Dexmedetomidine: an adjuvant making large inroads into clinical practice

The Effects of Dexmedetomidine on Pain-Related Outcomes in Craniotomy: A Systematic Review and Meta-Analysis

BACKGROUND

Craniotomy is associated with several undesirable effects including postoperative pain. This systematic review and meta-analysis aimed to evaluate evidence on the efficacy and safety of dexmedetomidine (DEX) for pain management in patients undergoing craniotomy.

METHODS

We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The protocol was registered in Open Science Framework. We searched for existing randomized controlled studies published before June 2023 that used DEX during the perioperative period in craniotomy in PubMed, Scopus, and the Cochrane Library. A meta-analysis was conducted in RevMan. Cochrane RoB2 and GRADE were used for quality assessment.

RESULTS

A total of 19 randomized controlled trials comprising 3153 patients were included. Pain intensity was lower in the DEX group than the control group at a mean difference [95% confidence interval] of -0.64 [-1.16, -0.13], P-value = 0.01. The DEX group overall consumed less opioids in comparison with the control group at a mean difference = -4.00 [-6.16, -1.83], P value = 0.0003. However, heterogeneity was considerable for both outcomes (I2 = 81% and I2 = 96%, respectively). There was no difference between the DEX and control groups in the time to first postanalgesic requirement, hypertension, hypotension, or cough.

CONCLUSIONS

The results showed that the use of DEX was associated with lower pain intensity and less opioid use. Patients in the DEX group experienced fewer episodes of nausea and vomiting, agitation, and shivering but more episodes of bradycardia. There was no difference between DEX and control groups in other adverse events.

Risk of Rhabdomyolysis Associated with Dexmedetomidine Use over the Past 10 Years: Insights from the EudraVigilance Database

Dexmedetomidine, a selective α2-adrenergic agonist, is favoured in intensive care for its minimal respiratory depression. This study evaluated the reporting frequency of rhabdomyolysis with dexmedetomidine compared to midazolam and propofol using the European pharmacovigilance database Eudravigilance. We conducted an observational, retrospective analysis of Individual Case Safety Reports (ICSRs) from 1 January 2013, to 31 December 2023. Primary and secondary outcomes included the reporting frequencies of rhabdomyolysis and its indicative signs and symptoms, respectively. We retrieved 19,268 ICSRs, of which 364 reported rhabdomyolysis associated with dexmedetomidine (3.8%), midazolam (10.2%), propofol (76.9%), or combinations thereof (9.1%). Dexmedetomidine showed a significantly lower reporting frequency of rhabdomyolysis compared to propofol (ROR, 0.32; 95% CI, 0.19-0.55) but no significant difference compared to midazolam. Subgroup analyses revealed higher frequencies in males, especially with propofol. Despite limitations such as underreporting, our findings suggest dexmedetomidine poses a lower rhabdomyolysis risk than propofol, supporting its safe use for sedation in high-risk patients. It is important to note that due to the retrospective design of this study our findings are indicative of correlations rather than causation. Continuous monitoring and further studies are recommended to validate these results.

Ultrasound‑guided erector spinae plane block in posterior lumbar surgery (Review)

The erector spinae plane block (ESPB) is a novel fascial planar block technique, which is used to reduce postoperative pain in several surgical procedures, including breast, thoracic, spine and hip surgery. Due to its recognizable anatomy and low complication rate, the application of ESPB has been significantly increased. However, it is rarely used in clinical practice for postoperative analgesia after posterior lumbar spine surgery, while the choice of adjuvant drugs, block levels and drug doses remain controversial. Based on the current literature review, ropivacaine and dexmedetomidine could be considered as the best available drug combination. The present review aimed to analyze the currently available clinical evidence and summarize the benefits and challenges of ESPB in spinal surgery, thus providing novel insights into the application of ESPB in the postoperative management of posterior lumbar surgery.

Dexmedetomidine Prevents Chronic Incisional Pain After Brain Tumor Resection: A Secondary Analysis of the Randomized Control Trial

BACKGROUND

Dexmedetomidine was reported to reduce postoperative acute pain after neurosurgery. However, the efficacy of dexmedetomidine for preventing chronic incisional pain is uncertain.

METHODS

This article is a secondary analysis of a randomized, double-blind, placebo-controlled trial. Eligible patients were randomly allocated to either the dexmedetomidine group or the placebo group. Patients assigned to the dexmedetomidine group were given a 0.6 μg kg -1 dexmedetomidine bolus followed by a 0.4 μg kg -1 h -1 maintenance dose until dural closure; placebo patients were given comparable amounts of normal saline. The primary end point was the incidence of incisional pain at 3 months after craniotomy evaluated by numerical rating scale scores and defined as any score >0. The secondary end points were postoperative acute pain scores, sleep quality, and Short-Form McGill Pain Questionnaire (SF-MPQ-2) at 3 months after craniotomy.

