Comparative Evaluation of Remifentanil and Dexmedetomidine in General Anesthesia for Cesarean Delivery

Low-Dose Remifentanil in Preterm Cesarean Section with General Anesthesia: A Randomized Controlled Trial

BACKGROUND AND OBJECTIVE

The conventional technique of general anesthesia induction during a Cesarean section involves the use of opioids only after cord clamping. We hypothesized that the use of remifentanil before cord clamping might reduce the use of maternal supplemental anesthetic agents and improve the maternal hemodynamics status and neonatal adaptation of the preterm neonate.

METHODS

A phase III, double-blind, randomized, placebo-controlled, hospital-based trial enrolled parturients undergoing a Cesarean section under general anesthesia before 37 weeks of gestation. Block randomization allocated pregnant women to remifentanil or placebo. The primary outcome was the rate of newborns with Apgar scores < 7 at 5 min. Secondary outcomes were maternal hemodynamic parameters, complications of anesthetic induction, use of adjuvant anesthetic agents, neonatal respiratory distress, umbilical cord pH, and lactate levels.

RESULTS

A total of 52/55 participants were analyzed, comprising 27 women in the remifentanil group and 25 in the placebo group. Nine of 27 (33.3%) neonates had an Apgar score < 7 at 5 min in the remifentanil group versus 11/25 (44.0%) in the placebo group (p = 0.45, odds ratio = 0.66, 95 confidence interval 0.20-2.18). The blood cord gases, cognitive, behavior, sensory, sleeping, and feeding scores at 1 and 2 years of corrected age were not different. For the mothers, hemodynamic parameters, anesthesia duration, and the cumulative treatment dose until cord clamping did not differ between the groups.

CONCLUSIONS

The use of a low dose of remifentanil before cord clamping for a Cesarean section appears to be safe both for the mother and the preterm newborn, but it does not improve maternal or neonatal outcomes.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov: NCT02029898.

Fetal, Preterm, and Term Neonate Exposure to Remifentanil: A Systematic Review of Efficacy and Safety

BACKGROUND

Owing to its pharmacodynamic properties, especially the rapid onset and short duration of its action, the use of remifentanil in obstetric anesthesia, as well as in neonatology, might be increasingly used.

OBJECTIVE

We conducted a systematic review to assess the efficacy and safety of remifentanil in preterm and term neonates. Outcomes of interest were neonatal adaptation after fetal exposure; neonatal pain, distress, and discomfort control during invasive procedures; and the occurrence of hemodynamic effects or respiratory depression induced by remifentanil infusion.

METHODS

Given the different contexts of use, we have organized this work into three parts: (A) use of remifentanil for labor or cesarean section, with exposure of the fetus before birth, (B) brief use for neonatal procedural analgesia, and (C) prolonged use for sedation/analgesia of neonates. The bibliographic search was conducted based on keywords using electronic medical databases (DATABASE, Cochrane Library, PubMed, and EMBASE) from 1 January 2000 until 31 December 2022.

RESULTS

Twenty-two articles were included (10 in part A, 5 in part B and 7 in part C). Prospective, controlled, randomized, blinded, and intention-to-treat trials were retained. Neonates were well adapted after exposure to remifentanil in the fetal period. Pain, stress, and discomfort were controlled during a brief or prolonged invasive procedure when remifentanil was used for sedation/analgesia. The physiological parameters were stable and the procedures were straightforward. Chest wall rigidity appeared to be a common side effect, but this can be managed by slow and continuous infusion and by using the minimum effective dose.

CONCLUSIONS

Remifentanil appears to be effective and safe in the short term in preterm and full-term neonates. However, its safety is compromised by the risk of chest wall rigidity. It should be used in appropriate neonatal units and in the presence of physicians able to monitor its side effects. Long-term outcomes have not been evaluated, to our knowledge.

