A Comparison of the Effects of Dexmedetomidine and Propofol in Controlling the Hemodynamic Responses after Intubation: A Double-Blind, Randomized, Clinical Trial Study

The use of dexmedetomidine in the emergency department: A systematic review

BACKGROUND

Dexmedetomidine (DEX), a centrally acting alpha-2 agonist, is increasingly used for sedation in multiple clinical settings. Evidence from the intensive care unit and operative settings suggests DEX may have significant advantages over traditional GABAergic sedatives such as benzodiazepines. There has been limited research on the use of DEX in the emergency department (ED).

METHODS

We performed a systematic review of the medical literature to identify all published evidence regarding the use of DEX in the ED. We included randomized and nonrandomized studies and studies reporting any use of DEX in the ED, even when it was not the primary focus of the study. Two authors reviewed studies for inclusion, and a single author assessed studies for quality and risk of bias and abstracted data.

RESULTS

We identified 35 studies meeting inclusion criteria, including 11 randomized controlled trials, 13 cohort and other nonrandomized studies, and 11 case reports and case series. Significant heterogeneity in interventions, comparators, indications, and outcomes precluded data pooling and meta-analysis. We found modest evidence that DEX was efficacious in facilitating medical imaging and mixed and limited evidence regarding its efficacy for procedural sedation and sedation of nonintubated medical and psychiatric patients. Our results suggested that DEX is associated with bradycardia and hypotension, which are generally transient and infrequently require medical intervention.

CONCLUSIONS

A limited body of generally poor- to moderate-quality evidence suggests that the use of DEX may be efficacious in certain clinical scenarios in the ED and that DEX use in the ED is likely safe. Further high-quality research into DEX use in the ED setting is needed, with a particular focus on clear and consistent selection of indications, identification of clear and clinically relevant primary outcomes, and careful assessment of the clinical implications of the hemodynamic effects of DEX therapy.

A Response Surface Analysis of the Combination of Dexmedetomidine and Sufentanil for Attenuating the Haemodynamic Response to Endotracheal Intubation

Purpose

Dexmedetomidine combined with opioids has been extensively used to blunt cardiovascular responses to endotracheal intubation. To determine their interaction, we aimed to develop a response surface model between dexmedetomidine and sufentanil.

Methods

One hundred and twenty patients undergoing scheduled gynaecological surgery were recruited. According to a simulation of slice design, patients received different dose pairs of dexmedetomidine (0 to 1.1 μg/kg) and sufentanil (.1 to .5 μg/kg). The mean arterial blood pressure and heart rate of patients were recorded just before endotracheal intubation, immediately after intubation, and during the first 3 min after intubation. The primary outcomes were haemodynamic changes. The full dose–response relationship between dexmedetomidine and sufentanil was analysed using a logit model.

Results

This response surface model revealed that the interaction between dexmedetomidine and sufentanil was additive. The dose pairs that could effectively attenuate the haemodynamic response to endotracheal intubation primarily ranged from .3 to .4 μg/kg and .5 to 1.1 μg/kg for sufentanil and dexmedetomidine, respectively.

Conclusion

When used propofol as the main hypnotic drug during anaesthesia induction, dexmedetomidine could effectively reduce the requirement of sufentanil in an additive manner. However, it is not an effective drug for ablating the cardiovascular response to endotracheal intubation when used alone. The clinical trial registry. The trial registry name: Chinese Clinical Trial Registry. Registration number: ChiCTR1800015273. URL: http://www.chictr.org.cn

Effect of Dexmedetomidine on Perioperative Hemodynamics and Myocardial Protection in Thoracoscopic-Assisted Thoracic Surgery

BACKGROUND This study aimed to clarify the protective role of dexmedetomidine in thoracoscopic-assisted thoracic surgery (TATS), including control of the intraoperative heart rate, blood pressure, and myocardial injury markers. MATERIAL AND METHODS The patients who underwent TATS were divided into 2 equal groups: the dexmedetomidine group (dexmedetomidine pumped at 0.5 µg/kg for >10 min before the administration of anesthesia and at 0.5 µg/kg in the maintenance period) and the control group (pumped normal saline for >10 min before the administration of anesthesia). The data recorded for each patient were heart rate (preoperative, maximum intraoperative, and minimum intraoperative), systolic and diastolic blood pressure, intraoperative hemodynamic data, and intraoperative cardiovascular drugs administered. An enzyme-linked immunosorbent assay was performed to assess the postoperative levels of cardiac troponin I (cTnI), creatine kinase isoenzyme, myoglobin, and N-terminal pro-B-type natriuretic peptide (NT-proBNP). RESULTS There were no significant differences in the age, sex, body height, body weight, American Society of Anesthesiologists classification grade, resection mode, operation time, ejection fraction, basal heart rate, and systolic and diastolic blood pressure of the 2 groups. In the dexmedetomidine group, the patients' maximum intraoperative heart rate and diastolic pressure decreased, and the postoperative hospital stay period was shorter. The postoperative peripheral blood test for the dexmedetomidine group showed higher NT-proBNP levels and lower cTnI levels. CONCLUSIONS Preoperative administration of dexmedetomidine can benefit hemodynamic stability, protect the cardiovascular system in the intraoperative and postoperative periods, and shorten postoperative hospitalization.