RESULTS

From January 2021 to December 2021, a total of 252 patients were included in the final analysis: the dexmedetomidine group (n = 128) and the placebo group (n = 124). The incidence of chronic incisional pain was 23.4% (30 of 128) in the dexmedetomidine group versus 42.7% (53 of 124) in the placebo group (risk ratio, 0.55; 95% confidence interval, 0.38-0.80; P = .001). The overall severity of chronic incisional pain was mild in both groups. Patients in the dexmedetomidine group had lower acute pain severity on movement than those in the placebo group for the first 3 days after surgery (all adjusted P < .01). Sleep quality did not differ between groups. However, the SF-MPQ-2 total sensory ( P = .01) and neuropathic pain descriptor ( P = .023) scores in the dexmedetomidine group were lower than those in the placebo group.

CONCLUSIONS

Prophylactic intraoperative dexmedetomidine infusion reduces the incidence of chronic incisional pain as well as acute pain score after elective brain tumor resections.

Common challenges in cochlear implant surgery performed under local anaesthesia and how to overcome them: the experience of UK surgeons

BACKGROUND

Cochlear implantation performed under local anaesthesia is an increasingly accepted technique worldwide, though the literature to date includes only single-surgeon and single-centre experiences. This study explored the national experience of UK surgeons using this challenging surgical technique, with the goal of providing consensus recommendations.

METHODS

A qualitative analysis was conducted of semi-structured interviews with 10 UK-based cochlear implantation surgeons, focusing on common challenges, how to overcome them and candidate selection.

RESULTS

Cochlear implantation under local anaesthesia can potentially be offered to all eligible adult patients with favourable anatomy. A posterior tympanotomy and round window approach is recommended. Common challenges and recommendations are explored thematically: managing patient, surgeon and staff expectations; optimising communication; patient comfort and position; minimising pain and vertigo; and safe use of sedation.

CONCLUSION

This is the first study of national experience of cochlear implantation performed under local anaesthesia. Key themes, including refinements to surgical technique and optimising patient comfort and communication, have been explored in depth.

Perioperative use of ketamine infusion versus dexmedetomidine infusion for analgesia in obese patients undergoing bariatric surgery: a double-blinded three-armed randomized controlled trial

BACKGROUND

Bariatric surgery depends on the development of novel anesthetic techniques to reduce the incidence of complications and improve postoperative outcomes. Ketamine and dexmedetomidine have been used for perioperative analgesia and we hypothesized that they would decrease postoperative morphine requirements. The objective of this trial is to study whether choice of ketamine or dexmedetomidine infusion would affect postoperative total morphine consumption.

METHODS

Ninety patients were equally randomized into three groups. The ketamine group received a bolus dose (0.3 mg/kg) of ketamine over 10 min, followed by an infusion of the same drug (0.3 mg/kg/h). The dexmedetomidine group received a bolus dose (0.5 mcg/kg) of dexmedetomidine over 10 min, followed by an infusion of this drug (0.5 mg/kg/h). The control group received a saline infusion. All infusions were given till 10 min before the end of surgeries. Intraoperative fentanyl was given when patient developed hypertension and tachycardia despite adequate anesthesia and muscle relaxation. Postoperative pain was managed by a rescue dose of 4 mg of IV morphine, with a minimum interval of 6 h between morphine doses if the numerical rating scale (NRS) score was ≥ 4. The primary outcome was the total morphine dose, and the secondary outcomes were intraoperative fentanyl requirement, time to extubation, postoperative nausea and vomiting (PONV), NRS scores, and modified observer's agitation/sedation scale (MOASS) scores.

RESULTS

Compared with ketamine, dexmedetomidine decreased the need for fentanyl intraoperatively (160 ± 42 µg), shortened the time to extubation (3 ± 1 min), and improved MOASS and PONV scores. In turn, ketamine decreased postoperative NRS scores and the need for morphine (3 ± 3 mg).

CONCLUSIONS

Dexmedetomidine treatment was associated with lower fentanyl doses, a shorter time to extubation, and better MOASS and PONV scores. Ketamine treatment was associated with significantly lower NRS scores and morphine doses. These results indicated that dexmedetomidine effectively decreased intraoperative fentanyl requirement and the time to extubation, while ketamine decreased the need for morphine.

TRIAL REGISTRATION

This trail was registered on the clinicaltrials.gov registry (NCT04576975) on October 6, 2020.

The effect and safety of dexmedetomidine as an adjuvant to local anesthetics in erector spinae plane block: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Dexmedetomidine (DEX) has been thought to be an effective adjuvant to local anesthetics (LAs) in erector spinae plane block (ESPB), however, this method of use is not recorded in the drug instructions. Hence, our meta-analysis will evaluate its efficacy and safety for the first time.

