausea and vomiting were significantly increased in Group L.

Conclusion:

Adjuvant dexmedetomidine has a significant beneficial impact on postoperative analgesic profile. Its use as an adjuvant to peripheral and neuraxial nerve blocks should be recommended in pain management practice.

Mid-axillary transversus abdominis plane block and stress response after abdominal hysterectomy: A randomised controlled placebo trial

BACKGROUND

The hormonal response to surgical trauma can have detrimental effects on patients. Transversus abdominis plane (TAP) block, which can improve analgesia after total abdominal hysterectomy (TAH) might attenuate the peri-operative stress response.

OBJECTIVE

To evaluate the ability of the TAP block to reduce stress response, opioid consumption and pain following TAH and multimodal analgesia.

DESIGN

Randomised, placebo-controlled double-blind study.

SETTING

The current study was conducted at a university hospital from July 2016 to September 2017.

PATIENTS

Fifty patients scheduled for TAH were included. Anaesthesia and postoperative analgesia were standardised.

INTERVENTION

After induction of anaesthesia, patients were allocated into two groups: ultrasound-guided bilateral mid-axillary TAP block with 20 ml of bupivacaine 0.25% (Group T) or 0.9% saline (Group C).

MAIN OUTCOME MEASURES

Levels of free serum cortisol, metanephrine and normetanephrine at 60 min and 6, 12 and 24 h after surgical incision. Pain scores and opioid consumption during the first 24 h after surgery.

RESULTS

There was no statistically significant difference between the median [IQR] peri-operative levels of stress hormones and pain scores between groups. Compared with baseline value 9.90 [4.2 to 23.1], free serum median cortisol levels were significantly high at 6 h in Group T, 23.6 [10.1 to 42.9] P = 0.015 and Group C 23.6 [9.9 to 46.3] P = 0.014. Only Group C showed significant elevation from the baseline median levels of plasma metanephrine at 60 min, 52.8 [33.4 to 193.2] P = 0.001, 6 h, 92.70 [2.4 to 202.6] P = 0.005 and normetanephrine at 60 min 83.44 [28.98 to 114.86] P = 0.004, 6 h 78.62 [36.6 to 162.31] P = 0.0005 and 24 h 80.96 [8.6 to 110.5] P = 0.025. Mean ± SD opioid consumption was similar in both groups: 39.60 ± 14.87 in Group T vs. 43.68 ± 14.93 in Group C (P = 0.338).

CONCLUSION

Mid-axillary TAP block does not improve stress response and analgesia in patients undergoing TAH receiving multimodal analgesia.

TRAIL REGISTRATION

ClinicalTrial.gov identifier: NCT03443271.

A systematic review and meta-analysis of the safety and efficacy of remifentanil and dexmedetomidine for awake fiberoptic endoscope intubation

BACKGROUND

Awake fiberoptic endoscope intubation (AFOI) is the primary strategy for managing anticipated difficult airways. Adequate sedation, most commonly being achieved with remifentanil and dexmedetomidine, is integral to this procedure. This meta-analysis aimed to compare the safety and efficacy of these 2 sedatives.

METHODS

We conducted electronic searches in Embase, Web of Science, PubMed, Google Scholar, Medline, Springer, and Web of Science with no language restrictions. Studies comparing safety and efficacy between the sole use of remifentanil and dexmedetomidine among patients who underwent AFOI were included. Eight randomized controlled trials, comprising 412 patients, met the inclusion criteria. The primary outcomes were first attempt intubation success rate and incidence of hypoxia. The secondary outcomes were the Ramsay Sedation Scale score at intubation, memory recall of endoscopy, and unstable hemodynamic parameters during intubation.

RESULTS

Dexmedetomidine significantly reduced the incidence of hypoxemia during AFOI (risk ratio: 2.47; 95% confidence [CI]: 1.32-4.64]) compared with remifentanil; however, the first intubation success rates were equivalent (risk ratio: 1.12; 95% CI: 0.87-1.46]. No significant differences between the 2 sedatives were found for the Ramsay Sedation Scale score at intubation (mean difference: -0.14; 95% CI: -0.66-0.38) or unstable hemodynamic parameters during intubation (risk ratio: 0.83; 95% CI: 0.59-1.17). Dexmedetomidine reduced memory recall of endoscopy (risk ratio: 1.39; 95% CI: 1.13-1.72).

CONCLUSIONS

While both remifentanil and dexmedetomidine are effective for AFOI and well-tolerated, dexmedetomidine may be more effective in reducing the incidence of hypoxemia and memory recall of endoscopy.

PROSPERP REGISTRATION NUMBER

CRD42020169612.

Dexmedetomidine versus clonidine adjuvants to levobupivacaine for ultrasound-guided transversus abdominis plane block in paediatric laparoscopic orchiopexy: Randomized, double-blind study

BACKGROUND

Laparoscopic surgeries are associated with less postoperative pain and adverse events compared to open procedures. But, it still reduces the quality of life in children. Transversus abdominis plane (TAP) block is used to reduce pain. We hypothesized that dexmedetomidine or clonidine could improve the analgesic profile of levobupivacaine to the same extent during TAP block in children.

METHODS

Ninety children were randomly allocated in a randomized double-blind trial to receive bilateral TAP block with levobupivacaine plus normal saline (group B, n = 30), or dexmedetomidine (group D, n = 30) or clonidine (group C, n = 30). Primary outcome was the modified Children's Hospital of Eastern Ontario Pain Scale score. Secondary outcomes included time to initial analgesic request, number of analgesic claims, total analgesic consumption, parents' satisfaction, sedation score and complications.

RESULTS

Children of group D showed reduced pain scores compared to other groups. They represented the longest period of analgesia (565.00 ± 71.5 min) with p < 0.001, and fewer patients required two doses of analgesia during the first postoperative day. The cumulative amount of backup analgesia was significantly different between these groups (p = 0.026). Higher parents' satisfaction scores were recorded in groups D and C compared to group B. Sedation among the study groups revealed significant differences (p = 0.035), but no severe complications were recorded.

CONCLUSIONS

Adding dexmedetomidine to levobupivacaine can extend the time of analgesia and reduce the use of postoperative backup analgesics with minimal sedation effects when used in TAP block in paediatrics undergoing laparoscopic orchiopexy. Clonidine can be used as an alternative adjuvant to local anaesthetics with good postoperative analgesic profiles.

SIGNIFICANCE

Clonidine can alternate dexmedetomidine during TAP block with local anesthetics for pediatrics laparoscopies. Both can lead to better postoperative analgesic profiles. Clonidine may be preferred, especially in our developing regions, because of its easy availability and lower cost than that of dexmedetomidine.