Prolonged Anesthesia Induction to Delivery Time Did Not Influence Plasma Remifentanil Concentration in Neonates

Objective

Remifentanil, in combination with etomidate and sevoflurane, is commonly used in clinics for general anesthesia induction in cesarean section (CS). This study aimed to evaluate the correlation between the induction to delivery (I-D) time and neonatal plasma drug concentration and anesthesia, as well as its effects on neonates.

Methods

Fifty-two parturients in whom general anesthesia was induced for CS were divided into group A (I-D<8 min) and group B (I-D≥8 min). Maternal arterial (MA), umbilical venous (UV), and umbilical arterial (UA) blood samples were collected at delivery to analyze the remifentanil and etomidate concentrations using liquid chromatography-tandem mass spectrometry.

Results

There were no statistically significant differences between the two groups in terms of plasma concentrations of remifentanil in the MA, UA, and UV blood (P > 0.05). The plasma concentration of etomidate in MA and UV was higher in group A than that in group B (P<0.05), whereas the UA/UV ratio of etomidate was higher in group B than that in group A (P<0.05). The Spearman rank correlation test showed no correlation between the I-D time and plasma remifentanil concentration in the MA, UA, and UV plasma (P>0.05). The concentrations of etomidate in the MA and UV were negatively correlated with the I-D time (P < 0.05).

Conclusion

Prolonged I-D time did not significantly influence the maternal or neonatal plasma concentration of remifentanil. It is safe to administer remifentanil target-controlled infusion in combination with etomidate and sevoflurane for general anesthesia induction during CS.

Intraoperative Awareness in Patients Undergoing Cardiac Surgery in an Academic Center in the North of Iran

Background

Coronary artery bypass grafting (CABG) has distinctive characteristics that may increase the risk of awareness during general anesthesia (AGA).

Objectives

This study was conducted to assess the incidence of AGA in cardiac surgery in an academic hospital in Guilan, Iran.

Methods

This descriptive cross-sectional study was performed in Dr. Heshmat Hospital in Rasht, Iran. Eligible patients candidates for CABG were enrolled in the survey in 2022. After surgery, when the patient was cooperative enough, a questionnaire including demographic data and specialized questions related to different stages of anesthesia was completed via face-to-face interviews. The data were analyzed using IBM SPSS Statistics 21 with chi-square, Fisher's exact, and t-test.

Results

The data from 322 patients were analyzed, of whom 14 (4.3%) experienced AGA. Among them, the "feeling of fear and anxiety" reported by 9 (39.1%) cases was the most common awareness state. "Dreaming during surgery and anesthesia" and "feeling unable to move during anesthesia,", each reported by 6 (26.1%) cases, were the other common types of awareness state. None of the demographic data had a significant association with the occurrence of AGA.

Conclusions

The incidence of AGA during CABG was almost acceptable according to the credible evidence.

Possibility to use quanadex (dexmedetomidine) for caesarean section in patients with pre-eclampsia

A prospective, double­blind, randomized, con­trolled clinical trial was conducted at the Republican Spe­cialized Scientific and Practical Medical Center of Obstet­rics and Gynecology of the Ministry of Health of the Repub­lic of Uzbekistan. The inclusion criteria for pregnant wom­en in the study was preeclampsia. All women were divided into 2 groups. In group I, premedication was performed on the table with sibazon 5 mg. In group II, starting from the moment of premedication, 0.5 µg/kg of quanadex (Yuriya Pharm) was administered intravenously for 15 minutes. The maintaining dose was 0.5–0.8 µg/kg/h. 0.5 % hyper­baric longocaine heavy was administered intrathecally at the LII–LIV level. Hemodynamics was assessed by echocardi­ography. BAC and electrolytes, lactate, glucose, hematocrit were studied on a gas analyzer “BGA­102” Wondfo (Rain Sen Da), NTproBNP, Cystatin­C, interleukin­6 and protein S­100 were determined on an immunofluorescence ana­lyzer Finecare™ FIA MeterPlus/FS 113 (Wonfo), sedation was assessed using the Richmond scale. Newborns were assessed for Apgar scores in the 1st and 5th minutes.The data obtained showed that patients randomized to the group with dexmedetomidine (Group II) were almost al­ways better able to awaken than patients in the group with sibazon, and were distinguished by better hemodynamic stability, antinociceptive protection for surgical and anes­thetic intervention, without pronounced arterial hypoten­sion and bradycardia. It did not cause significant adverse outcomes in newborns.