METHODS

A systematic search of published articles was conducted in the PubMed, Embase, Web of science, and Cochrane Library databases up to July 17, 2022, using specific keywords related to our aims. The time first to request rescue analgesia, number of patient controlled intravenous analgesia (PCIA) presses, rate of rescue analgesia use, postoperative nausea and vomiting (PONV), arrhythmia, and hypotension were calculated by using random-effect models. This systematic review and meta-analysis was registered with PROSPERO (registration number: CRD42022345488).

RESULTS

Numerous electronic databases were searched and finally 8 studies with a total of 570 patients, 303 in the DEX arm, 267 in the control arm were included. As an adjuvant to LAs, DEX significantly increased the time to first request of rescue analgesia (mean difference [MD] = 8.40, 95% confidence interval [CI] = 4.70-12.10, P < 0.00001), reduced the number of PCIA presses (MD = -4.12, 95% CI = -7.79 to -0.45, P = 0.03) and the rate of rescue analgesia (odds ratio [OR] = 0.33, 95% CI = 0.17-0.65, P = 0.002). Moreover, the combination reduced the risk of PONV (OR = 0.57, 95% CI = 0.36-0.91, P = 0.02). In addition, there was no difference in the incidence of hypotension (OR = 1.01, 95% CI = 0.37-2.74, P = 0.99) and arrhythmia (OR = 0.76, 95% CI = 0.19-3.07, P = 0.70).

CONCLUSION

DEX can reduce analgesic requirements after various surgical procedures when used as an adjuvant to LAs for ESPB. Moreover, there was no significant difference between the two groups in terms of safety indicators (arrhythmia, hypotension).

Study on the protective mechanism of dexmedetomidine on the liver of perioperative diabetic patients: A randomized controlled trial

BACKGROUND

Although several studies have reported that dexmedetomidine is a highly selective α2-adrenergic receptor agonist that protects liver function in perioperative patients by inhibiting oxidative stress (OS) and inflammatory response, patients with type 2 diabetes mellitus (T2DM) have not been included in the previous studies. The purpose of this study was to investigate the effects of perioperative low-dose dexmedetomidine on perioperative liver function in T2DM patients.

METHODS

This was a single-center, placebo-controlled randomized trial. Fifty-four T2DM patients scheduled for debridement of lower extremity ulcers were included in this study and randomly divided into 2 groups (n = 27 per group): the dexmedetomidine group (DEX group) and the control group (CON group). Continuous intravenous infusion of dexmedetomidine (DEX group) or normal saline (CON group) was administered from the completion of monitoring to the end of surgery. All participants received femoral and sciatic nerve block with 0.33% ropivacaine. The main result was the activity of liver enzymes (AST, ALT) reflecting liver function. The secondary results included variables reflecting blood glucose (Glu), blood lipids (TG, HDL, LDL, total cholesterol), biomarkers of OS (MDA, SOD), and systemic inflammatory response (TNF-α, IL-6).

RESULTS

Compared with CON group, DEX group exhibited a reduction in hemodynamic parameters, Glu, systemic inflammatory response, and liver injury indicators. OS response MDA activity was lower in DEX group than in CON group, while SOD was higher than that in CON group. The variables reflecting lipid metabolism function showed no differences between the groups.

CONCLUSION SUBSECTIONS

Dexmedetomidine administered perioperatively can reduce Glu levels and protect the liver by attenuating OS injury and inflammatory response in T2DM patients without any potential risk.

The role for high volume local infiltration analgesia with liposomal bupivacaine in total hip arthroplasty: A scoping review

Introduction

Liposomal bupivacaine has been integrated into clinical practice within many surgical disciplines to reduce post-operative pain and opioid consumption. This novel agent has been utilized in this regard in many subdisciplines of orthopedic surgery. Total hip arthroplasty has significant opioid use post-operatively as compared to many other orthopedic disciplines.

Objectives

The purpose of the present investigation is to summarize the current use of liposomal bupivacaine after total hip arthroplasty and to shed light on the prospect of liposomal bupivacaine to reduce opioid use after total hip arthroplasty. A tertiary purpose is to identify future areas of adjunctive pain measures that can assist in the reduction of opioid use after total hip arthroplasty.

Methods

This IRB-exempt scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist strictly. The literature search was performed in Mendeley. Search fields were varied until redundant. All articles were screened by title and abstract and a preliminary decision to include an article was made. The full-text screening was performed on the selected articles. Any question regarding the inclusion of an article was discussed by three authors until an agreement was reached.

