Effect of intrathecal dexmedetomidine on cesarean section during spinal anesthesia: a meta-analysis of randomized trials

Esketamine Combined with Dexmedetomidine to reduce Visceral Pain During elective Cesarean Section Under Combined Spinal-Epidural Anesthesia: A double-Blind Randomized Controlled Study

Purpose

We aimed to evaluate the effect of intravenous esketamine combined with dexmedetomidine as supplemental analgesia in reducing intraoperative visceral pain during elective cesarean section under combined spinal-epidural anesthesia (CSEA).

Patients and Methods

A total of 269 parturients scheduled for elective cesarean section under CSEA between May 2023 and August 2023 were assessed. The parturients were randomly allocated to receiving either intravenous infusion of 0.3-mg/kg esketamine combined with 0.5-μg/kg dexmedetomidine (group ED, n=76), 0.5-μg/kg dexmedetomidine (group D, n=76), or normal saline (group C, n=76) after umbilical cord clamping. The primary outcome was intraoperative visceral pain. Secondary outcomes included the visual analog scale (VAS) score for pain evaluation and other intraoperative complications.

Results

The incidence of visceral pain was lower in group ED [9 (12.7%)] than in group D [32 (43.8%)] and group C [36 (48.6%), P <0.0001]. The VAS score was also lower in group ED when exploring abdominal cavity [0 (0), P <0.0001] and suturing the muscle layer [0 (0), P =0.036]. The mean arterial pressure was higher in group D [83 (9) mmHg] and group ED [81 (11) mmHg] than in group C [75 (10) mmHg, P <0.0001] after solution infusion. The heart rate after infusion of the solution was lower in group D [80 (12) bpm] than in group C [86 (14) bpm] and group ED [85 (12) bpm, P = 0.016]. The incidence of transient neurologic or mental symptoms was higher in group ED compared to group C and group D (76.1% vs 18.9% vs 23.3%, P<0.0001).

Conclusion

During cesarean section, 0.3-mg/kg esketamine combined with 0.5-μg/kg dexmedetomidine can alleviate visceral traction pain and provide stable hemodynamics. Parturients receiving this regimen may experience transient neurologic or mental symptoms that can spontaneously resolve at the end of the surgery.

Effectiveness of intrathecal dexmedetomidine vs fentanyl as additives to hyperbaric bupivacaine for postoperative analgesia in women undergoing cesarean section: a systematic review protocol

OBJECTIVE

The aim of this review is to compare the effectiveness of intrathecal dexmedetomidine vs fentanyl as additives to hyperbaric bupivacaine in providing postoperative analgesia in patients undergoing cesarean section.

INTRODUCTION

Pain following cesarean section remains a challenge, with limited treatment options due to potential undesirable parturient and neonatal side effects. Intrathecal dexmedetomidine has emerged as a favorable alternative to opioid additives to hyperbaric bupivacaine in prolonging postoperative analgesia, but its effectiveness requires further investigation.

INCLUSION CRITERIA

The review will evaluate studies of patients who underwent cesarean section under spinal anesthesia where dexmedetomidine and fentanyl were compared as intrathecal additives to hyperbaric bupivacaine for postoperative analgesia. This review will consider randomized controlled trials, non-randomized controlled trials, and prospective cohort studies for inclusion. No limits regarding publication date or language will be applied.

METHODS

A preliminary search of PubMed and Cochrane Central Register of Controlled Trials has been conducted to identify relevant index terms and keywords, which will be applied in a second search across PubMed, Cochrane CENTRAL, Scopus, and Embase. Google Scholar, National Library of Medicine (Clinicaltrials.gov), and the World Health Organization International Clinical Trial Registry Platform will be searched to identify unpublished literature. Full-text studies will be subjected to an assessment of methodological quality, and data extraction will be performed independently by 2 reviewers. The results will be presented in both tabular and narrative format and, where possible, pooled into a meta-analysis. A Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Summary of Findings will be created to grade the certainty of evidence of the reported outcomes.

REVIEW REGISTRATION

PROSPERO CRD42022364815.

Intrathecal dexmedetomidine as an adjuvant to plain ropivacaine for spinal anesthesia during cesarean section: a prospective, double-blinded, randomized trial for ED50 determination using an up-down sequential allocation method

BACKGROUND

Intrathecal dexmedetomidine, as an adjuvant to local anesthetics, has been reported to improve the quality of spinal anesthesia and reduce the required local anesthetic dose. However, the optimal dosage regimen for intrathecal dexmedetomidine combined with plain ropivacaine for cesarean section (CS) remains undetermined. The present study aimed to determine the median effective dose (ED50) of intrathecal dexmedetomidine as an adjuvant to plain ropivacaine for spinal anesthesia during CS.