Recent Advances in the Clinical Value and Potential of Dexmedetomidine

Dexmedetomidine, a highly selective α2-adrenoceptor agonist, has sedative, anxiolytic, analgesic, sympatholytic, and opioid-sparing properties and induces a unique sedative response which shows an easy transition from sleep to wakefulness, thus allowing a patient to be cooperative and communicative when stimulated. Recent studies indicate several emerging clinical applications via different routes. We review recent data on dexmedetomidine studies, particularly exploring the varying routes of administration, experimental implications, clinical effects, and comparative advantages over other drugs. A search was conducted on the PubMed and Web of Science libraries for recent studies using different combinations of the words “dexmedetomidine”, “route of administration”, and pharmacological effect. The current routes, pharmacological effects, and application categories of dexmedetomidine are presented. It functions by stimulating pre- and post-synaptic α2-adrenoreceptors within the central nervous system, leading to hyperpolarization of noradrenergic neurons, induction of an inhibitory feedback loop, and reduction of norepinephrine secretion, causing a sympatholytic effect, in addition to its anti-inflammation, sleep induction, bowel recovery, and sore throat reduction effects. Compared with similar α2-adrenoceptor agonists, dexmedetomidine has both pharmacodynamics advantage of a significantly greater α2:α1-adrenoceptor affinity ratio and a pharmacokinetic advantage of having a significantly shorter elimination half-life. In its clinical application, dexmedetomidine has been reported to present a significant number of benefits including safe sedation for various surgical interventions, improvement of intraoperative and postoperative analgesia, sedation for compromised airways without respiratory depression, nephroprotection and stability of hypotensive hemodynamics, reduction of postoperative nausea and vomiting and postoperative shivering incidence, and decrease of intraoperative blood loss. Although the clinical application of dexmedetomidine is promising, it is still limited and further research is required to enhance understanding of its pharmacological properties, patient selection, dosage, and adverse effects.

Effect of intravenous dexmedetomidine and remifentanil on neonatal outcomes after caesarean section under general anaesthesia: A systematic review and meta-analysis

BACKGROUND

Various strategies have been used to mitigate haemodynamic instability during general anaesthesia for caesarean section. However, the safety of these strategies for neonates remains controversial.

OBJECTIVE

To investigate the effects of intravenous dexmedetomidine and remifentanil on neonatal outcomes during caesarean section under general anaesthesia.

DESIGN

Systematic review and meta-analysis of randomised controlled trials.

DATA SOURCES

Databases of PubMed, EMBASE and CENTRAL were searched until March 2020 and updated in February 2021.

ELIGIBILITY CRITERIA

Randomised controlled trials were included if they compared dexmedetomidine and remifentanil infusion on neonatal outcomes after elective caesarean section under general anaesthesia. Primary outcomes were 1 and 5 min Apgar scores. Secondary outcomes were the incidence of neonatal mask ventilation or endotracheal intubation, and pH of the umbilical artery and vein. Studies that did not report primary outcomes were excluded.

RESULTS

Five studies with 258 patients in total were included. The Apgar score at 1 min in the remifentanil group was lower than that in the dexmedetomidine group for both quantitative [weighted mean difference (WMD): 0.75; 95% CI, 0.44 to 1.07; τ2 = 0.00] and categorical outcomes (≥Apgar 7 vs.

CONCLUSION

In our study, Apgar score at 1 min reported using both quantitative and categorical variables were lower in the remifentanil group than in the dexmedetomidine group but TSA showed that these differences were inconclusive for categorical variables. Data for other outcomes were scarce and did not allow any conclusions to be drawn. Thus, further studies with larger numbers of parturients and with neonatal outcomes as a primary endpoint are warranted to clarify the effects of intravenous dexmedetomidine and remifentanil.