Results

A total of 21 articles were included for qualitative description of the opioid epidemic, opioid overuse in total hip arthroplasty, and risk factors for opioid overuse in total hip arthroplasty. A total of 9 articles were included regarding the use of liposomal bupivacaine in total hip arthroplasty. Several risk factors have been identified for opioid overuse after total hip arthroplasty. These include younger age, an opioid risk tool score of > 7, a higher body mass index, chronic obstructive pulmonary disease, immunodeficiency syndromes, preexisting pain syndromes, peripheral vascular disease, anxiety and mood disorders, and substance abuse disorders. Liposomal bupivacaine reduces postoperative opioid use, patient-reported outcomes, length of stay, and time to ambulation, yet is more expensive than traditional bupivacaine.

Conclusions

Liposomal bupivacaine represents a useful adjunct for multimodal pain strategies in total hip arthroplasty with sufficient evidence to suggest that it may be useful in decreasing postoperative opioid use. The high costs of LB represent a barrier to institutional acceptance of LB into standardized multimodal pain strategies. Further efforts should be aimed toward better understanding the current state of integration of LB into academic and private practice settings, industry movements to decrease the cost, and the role other adjunctive measures may have in reducing post-operative opioid use.

Alpha-2-adrenergic receptor agonists for the prevention of delirium and cognitive decline after open heart surgery (ALPHA2PREVENT): protocol for a multicentre randomised controlled trial

INTRODUCTION

Postoperative delirium is common in older cardiac surgery patients and associated with negative short-term and long-term outcomes. The alpha-2-adrenergic receptor agonist dexmedetomidine shows promise as prophylaxis and treatment for delirium in intensive care units (ICU) and postoperative settings. Clonidine has similar pharmacological properties and can be administered both parenterally and orally. We aim to study whether repurposing of clonidine can represent a novel treatment option for delirium, and the possible effects of dexmedetomidine and clonidine on long-term cognitive trajectories, motor activity patterns and biomarkers of neuronal injury, and whether these effects are associated with frailty status.

METHODS AND ANALYSIS

This five-centre, double-blind randomised controlled trial will include 900 cardiac surgery patients aged 70+ years. Participants will be randomised 1:1:1 to dexmedetomidine or clonidine or placebo. The study drug will be given as a continuous intravenous infusion from the start of cardiopulmonary bypass, at a rate of 0.4 µg/kg/hour. The infusion rate will be decreased to 0.2 µg/kg/hour postoperatively and be continued until discharge from the ICU or 24 hours postoperatively, whichever happens first.Primary end point is the 7-day cumulative incidence of postoperative delirium (Diagnostic and Statistical Manual of Mental Disorders, fifth edition). Secondary end points include the composite end point of coma, delirium or death, in addition to delirium severity and motor activity patterns, levels of circulating biomarkers of neuronal injury, cognitive function and frailty status 1 and 6 months after surgery.

ETHICS AND DISSEMINATION

This trial is approved by the Regional Committee for Ethics in Medical Research in Norway (South-East Norway) and by the Norwegian Medicines Agency. Dissemination plans include publication in peer-reviewed medical journals and presentation at scientific meetings.

TRIAL REGISTRATION NUMBER

NCT05029050.

Effects of Intraoperative Dexmedetomidine Infusion on Postoperative Pain after Craniotomy: A Narrative Review

Craniotomy involves procedures with high incidences of postoperative pain. Dexmedetomidine, a highly selective a₂-adrenoreceptor agonist, has been shown to be beneficial in neuroanaesthesia. The purpose of this narrative review was to assess the effect and safety of dexmedetomidine given intraoperatively during anaesthesia compared to placebo and demonstrate the effect on acute postoperative pain in adult patients undergoing craniotomy. Literature published from 1996 until 2021 were analysed through a search of PubMed, Medline and Embase. Randomised controlled trials investigating intraoperative administration of Dexmedetomidine with evaluation of postoperative pain were included. Medical Subject Headings terms and free-text words were used to identify articles related to the intraoperative use of Dexmedetomidine and postcraniotomy pain. Thirteen distinct randomized controlled trials with 882 recruited patients undergoing craniotomy were identified as eligible for final inclusion. Intraoperative administration of dexmedetomidine is associated with decreased postoperative pain and opioid consumption, and it assures haemodynamic stability. Dexmedetomidine is an efficacious adjunct in craniotomy in adults, showing benefits in reduction of postoperative pain and analgesic consumption. Dexmedetomidine also offers haemodynamic stability. However, widespread methodological heterogeneity of the papers prohibits a valid meta-analysis.

Dexmedetomidine vs. lidocaine for postoperative analgesia in pediatric patients undergoing craniotomy: a protocol for a prospective, randomized, double-blinded, placebo-controlled trial

Background

Postoperative pain is a common problem that occurs in pediatric patients following neurosurgery which may lead to severe complications. Dexmedetomidine is a commonly used adjuvant medicine in craniotomy owing to its sedative, amnestic, analgesic, and neuroprotective properties. Besides, studies suggest that lidocaine has similar effects on sedation, analgesia, and neuroprotection. Both two adjuvants can reduce postoperative pain after neurosurgery in adults. However, it is still unknown whether dexmedetomidine or lidocaine can reduce postoperative pain in children undergoing craniotomy, and if yes, which is a better medicine choice. Therefore, we aimed to compare the effect of dexmedetomidine vs. lidocaine on postoperative pain in pediatric patients after craniotomy.