METHODS

Sixty parturients undergoing CS were randomly assigned to either group: plain ropivacaine 8 mg (Group Rop8) or plain ropivacaine 10 mg (Group Rop10). The initial dosage of intrathecal dexmedetomidine in each group was 5 µg. The effective dose was defined as a bilateral sensory block at the level of T6 or above to pinprick attained within 10 min after intrathecal injection, without the need for supplementary intraoperative epidural anesthesia. Effective or ineffective responses were determined, followed by a 1 µg increment or decrement in the dose of intrathecal dexmedetomidine for the next parturient using up-down sequential allocation. ED50 were calculated using probit regression.

RESULTS

The ED50 of intrathecal dexmedetomidine with plain ropivacaine was 5.9 µg (95% confidence interval [CI], 4.9-7.4 µg) in Group Rop8 and 3.1 µg (95% CI, 0.1-4.8 µg) in Group Rop10 (P < 0.05). Hemodynamic stability, side effects, patient satisfaction and neonatal outcomes were comparable between the two groups.

CONCLUSIONS

The present data suggested that the ED50 of intrathecal dexmedetomidine as an adjuvant to 8 mg and 10 mg plain ropivacaine in spinal anesthesia during cesarean section was approximately 6 µg and 3 µg, respectively.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, identifier: ChiCTR2200055928.

Dexmedetomidine Combined with Low-Dose Norepinephrine Continuous Pumping to Prevent Hypotension after Cesaresan Section: A Randomized Controlled Trial

Objective

The aim of the study is to explore the clinical effect of dexmedetomidine combined with low-dose norepinephrine (NE) continuous pumping in preventing supine hypotension.

Methods

A total of 160 puerperaes who underwent elective cesarean section were selected. The puerperaes were equally divided into S group (saline), D group (dexmedetomidine), N group (norepinephrine), and DN group (dexmedetomidine combined with norepinephrine) by a random number table method. Apgar scores and umbilical cord venous blood gas values were recorded at 1 and 5 minutes.

Results

There were no statistically significant differences in the age, gestational age, body mass index, bleeding volume, fluid supplement volume, Apgar scores of new borns at the 1st and 5th minute, the blood gas values of umbilical cord arterial and venous in the four groups (P > 0.05). Compared with the S group, the incidence of supine hypotension, the number of NE supplements, the supplementary doses of NE, and the incidence of adverse reactions were significantly reduced in the D, N, and DN groups after spinal anesthesia (P < 0.05). Compared with group D, the incidence of supine hypotension, the number of additional NE, additional dose of NE, and the incidence of adverse reactions in the DN group after spinal anesthesia were significantly reduced (P < 0.05). Compared with the N group, the incidence of supine hypotension, the number of additional NE, the additional dose of NE, and the incidence of adverse reactions in the DN group after spinal anesthesia were significantly reduced (P < 0.05).

Conclusion

Dexmedetomidine combined with continuous pumping of low-dose norepinephrine can effectively prevent the occurrence of supine hypotension, reduce the occurrence of other adverse reactions, and have no obvious adverse effects on neonates. Registration. Chinese Clinical Trial Registry (https://www.chictr.org.cn/enIndex.aspx; ChiCTR2000040979).

What Is the Role of Dexmedetomidine in Modern Anesthesia and Critical Care?

Dexmedetomidine's unique sedative properties have led to its widespread use. Dexmedetomidine has a beneficial pharmacologic profile including analgesic sparing effects, anxiolysis, sympatholysis, organ-protective effects against ischemic and hypoxic injury, and sedation which parallels natural sleep. An understanding of predictable side effects, effects of age-related physiologic changes, and pharmacokinetic and pharmacodynamic effects of dexmedetomidine is crucial to maximize its safe administration in adults and children. This review focuses on the growing body of literature examining advances in applications of dexmedetomidine in children and adults.

Sufentanil vs. Dexmedetomidine as Neuraxial Adjuvants in Cesarean Section: A Mono-Centric Retrospective Comparative Study