TRIAL REGISTRATION

The protocol of this study has been registered in PROSPERO (CRD42019141102).

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MESH Headings

• Anesthesia, General/adverse effects
• Cesarean Section
• Dexmedetomidine/adverse effects
• Female
• Humans
• Infant, Newborn
• Piperidines/adverse effects
• Pregnancy
• Remifentanil

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Affiliation(s)

Myeongjong Lee From the Department of Anesthesiology and Pain Medicine (ML), Research Institute of Medical Science, Konkuk University School of Medicine, Chungju (ML), Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul (HK), Department of Anesthesiology and Pain Medicine, Wonkwang University School of Medicine, Muwang-ro, Iksan (CL) and Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Heukseok-ro, Dongjak-gu, Seoul, Republic of Korea (HK)
Hyungtae Kim
Cheol Lee
Hyun Kang

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Impact of Intraoperative Infusion and Postoperative PCIA of Dexmedetomidine on Early Breastfeeding After Elective Cesarean Section: A Randomized Double-Blind Controlled Trial

Objective

Few studies have investigated the effects of dexmedetomidine (DEX) on breastfeeding after cesarean delivery. A randomized double-blind controlled trial was conducted to investigate whether the administration of DEX, immediately after delivery and for patient-controlled intravenous analgesia (PCIA), can be beneficial for breastfeeding.

Patients and Methods

One hundred sixty parturients scheduled for elective cesarean section under spinal anesthesia were randomly allocated to the DEX group (a loading dose of DEX was pumped at 0.5 μg/kg within 10 min, followed by a further infusion of DEX at 0.5 μg/kg/h until the end of the surgery and PCIA for 2 days with DEX plus sufentanil) or the standard care group (infusion saline intraoperatively, and PCIA for 2 days with sufentanil). The number of days required to switch to exclusive breastfeeding within six weeks of delivery, the time to first lactation and breast milk volume on day 1 and day 2 after delivery were recorded. Recovery quality, comfort, anxiety, depression, postoperative analgesia, and adverse reactions of parturients were also assessed.

Results

Compared with the standard care group, parturients in the DEX group could be converted to exclusive breastfeeding earlier (11 [14] vs 8 [10] days, log-rank P=0.025), the first lactation time was sooner (28.38 [13.82] vs 33.79 [14.85] hrs, P=0.024), and the amount of breast milk on the second day after delivery increased (P=0.012). There was no difference between the two groups in postpartum uterine contraction pain, but postpartum rest and movement VAS scores and recovery quality score in the DEX group were better than those in the standard care group (all P<0.05). Moreover, the hospital anxiety and depression scale and anxiety subscale score on the second day after delivery and the comfort score on the third day after delivery in the DEX group were significantly better than those in the standard care group (5 [5] vs 6 [8], 2 [2] vs 3 [3], 83.58 [6.75] vs 80.48 [6.58]; P=0.013, P=0.005, P=0.006, respectively). The incidence of adverse events, such as bradycardia, vomiting, hypersomnia, hypertension and hypotension, was not significantly different between the DEX and standard care groups (6.9% vs 2.7%, 5.6% vs 13.7%, 4.2% vs 0%, 5.6% vs 2.7%, 11.1% vs 8.2%; P=0.275, P=0.158, P=0.366, P=0.681, P=0.556, respectively), except more parturients experienced nausea in the standard care group than in the DEX group (28.8% vs 11.1%, P=0.012). Furthermore, there was no difference in Neonatal Behavioral Neurological Assessment scores on the first and second days after delivery between the DEX and standard care groups (38 [3] vs 37 [2], 38.5 [2] vs 38 [2]; P=0.173, P=0.312, respectively).

Conclusion

The application of DEX in the perioperative period of cesarean section was not only conducive to the early conversion of infant feeding to exclusive breastfeeding but could also improve the recovery quality and comfort of the parturient, optimize analgesia, shorten the time to first lactation, and increase lactation.