Methods/design

We will perform a randomized (1:1:1), double-blind, placebo-controlled, single-center trial. Children aged 1–12 years scheduled for craniotomy will be eligible for inclusion. The 255 recruited participants will be stratified by age in two strata (1–6 years and 7–12 years), and then each stratum will be equally randomized to three groups: group D (infusion of dexmedetomidine [intervention group]), group L (infusion of lidocaine [intervention group]), and group C (infusion of normal saline [control group]). Patients will be followed up at 1 h, 2 h, 4 h, 24 h, and 48 h after surgery. The primary outcome will be total sufentanil consumption within 24 h after surgery.

Discussion

In this clinical trial, we expect to clarify and compare the postoperative analgesic effect of dexmedetomidine vs. lidocaine infusion on pediatric patients undergoing craniotomy. We believe that the results of this trial will provide more choices for postoperative analgesia for the pediatric population.

Trial registration

Chinese ClinicalTrials.gov ChiCTR1800019411. Registered on 10 November 2018

Reflections on dexmedetomidine as an optimum therapy for emergence delirium in the elderly with emergency abdominal surgery

Emergence delirium (ED) is a common complication in elderly patients in post post-anesthesia care units (PACU), To our knowledge, there is currently no specific treatment for ED in the elderly, especially for patients combined with vital organs dysfunction. This article described an elderly patient with ED was successfully treated with dexmedetomidine. Although dexmedetomidine has been widely used in recent years, there are few articles on the administration of dexmedetomidine in PACU. The purpose of this paper is to review the literature and analyze related hazardous factors for ED in the elderly with complications of emergency abdominal surgery and angiocardiopathy, and to further confirm and explain the effectiveness and validation of dexmedetomidine as a rescue therapy in PACU. Finally, we look forward to more samples being collected to persuasively prove our opinion in this case.

Cochlear Implantation Under Local Anesthesia With Conscious Sedation in the Elderly: First 100 Cases

OBJECTIVE

To report the outcomes on a large series of elderly patients who underwent cochlear implantation (CI) surgery under local anesthesia with conscious sedation (LA-CS).

METHODS

Retrospective chart review on 100 consecutive elderly patients (> 65 years) who underwent CI with LA-CS at a tertiary care center between August 2013 and January 2020. An age-matched control group of 50 patients who underwent CI with general anesthesia (GA) are used for comparison. Outcomes measured included time in the operating room, time in the postanesthesia care unit (PACU), and rate of adverse events.

RESULTS

Cochlear implant surgery under LA-CS was successfully performed in 99 (99%) patients. One patient requiring conversion to GA intraoperatively. No patients in the LA-CS group experienced cardiopulmonary adverse events; however, three patients (6%) in the GA group experienced minor events including atrial fibrillation and/or demand ischemia. Overnight observation in the hospital due to postoperative medical concerns or prolonged wake-up from anesthesia was required in one patient (1%) from the LA-CS cohort and 12 patients (24%) from the GA cohort. Perioperative adverse events exclusive to the LA-CS group included severe intraoperative vertigo (8%), temporary facial nerve paresis (3%), and wound infection (1%). The average amount of time spent in the operating room was 37 minutes less for procedures performed under LA-CS compared to GA (P < .05). The average amount of time in recovery was similar for both groups (P > .05).

CONCLUSION

Cochlear implant surgery under LA-CS offers many benefits and is a safe, feasible, and cost-effective alternative to GA when performed by experienced CI surgeons.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:E946-E951, 2021.

A prospective randomized double-blinded study of dexmedetomidine versus propofol infusion for orbital surgeries

PURPOSE

Orbital surgeries are traditionally taken up under general anesthesia. Local anesthesia combined with moderate sedation can also be considered as an alternative option. This study was performed to compare the safety and efficacy of dexmedetomidine and propofol infusion for orbital surgeries under local anesthesia.

METHODS

Twenty patients undergoing orbital surgery by a single surgeon were enrolled in this prospective randomized study. Selected patients were randomly administered dexmedetomidine (Group D) or propofol (Group P). Hemodynamic and respiratory effects, sedation levels, recovery profile, analgesic properties, and satisfaction levels of the patients and the surgeon were assessed.