Spinal anesthesia is the best choice for caesarean delivery. This technique is characterized by a complete and predictable nerve block with a fast onset and few complications. Several intrathecal adjuvants are used in order to improve the quality and duration of anesthesia and reduce its side effects. Sixty-two patients who underwent caesarean delivery under spinal anesthesia were included in this medical records review. In this retrospective study, after adopting exclusion criteria, we assessed 24 patients who received Hyperbaric Bupivacaine 0.5% 10 mg and dexmedetomidine 10 μg (G1), and 28 patients who received an institutional standard treatment with Hyperbaric Bupivacaine 0.5% 10 mg and sufentanil 5 μg (G2). We evaluated the difference in terms of motor and sensory block, postoperative pain, and adverse effects during the first 24 h following delivery and neonatal outcome. Our study found that the sufentanil group had a significantly lower requirement for analgesia than the dexmedetomidine group. Postoperative pain, assessed with the VAS scale, was stronger in G1 than in G2 (4 ± 2 vs. 2 ± 1, p-value < 0.01). Differences between the two groups regarding the intraoperative degree of motor and sensory block, motor recovery time, and neonatal Apgar scores were not noticed. Pruritus and shivering were observed only in G2. Itching and shivering did not occur in the dexmedetomidine group. Postoperative analgesia was superior in the sufentanil group, but the incidence of side effects was higher. Adjuvant dexmedetomidine prevented postoperative shivering.

Effect of Dexmedetomidine as an adjuvant in quadratus lumborum block in patient undergoing caesarean section - A randomised controlled study

STUDY OBJECTIVE

This study was conducted to evaluate the effect of Dexmedetomidine as an adjuvant in quadratus lumborum block (QLB) for postoperative pain relief at rest in patients undergoing caesarean section (CS). The primary objective was to compare the time to the first request of rescue analgesia. Secondary objectives were to compare the amount of rescue analgesia, patient satisfaction, Numeric rating scale (NRS), and Ramsay sedation score (RSS) during the first 24 h.

DESIGN

A randomised, double-blinded study.

SETTING

The study was conducted at AIIMS Bhubaneswar from December 2019 to February 2021in the Operating Theatre complex (for the immediate postoperative follow-up) and in the Obstetric Ward (for follow-up at the later time points).

PATIENTS

A total of 70 patients were enrolled with singleton term pregnancies scheduled for CS under spinal anaesthesia after written informed consent.

INTERVENTION

Bilateral QLB was given in the recovery area. Group A received 30 ml of 0.25% Bupivacaine and group B received 30 ml 0.25% bupivacaine with Dexmedetomidine 1 μg/kg. They received inj. Paracetamol 15 mg/kg intravenously TDS and Inj. Tramadol 1 mg/kg as rescue analgesia (if Numeric rating scale (NRS) Score ≥ 4). We also compared the rescue analgesia in the first 24 h, patient satisfaction scores, Ramsay sedation score (RSS), and NRS scores at 2, 4, 6, 8, 12, 18, and 24 h.

MAIN RESULTS

The time to request the first rescue analgesia was significantly prolonged in group B [Mean ± SD (95% CI)] 880 ± 351 (720-1040) min. vs group A 439 ± 208 (368-510) min., p < 0.001). There was a significant decrease in the amount of rescue analgesia [(Inj. Tramadol (1 mg/ kg)] used in the group with dexmedetomidine [group B Mean ± SD (95% CI) (57 ± 18 (49-65) mg. vs group A - 81 ± 25 (73-90)] mg., p < 0.001]. A significant difference was seen in patient satisfaction scores and pain scores between the groups up to 18 h. (p < 0.05) but not in RSS.

CONCLUSION

Dexmedetomidine can be considered an effective adjuvant for QLB in CS in the absence of intrathecal morphine.

Effect of dexmedetomidine on oxytocin-induced uterine contraction during optimal caesarean section anaesthesia

Numerous drugs are used during caesarean sections to provide regional and general anaesthesia. Dexmedetomidine has been used in some recent obstetric trials, but there are concerns about postpartum changes in uterine contractions. This study evaluated the effect of dexmedetomidine on oxytocin-induced uterine contractions in women undergoing caesarean section. Sixty women undergoing caesarean section in Lianyungang Second People's Hospital were randomly assigned to dexmedetomidine (group D, n = 30) or saline (group C, n = 30) groups. Equal volumes of saline or dexmedetomidine were administered intravenously (IV). During the intraoperative delivery of the foetus and placenta, oxytocin was administered to promote contractions. Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP) were compared. The Ramsay scale was used to assess sedation, while the Tsai and Chu methods assessed shivering. Adverse intraoperative events were observed. All variables fluctuated significantly after anaesthesia onset in both groups but were most pronounced in group D. The VAS, Ramsay and shivering scores were significantly lower in group D compared to group C. During rapid IV infusion of oxytocin after foetal delivery, the incidence of nausea, vomiting, chest tightness and hypotension was significantly lower in group D than in group C.

Reconstruction Algorithm-Based Ultrasonic and Spiral CT Images in Evaluating the Effects of Dexmedetomidine Anesthesia for Acute Abdomen

OBJECTIVE

The study focused on the application value of iteration reconstruction algorithm-based ultrasound and spiral computed tomography (CT) examinations, and the safety of dexmedetomidine anesthesia in acute abdominal surgery.