Clinical Trials Registration

NCT03805945.

Ropivacaine vs. levobupivacaine: Analgesic effect of combined spinal-epidural anesthesia during childbirth and effects on neonatal Apgar scores, as well as maternal vital signs

The present study aimed to investigate and compare the analgesic effect and safety of ropivacaine or levobupivacaine in combined spinal-epidural anesthesia during childbirth and their effects on neonatal Apgar scores, as well as maternal and neonatal vital signs. A total of 615 maternal patients undergoing labor between April 2016 and March 2017 were divided into two groups according to the analgesic used for combined spinal-epidural anesthesia during childbirth: The ropivacaine group (n=318) and the levobupivacaine group (n=297). The onset time of analgesia in the two groups was determined and the pain score on the visual analog scale was assessed at the time of delivery (T3). At pre-analgesia, 30 min after analgesia (T2), at T3 and during maternal wound suturing (T4), the systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR) were assessed. The cesarean section rate, neonatal 1- and 5-min Apgar scores and neonatal asphyxia at T4 were also determined. The onset time of analgesia in the ropivacaine group was significantly reduced compared with that in the levobupivacaine group (P<0.05). At T2 and T4, the SBP was significantly higher in the levobupivacaine group than that in the ropivacaine group (P<0.05). At T2, T3 and T4, the DBP was significantly lower in the levobupivacaine group compared with those in the ropivacaine group (P<0.05). At T2, the HR was significantly lower in the levobupivacaine group than that in the ropivacaine group (P<0.05). The cesarean section rate was significantly lower in the ropivacaine group compared with that in the levobupivacaine group [4.09% (n=13) vs. 22.89% (n=68); P<0.01]. In conclusion, the use of combined spinal-epidural anesthesia with ropivacaine or levobupivacaine has an excellent analgesic effect during childbirth. However, compared with levobupivacaine, ropivacaine for labor analgesia had a faster onset and a lesser impact on maternal vital signs, and was associated with a reduced maternal cesarean section rate among patients who did not opt for cesarean section in the beginning; therefore, it is useful in clinical practice.

Effectiveness and safety of intravenous application of dexmedetomidine for cesarean section under general anesthesia: a meta-analysis of randomized trials

Objective

The meta-analysis was conducted to assess the effectiveness and safety of intravenous administration of dexmedetomidine for cesarean section under general anesthesia, as well as neonatal outcomes.

Materials and methods

We searched PubMed, Embase, Cochrane Central Register of Controlled Trials and the China National Knowledge Infrastructure database for relevant randomized controlled trials (RCTs) about the application of intravenous dexmedetomidine under general anesthesia for cesarean section. RevMan 5.3 was used to conduct the meta-analysis of the outcomes of interest.

Results

Eight RCTs involved 376 participants were included in this study. The meta-analysis showed that the mean blood pressure at the time of intubation (weighted mean difference [WMD]: -15.67, 95% CI: -21.21, -10.13, P<0.00001), skin incision (WMD: -12.83, 95% CI -20.53, -5.14, P=0.001), and delivery (WMD: -11.65, 95% CI -17.18, -6.13, P<0.0001) in dexmedetomidine group were significantly lower than that in the control group. The heart rate (HR) at the time of intubation (WMD: -31.41, 95% CI -35.01, -27.81, P<0.00001), skin incision (WMD: -22.32, 95% CI -34.55, -10.10, P=0.0003), and delivery (WMD: -19.07, 95% CI -22.09, -16.04, P<0.00001) were also lower than that in control group. For neonatal parameters, no differences existed in umbilical blood gases at delivery, and Apgar scores at 1 minute (WMD: -0.12, 95% CI -0.37, 0.12, P=0.33) and 5 minutes (WMD: -0.17, 95% CI -0.13, 0.46, P=0.27) among two groups.