RESULTS

There was a significant decrease in mean arterial pressures following drug administration compared to initial measurements in both the groups. However, a statistically significant decrease in heart rate was observed only in Group P. The sedation score at the end of loading dose was 3.3 ± 0.82 in Group D and 2.5 ± 0.52 in Group P and this difference was also statistically significant (P value-0.027). The surgeon's satisfaction score was 6.5 ± 0.71 in Group D and 5.6 ± 1.07 in Group P (P value - 0.045). There were no statistically significant differences observed in patients' satisfaction, pain, and anxiety scores in either group. No major hemodynamic changes or complications were noted in either of the groups.

CONCLUSION

Dexmedetomidine, in comparison to propofol, provides better sedation levels with good hemodynamic stability. It also offers better surgeon satisfaction, thus providing a useful alternative for general anesthesia in selective patients undergoing orbital surgery.

Combination of post-fascia iliaca compartment block and dexmedetomidine in pain and inflammation control after total hip arthroplasty for elder patients: a randomized control study

Objective

This study aims to investigate the efficiency of fascia iliaca compartment block (FICB) combined with dexmedetomidine (DEX) in postoperative and inflammation management for elder patients after total hip arthroplasty.

Methods

The present randomized controlled study included a total of 119 elder patients who received total hip arthroplasty in our hospital from March 2016 to December 2018. These patients were divided into three groups: control group, patients received routine general anesthesia; FICB group, patients received additional FICB after surgery; and combined group, patients received both pre-treatment of DEX and post-treatment of fascia iliaca compartment block. The serum levels of interleukin (IL)-1β, IL-6, and C-reactive protein (CRP) were measured by ELISA. The visual analog scale (VAS) score was measured at 12, 24, 48, and 72 h after surgery, and the patient-controlled intravenous analgesia (PCIA) pressing time within 48 h after surgery was also recorded. The Pittsburgh sleep quality index (PSQI) was used to measure the sleep quality before and at 1 month after surgery.

Results

The VAS scores were significantly lower in patients in the combined group, when compared with the other two groups, at 12, 24, 48, and 72 h after surgery. In addition, the VAS scores at all time points were significantly lower in the FICB group than the control group. The PCIA pressing times were also remarkably lower in the combined group. At 4, 24, 48, and 72 h after surgery, the serum levels of these inflammatory factors were the lowest in the combined group, and the PSQI scores were significantly lower in the combined group, when compared with the other two groups, while the control group had the highest PSQI scores among the three groups. There was no severe side effects and significant difference observed.

Conclusion

FICB combined with DEX reduced the postoperative pain, improved the sleep condition, and decreased the serum levels of inflammatory factors after total hip arthroplasty.

The Oslo Study of Clonidine in Elderly Patients with Delirium; LUCID: a randomised placebo-controlled trial

OBJECTIVES

The aim of this double-blinded randomised placebo-controlled trial was to investigate the efficacy of clonidine for delirium in medical inpatients greater than 65 years.

METHODS

Acutely admitted medical patients greater than 65 years with delirium or subsyndromal delirium were eligible for inclusion. Included patients were given a loading dose of either placebo or clonidine; 75 μg every third hour up to a maximum of four doses to reach steady state and further 75 μg twice daily until delirium free for 2 days, discharge or a maximum of 7 days of treatment. The primary endpoint was the trajectory of the Memorial Delirium Assessment Scale (MDAS) for the 7 days of treatment. Presence of delirium according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria and severity measured by MDAS were assessed daily until discharge or a maximum of 7 days after end of treatment.

RESULTS

Because of slower enrolment than anticipated, the study was halted early. Ten patients in each group were studied. The low recruitment rate was mainly due to the presence of multiple patient exclusion criteria for patient safety. There was no significant difference between the treatment group in the primary endpoint comparing the trajectory of MDAS for the 7 days of treatment using mixed linear models with log transformation, (P = .60). The treatment group did not have increased adverse effects.

CONCLUSIONS

No effect of clonidine for delirium was found, although the study was under powered. Further studies in less frail populations are now required.

Prevention of postoperative delirium in elderly patients planned for elective surgery: systematic review and meta-analysis

Introduction: Vulnerable or “frail” patients are susceptible to the development of delirium when exposed to triggers such as surgical procedures. Once delirium occurs, interventions have little effect on severity or duration, emphasizing the importance of primary prevention. This review provides an overview of interventions to prevent postoperative delirium in elderly patients undergoing elective surgery.

Methods: A literature search was conducted in March 2018. Randomized controlled trials (RCTs) and before-and-after studies on interventions with potential effects on postoperative delirium in elderly surgical patients were included. Acute admission, planned ICU admission, and cardiac patients were excluded. Full texts were reviewed, and quality was assessed by two independent reviewers. Primary outcome was the incidence of delirium. Secondary outcomes were severity and duration of delirium. Pooled risk ratios (RRs) were calculated for incidences of delirium where similar intervention techniques were used.