METHODS

80 cases having the acute abdomen surgery were selected as the research subjects. They were divided into group A (40 cases) and group B (40 cases) according to the anesthetic drugs used in the later period. The experimental group was injected with propofol, remifentanil, and atracurium combined with dexmedetomidine; the control group was injected with propofol, remifentanil, and atracurium only. After the operation, the patient was for observed for the pain, agitation, adverse reactions, heart rate (HR), and blood pressure. All patients received ultrasound and spiral CT examinations, and based on the characteristics of the back-projection algorithm, an accelerated algorithm was established and used to process the image, and according to which, the patient's condition and curative effects were evaluated.

RESULTS

After image reconstruction, the ultrasound and spiral CT images were clearer with less noise and more prominent lesions than before reconstruction. Before image reconstruction, the accuracy rates of ultrasound and spiral CT in diagnosing acute abdomen were 92.3% and 91.1%, respectively. After reconstruction, the corresponding numbers were 96.3% and 98.1%, respectively. After reconstruction, the accuracy of the two methods in diagnosing acute abdomen was significantly improved compared with that before reconstruction, and the difference was statistically significant (P < 0.05). The Ramsay score of the experimental group was significantly higher than that of the control group at each time period, P < 0.05; the agitation score and visual analogue scale (VAS) score of the experimental group were significantly lower than the control group at each time period after waking up, P < 0.05.

CONCLUSION

Reconstruction algorithm-based ultrasound and spiral CT images have high application value in the diagnosis of patients with acute abdomen, and dexmedetomidine has good safety in anesthesia surgery.

Intrathecal dexmedetomidine improves epidural labor analgesia effects: a randomized controlled trial

OBJECTIVE

α2‑agonists and opioids have been used as intrathecal adjuvants to local anesthetics for several years, but the effect of intrathecal dexmedetomidine (Dex) or sufentanil combined with epidural ropivacaine in labor analgesia is not fully understood.

METHODS

A total of 108 parturient women receiving combined spinal-epidural labor analgesia were randomly divided into three groups. Group C received l mL saline (0.9%) intrathecally, Group D received 5 µg Dex intrathecally, and Group S received 5 µg sufentanil intrathecally. All parturient women then received 0.1% epidural ropivacaine and 0.2 µg/mL sufentanil for patient-controlled epidural analgesia with standard settings. The visual analog scale score, onset time, duration of intrathecal injection, local anesthetic requirements, and side effects were recorded.

RESULTS

The labor analgesia effects in Groups D and S were better than those in Group C. Groups D and S displayed significantly shorter onset times, longer durations of intrathecal injection, and reduced local anesthetic requirements compared with Group C. The incidence of shivering and pruritus in Group D was lower than that in Group S.

CONCLUSION

Intrathecal administration of 5 µg Dex could improve epidural labor analgesia effects.This randomized controlled clinical trial was registered with the Chinese Clinical Registry Center (ChiCTR-1800014943, http://www.chictr.org.cn/).

Fever Associated With Dexmedetomidine in Adult Acute Care Patients: A Systematic Review of the Literature

Dexmedetomidine-associated fever has been reported in the literature and can lead to lengthy workups and unnecessary antibiotic exposure. We conducted a systematic review to evaluate and describe the evidence of fever or hyperthermia caused by dexmedetomidine in adult patients. Data sources included PubMed/MEDLINE, EMBASE, CINAHL, and Web of Sciences. English-language studies of any design published from inception through April 2020 including conference abstracts were included. The target population was hospitalized adult patients. Quality of evidence was determined based on GRADE recommendations and risk of bias assessed using the Evidence Project Risk of Bias tool. Naranjo scores were assessed to determine the likeliness of adverse event being caused by dexmedetomidine. All data were extracted independently and with the guidance of a medical librarian. Four hundred and eighty-eight total citations were found on formal search, with 329 left after removal of duplicates. Independent record screening was performed, leaving 17 citations including 4 retrospective cohort studies, 1 case series, and 12 case reports. Quality of evidence ranged from very low to low for identified analyses. Evidence with patient-level data (case reports and series) were combined to establish a cohort for descriptive results. The median Naranjo score was 4 (range, 3 to 8), and dexmedetomidine doses ranged from 0.1 to 2 μg·h/kg. Obesity and cardiac surgery appear to be significant risk factors. Dexmedetomidine-associated fever appears uncommon, but the true incidence is unknown. Clinicians should keep dexmedetomidine-associated fever in their differential, and stewardship programs should consider assessing for this adverse effect in their patient monitoring.