Conclusion

Intravenous administration of dexmedetomidine could efficiently attenuate the maternal cardiovascular response during cesarean section, without affecting Apgar score of the neonate.

Effects of Dexmedetomidine Combined with Sufentanil on Postoperative Delirium in Young Patients After General Anesthesia

Background

This study was designed to evaluate the effects of combined usage of dexmedetomidine (DEX) and sufentanil on young patients with postoperative delirium (POD) after general anesthesia.

Material/Methods

We randomized 100 young patients with POD into 4 groups: Group D, Group S, Group DS1, and Group DS2, with loading and maintenance doses of DEX and/or sufentanil administered according to the experimental protocol. Hemodynamic variables, standard visual analogue scale (VAS) scores, sedation agitation scale (SAS) scores, stress hormones, and inflammatory biomarkers were assessed at 5 time-points: baseline (T₁); 1 h (T₂), 2 h (T₃), 4 h (T₄), and 8 h (T₅) after completion of the loading dose.

Results

At T₃–T₅, hemodynamic indicators in group D were obviously higher than in the other groups (P<0.05). At T₂–T₅, the VAS and SAS scores were noticeably lower than those at T₁ in each group (P<0.05). The VAS and SAS scores were remarkably higher in group D than those in the other groups (P<0.05). Compared with DS1, the incidence of respiratory distress decreased and the incidence of POD increased in group DS2. Compared to T₁, plasma concentrations of epinephrine, norepinephrine, IL-6, and TNF-α all decreased at T₂ and T₅ (P<0.05).

Conclusions

DEX and sufentanil decrease the incidence of POD, ameliorate the abnormities of hemodynamic indicators, and decrease VAS scores, SAS scores, stress hormones, and inflammatory biomarkers, but increase the incidence of respiratory distress. DEX combined with sufentanil may play a synergistic reaction in causing respiratory distress, but remarkably decreases the incidence of POD.

Comparison of Dexmedetomidine and Fentanyl as an Adjuvant to Lidocaine 5% for Spinal Anesthesia in Women Candidate for Elective Caesarean

AIM

This study aimed to compare the effect of Dexmedetomidine and fentanyl as an adjuvant to lidocaine 5% in spinal anaesthesia to increase post-operative analgesia among women candidates for elective caesarean.

METHODS

Eighty-four pregnant women candidates for caesarian were randomly divided into fentanyl and Dexmedetomidine groups. In the first group, 25 μg fentanyl was added to lidocaine 5% while in the second group, 0.5 μg per kilogram Dexmedetomidine was added to lidocaine 5%. After the operation, a pain score of the patients in recovery and within 4, 12 and 24 hours after the operation, the average length of analgesia and the average amount of the analgesics taken within 24 hours and after the operation were recorded.

RESULTS

The average length of postoperative anaesthesia and the average amount of the drug taken within the first 24 hours after the operation in fentanyl group was more than the Dexmedetomidine group (P = 0.01). Shivering in Dexmedetomidine group was more common than what was observed in the fentanyl group (P = 0.001). Higher rates of nausea-vomiting were observed in the fentanyl group (P = 0.001).

CONCLUSIONS

Fentanyl results in a longer period of postoperative analgesia and less consumption of drugs after the operation. Fentanyl is recommended in caesarian.

Effect on Neonatal Outcome of Pharmacological Interventions for Attenuation of the Maternal Haemodynamic Response to Tracheal Intubation: A Systematic Review