Results: Thirty-one RCTs and four before-and-after studies were included for analysis. In 19 studies, intervention decreased the incidences of postoperative delirium. Severity was reduced in three out of nine studies which reported severity of delirium. Duration was reduced in three out of six studies. Pooled analysis showed a significant reduction in delirium incidence for dexmedetomidine treatment, and bispectral index (BIS)-guided anaesthesia. Based on sensitivity analyses, by leaving out studies with a high risk of bias, multicomponent interventions and antipsychotics can also significantly reduce the incidence of delirium.

Conclusion: Multicomponent interventions, the use of antipsychotics, BIS-guidance, and dexmedetomidine treatment can successfully reduce the incidence of postoperative delirium in elderly patients undergoing elective, non-cardiac surgery. However, present studies are heterogeneous, and high-quality studies are scarce. Future studies should add these preventive methods to already existing multimodal and multidisciplinary interventions to tackle as many precipitating factors as possible, starting in the pre-admission period.

Dexmedetomidine combined with local anesthetics in thoracic paravertebral block: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Dexmedetomidine (DEX) improves postoperative pain scores and prolongs the duration of blockage when combined with local anesthetics (LAs) for neuraxial and brachial plexus block; however, there is little information about the effectiveness of DEX as an adjuvant to LAs in paravertebral block (PVB). Therefore, a systematic review and meta-analysis were performed to evaluate the safety and efficacy of DEX combined with LAs in PVB.

METHOD

An electronic database search from inception date to February 2018 was performed. Randomized controlled trials (RCTs) comparing DEX as an adjuvant to LAs with LAs alone for PVB in adult patients were included. Postoperative pain scores, duration of analgesia, cumulative perioperative analgesic consumption, and adverse events were analyzed.

RESULT

We identified 7 trials enrolling 350 patients and found that DEX reduced pain scores at rest by standardized mean differences (SMD) -0.86 cm (95% confidence interval [CI] [-1.55, -0.17], P = .01) and SMD -0.93 cm (95% CI [-1.41, -0.26], P =.008) at postoperative 12 hours and 24 hours, respectively. DEX reduced pain scores while dynamic by SMD -1.63 cm (95% CI [-2.92, -0.34], P =.01) and SMD -1.78 cm (95% CI [-2.66, -0.90], P =.007) for postoperative 12 hours and 24 hours, respectively. DEX extended the duration of analgesia by weighted mean differences (WMD) 201.53 minutes (95% CI [33.45, 369.61], P =.02); and reduced cumulative postoperative analgesic consumption by WMD -7.71 mg (95% CI [-10.64, -4.78], P <.001) and WMD -45.64 mg (95% CI [-69.76, -21.53], P < .001) for 24 hours morphine and 48 hours tramadol subgroups, respectively. DEX also increased the odds of hypotension by odds ratio (OR) 4.40 (95% CI [1.37, 14.17], P = .01); however, there was no statistically significant difference for intraoperative fentanyl consumption and the incidence of the bradycardia.

CONCLUSIONS

DEX combined with LAs in PVB significantly improved postoperative pain scores, prolonged the duration of analgesia, reduced postoperative analgesic consumption, and increased the odds of hypotension. However, we cannot neglect the heterogeneity of the included RCTs. More large-scale prospective studies are needed to further clarify the above conclusions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number CRD42018090251.

Psychotropic drug therapy in patients in the intensive care unit - usage, adverse effects, and drug interactions: a review

Managing psychological problems in patients admitted to intensive care unit (ICU) is a big challenge, requiring pharmacological interventions. On the other hand, these patients are more prone to side effects and drug interactions associated with psychotropic drugs use. Benzodiazepines (BZDs), antidepressants, and antipsychotics are commonly used in critically ill patients. Therefore, their therapeutic effects and adverse events are discussed in this study. Different studies have shown that non-BZD drugs are preferred to BZDs for agitation and pain management, but antipsychotic agents are not recommended. Also, it is better not to start antidepressants until the patient has fully recovered. However, further investigations are required for the use of psychotropic drugs in ICUs.

Dexmedetomidine Reduces Perioperative Opioid Consumption and Postoperative Pain Intensity in Neurosurgery: A Meta-analysis

BACKGROUND

Dexmedetomidine (DEX) has been administered to patients during neurosurgery. Some studies have found that DEX could reduce perioperative opioid consumption and postoperative pain intensity. However, no firm conclusions have been reached. The purpose of this meta-analysis was to assess the efficacy of DEX for managing pain in neurosurgical patients.

MATERIALS AND METHODS

A comprehensive literature review was conducted to identify randomized controlled trials (RCTs) focusing on the effects of DEX on perioperative opioid consumption and postoperative pain intensity in patients undergoing neurosurgery. PubMed, the Web of science, the Cochrane Library, and Scopus were searched. The resulting data were combined to calculate the pooled mean differences (MDs), standard MDs or odds ratios (ORs), and 95% confidence intervals (CIs), as appropriate. Heterogeneity and potential publication bias were assessed. Furthermore, a trial sequential analysis was performed to improve the precision of our findings.