Effects of Propofol on Hemodynamic Profile in Adults Receiving Targeted Temperature Management

Background: Propofol is a key component for the management of sedation and shivering during targeted temperature management (TTM) following cardiac arrest. The cardiac depressant effects of propofol have not been described during TTM and may be especially relevant given the stress to the myocardium following cardiac arrest. The purpose of this study is to describe hemodynamic changes associated with propofol administration during TTM. Methods: This single center, retrospective cohort study evaluated adult patients who received a propofol infusion for at least 30 minutes during TTM. The primary outcome was the change in cardiovascular Sequential Organ Failure Assessment (cvSOFA) score 30 minutes after propofol initiation. Secondary outcomes included change in systolic blood pressure (SBP), mean arterial pressure (MAP), heart rate (HR), and vasopressor requirements (VR) expressed as norepinephrine equivalents at 30, 60, 120, 180, and 240 minutes after propofol initiation. A multivariate regression was performed to assess the influence of propofol and body temperature on MAP, while controlling for vasopressor dose and cardiac arrest hospital prognosis (CAHP) score. Results: The cohort included 40 patients with a median CAHP score of 197. The goal temperature of 33°C was achieved for all patients. The median cvSOFA score was 1 at baseline and 0.5 at 30 minutes, with a non-significant change after propofol initiation ( P = .96). SBP and MAP reductions were the greatest at 60 minutes (17 and 8 mmHg; P < .05 for both). The median change in HR at 120 minutes was −9 beats/minute from baseline. This reduction was sustained through 240 minutes ( P < .05). No change in VR were seen at any time point. In multivariate regression, body temperature was the only characteristic independently associated with changes in MAP (coefficient 4.95, 95% CI 1.6-8.3). Conclusion: Administration of propofol during TTM did not affect cvSOFA score. The reductions in SBP, MAP, and HR did not have a corresponding change in vasopressor requirements and are likely not clinically meaningful. Propofol appears to be a safe choice for sedation in patients receiving targeted temperature management after cardiac arrest.

Efficacy of dexmedetomidine and ketamine addition to bupivacaine 0.25% by epidural method in reducing postoperative pain in patients undergoing femur fracture surgery

Background and Aim:

One of the most complex medical problems is pain, that due to inappropriate management of patients after surgery could cause various side effects on the psychological, physiological, and metabolic state of the patients. The natural duration of analgesia can be increased by adding new efficient adjuvant. The present study is mainly aimed to investigate the differences between the epidural dexmedetomidine and ketamine effectiveness when administered as an adjuvant to epidural 0.25% bupivacaine for improving the postoperative analgesia duration.

Methods:

In the present double-blind clinical study, 105 patients of the age range of 40–85 years were selected for elective femoral surgery and then was divided into three of ketamine, dexmedetomidine, and control randomly. The scores of postoperative pain were evaluated in accordance with the visual Analogue Scale (VAS) criteria and the duration of analgesia and the amount of analgesics consumption were recorded.

Results:

The mean pain VAS score during the first day after the surgery and recovery of patients in the dexmedetomidine group was significantly lower in comparison with two other groups (p = 0.01). However, no significant difference was found in the mean VAS score of Paine during 12 and 24 hours after the operation (P ≥ 0.05). Comparisons among these groups demonstrated that the mean on opioid administration during the operation and 24 hours after that was significantly higher in both groups of ketamine and control in comparison with the dexmedetomidine group (P = 0.001 and P = 0.01). Besides, analgesia duration among patients belonged to the dexmedetomidine group was notably lower in comparison with two other groups (P = 0.001).

Conclusion:

In epidural anesthesia cases adding ketamine and dexmedetomidine as adjuvants to the solution of bupivacaine 0.25%, could increase the duration of analgesia and reduce the consumption of analgesics, which is more in the dexmedetomidine group when compared with ketamine.