The primary aim of this systematic review was to assess the effect on neonatal outcome of pharmacological interventions used for attenuation of the haemodynamic response to tracheal intubation in patients undergoing caesarean Section under general anaesthesia. A systematic search of randomised controlled trials from 1990 to 2015 was conducted. The primary outcome measure was the Apgar score at five minutes and secondary outcomes were umbilical arterial blood gas parameters and neurological adaptive capacity scores. Twenty-seven randomised controlled trials (1,689 patients) were included in the qualitative synthesis. Only five studies using opioids (383 patients) and five studies using non-opioid analgesics (358 patients) were subjected to meta-analysis. The Apgar score at five minutes was significantly lower in neonates of opioid-treated mothers (mean difference: −0.29, 95% confidence interval −0.56 to −0.02, P-value=0.03) compared to mothers in the control group; the umbilical arterial pH was lower and there was a higher requirement for tactile stimulation in neonates. No difference was seen in Apgar scores of neonates of mothers administered non-opioid analgesics compared to placebo. No difference was observed in other parameters between opioid- or non-opioid-treated mothers. This review suggests that opioid interventions for attenuation of the haemodynamic response to tracheal intubation in pregnant patients under general anaesthesia affect neonatal Apgar scores at five minutes in neonates but the difference did not appear to be clinically meaningful. We were unable to demonstrate any difference in safety.

Effects of remifentanil and dexmedetomidine on the mother's awareness and neonatal Apgar scores in caesarean section under general anaesthesia

Objective

This study aimed to compare the effects of remifentanil and dexmedetomidine on awareness during the induction of general anaesthesia.

Material and Methods

Ninety patients scheduled for elective caesarean section under general anaesthesia were included and randomly divided into three anaesthesia groups: 2 mg/kg propofol (control group); 2 mg/kg propofol and 1 µg/kg dexmedetomidine (dexmedetomidine group); and 2 mg/kg propofol and 1 µg/kg remifentanil (remifentanil group). All patients received routine monitoring, and Apgar scores at 1 and 5 minutes were recorded. The bispectral index and the isolated forearm technique were used to determine the depth of anaesthesia.

Results

Bispectral index values at skin and uterine incisions and at delivery were similar among the groups. The number of patients who responded positively to the isolated arm technique during the induction period was also similar. One-minute Apgar scores in the control group were significantly lower and 5-minute Apgar scores significantly higher than those in the other groups.

Conclusion

The effects of remifentanil and dexmedetomidine added to propofol on maternal awareness, neonatal Apgar scores, and bispectral index values were similar compared with propofol alone. However, it was observed that remifentanil controlled the haemodynamic responses to sympathetic stimuli in a better manner than dexmedetomidine.

Comparison of the effects of low doses of dexmedetomidine and remifentanil on the maternal hemodynamic changes during caesarean delivery in patients with severe preeclampsia: a randomized trial

BACKGROUND

Preoperative remifentanil administration blunts hemodynamic responses to tracheal intubation in parturients with severe preeclampsia. We hypothesized that the preoperative administration of low doses of remifentanil or dexmedetomidine would lead to comparable maternal neurohormonal responses and neonatal outcomes in patients with severe preeclampsia.

METHODS

Parturients diagnosed with severe preeclampsia undergoing caesarean delivery were randomLy allocated to receive remifentanil (0.1 µg/kg/min) or dexmedetomidine (0.4 µg/kg/h) at five min and 20 min before induction, respectively. Changes in maternal mean arterial BP(MAP), clinical recovery, cortisol level, and neonatal outcome, were recorded.

RESULTS

Patients who received remifentanil had higher response in MAP at the induction (94 9.8 vs. 104 4.5; P<0.001) and emergence from anesthesia (94 6.3 vs. 98 5.1; P<0.001), but shorter times to extubation (5.1 1.6 vs. 13.5 2.8 min; P<0.001). Five (27.8%) patients in the remifentanil group received ephedrine versus none in the dexmedetomidine group (P=0.023). The maternal plasma cortisol levels, the neonatal Neurologic and Adaptative Capacity Scores and acid-base satuses were similar in the two groups. Newborns in the remifentanil group presented lower Apgar scores at 1 minute (5.11 0.8 vs. 5.68 0.8; P=0.034) and a higher incidence of respiratory depression (72.2% vs. 36.8% P=0.048).

CONCLUSIONS

Compared with dexmedetomidine (0.4 µg/kg/h), the preoperative administration of remifentanil (0.1 µg/kg/min) produced a significantly higher effect on maternal hemodynamic responses to caesarean delivery in patients with severe preeclampsia, however maternal hypotension and neonatal respiratory depression were more common with the use of remifentanil.

Efficacy and safety of remifentanil for analgesia in cesarean delivery

BACKGROUND

This study aimed to assess the efficacy and safety of remifentanil as a general anesthetic during cesarean delivery.

MATERIAL AND METHODS

Fifty women with singleton pregnancies undergoing cesarean delivery were randomly divided into intervention and control groups, each group containing 25 subjects. Participants in the intervention group received remifentanil (infused at 2 μg/kg/h), whereas subjects in the control group were given dexmedetomidine (infused at 0.4 μg/kg/h). Outcome measurements included mean arterial blood pressure (MAP), heart rate (HR), bispectral index (BIS), Apgar scores at 1 and 5 minutes, and the pH, PCO2, PO2, and base excess (BE) of umbilical venous and arterial blood.

RESULTS

Forty-four participants completed the study. Patients in the intervention group did not experience greater effect and safety than those in the control group (P > .05), although MAP and BIS values decreased significantly immediately before laryngoscopy (P < .05). In addition, BIS values were reduced significantly at the time of skin incision, at uterine incision, and immediately after fetal delivery when compared with baseline values in both groups (P < .01).

CONCLUSION

This study concluded that remifentanil and dexmedetomidine exhibited similar efficacy and safety during general anesthesia for cesarean delivery.

Perinatal and neonatal use of sedation and analgesia

Optimal obstetric and neonatal care requires the provision of adequate analgesia for painful procedures. However, anesthetic and analgesic agents have the potential to adversely impact the developing fetal/neonatal brain. In this setting, clinicians must assess the risks and benefits of pharmacologic anesthesia and analgesia for specific indications in this population. General anesthesia is required for non-obstetric surgery and cesarean section in the absence of neuraxial anesthesia for the health of the mother and fetus. Although experimental data raise concerns, human data are reassuring and future research may focus on neuroprotective adjuncts in the setting of repeated or prolonged anesthetic exposures. Opioid analgesia is standard of care for preterm infants undergoing major procedures including invasive surgery and endotracheal intubation. The use of opioids for agitation resulting from mechanical ventilation is controversial, but prevalent. Randomized and retrospective studies detect short-term toxicity with inconclusive long-term impact, suggesting the need to explore alternative therapies.

Postoperative management with dexmedetomidine in a pregnant patient who underwent AVM nidus removal: a case report

Background

Following cerebral arteriovenous malformation (AVM) surgery, severe brain edema and hemorrhage may be caused by postoperative normal perfusion pressure breakthrough (NPPB). Sedation is necessary for this population. It is a challenge for the anesthesiologist to maintain hemodynamic stability without interfering with the neurological assessment. In Japan, propofol is contraindicated for pregnant patients. Dexmedetomidine is a versatile drug in anesthesia practice and may be useful for this situation. There is no report using dexmedetomidine for the purpose of NPPB control in pregnant patients. We describe the postoperative management with dexmedetomidine for a pregnant patient who underwent cerebral AVM nidus removal.

Case presentation

A 32-year-old patient presented with headache at the 16th week of gestation. Neuroimaging revealed an intraventricular hemorrhage and an AVM at the right anterior horn of the lateral ventricle which caused bleeding. A multidisciplinary team discussion was done, and then a craniotomy for AVM nidus removal was performed under general anesthesia. Preanesthetic aspiration prophylaxis and rapid sequence induction were added to our conventional anesthetic management. Hypotension occurred after anesthetic induction but the patient recovered by volume resuscitation and vasopressors. Anesthesia was maintained with 50% O₂ in air and sevoflurane. The AVM was completely removed, and no perioperative complications occurred. Postoperative sedation with dexmedetomidine was used to prevent breakthrough hyperperfusion and cerebral edema.

Conclusions

Dexmedetomidine infusion was used for postoperative sedation without causing any side effects, and it can be an alternative for sedation, especially when propofol is contraindicated.