RESULTS

A total of 11 published RCTs involving 674 patients undergoing neurosurgery (335 patients, 339 controls) were included in this meta-analysis. There were significant differences in postanesthesia care unit (PACU) visual analog scale scores between the groups (MD=-1.54, 95% CI, -2.33 to 0.75, I=87%, P=0.0001). In addition, there were significant differences in PACU opioid requirements between the treatment and control groups (standard MD=-0.88, 95% CI, -1.74 to 0.02, I=91%, P=0.05). Furthermore, intraoperative opioid consumption was significantly reduced in the treatment group (MD=-127.75, 95% CI, -208.62 to 46.89, I=98%, P=0.002).

CONCLUSIONS

DEX could reduce perioperative and PACU opioid consumption as well as postoperative pain intensity.

Anesthetic agent etiomidate induces apoptosis in N2a brain tumor cell line

The present study identified the cytotoxic effects of etomidate on the N2a neuroblastoma cell line. Etomidate induced apoptosis in N2a cells in a concentration-dependent manner, which was confirmed by western blotting and flow cytometry. Phase contrast microscopy was used to analyze the effect of etomidate on morphological characteristics. The number of the apoptotic cells was increased and confirmed by DAPI and PI staining, which served as a characteristic hallmark of apoptosis. Additionally, etomidate led to loss of mitochondrial membrane potential and resulted in the generation of reactive oxygen species in N2a cells. The western blot analysis revealed that N2a cells treated with etomidate had a significant modulation of pro-apoptotic proteins, includingpoly ADP-ribose polymerase (PARP), cleaved PARP, caspase-9 and procaspase-3. In conclusion, the present study determined that etomidate induced cytotoxic and apoptotic effects in N2a brain tumor cells in vitro.

The use of clonidine in elderly patients with delirium; pharmacokinetics and hemodynamic responses

Background

The Oslo Study of Clonidine in Elderly Patients with Delirium (LUCID) is an RCT investigating the effect of clonidine in medical patients > 65 years with delirium. To assess the dosage regimen and safety measures of this study protocol, we measured the plasma concentrations and hemodynamic effects of clonidine in the first 20 patients.

Methods

Patients were randomised to clonidine (n = 10) or placebo (n = 10). The treatment group was given a loading dose (75μg every 3rd hour up to a maximum of 4 doses) to reach steady state, and further 75μg twice daily until delirium free for 2 days, discharge or a maximum of 7 days. Blood pressure (BP) and heart rate (HR) were measured just before every dose. If the systolic BP was < 100 mmHg or HR < 50 beats per minute the next dose was omitted. Plasma concentrations of clonidine were measured 3 h after each drug intake on day 1, just before intake (day 2 and at steady state day 4–6) and 3 h after intake at steady state (C_max). Our estimated pre-specified plasma concentration target range was 0.3–0.7μg/L.

Results

3 h after the first dose of 75μg clonidine, plasma concentration levels rose to median 0.35 (range 0.24–0.40)μg/L. Median trough concentration (C₀) at day 2 was 0.70 (0.47–0.96)μg/L. At steady state, median C₀ was 0.47 (0.36–0.76)μg/L, rising to C_max 0.74 (0.56–0.95)μg/L 3 h post dose. A significant haemodynamic change from baseline was only found at a few time-points during the loading doses within the clonidine group. There was however extensive individual BP and HR variation in both the clonidine and placebo groups, and when comparing the change scores (delta values) between the clonidine and the placebo groups, there were no significant differences.

Conclusions

The plasma concentration of clonidine was at the higher end of the estimated therapeutic range. Hemodynamic changes during clonidine treatment were as expected, with trends towards lower blood pressure and heart rate in patients treated with clonidine, but with dose adjustments based on SBP this protocol appears safe.

Trial registration

ClinicalTrials.gov NCT01956604, 09.25.2013. EudraCT Number: 2013–000815-26, 03.18.2013. Enrolment of first participant: 04.24.2014.

Effects of an Intraoperative Dexmedetomidine Bolus on the Postoperative Blood Pressure and Pain Subsequent to Craniotomy for Supratentorial Tumors

BACKGROUND

Control of emergence hypertension and pain is important after craniotomy for monitoring the neurological status. This prospective double-blinded study investigated the hemodynamics after a single bolus of dexmedetomidine (DEX) infusion administered to the patient undergoing craniotomy under general anesthesia, and its effect on emergence hypertension and postsurgical pain.

METHODS

Adult patients scheduled for elective surgery for supratentorial tumors were randomized to receive a 10-minute intraoperative DEX infusion of 0.4 μg/kg (small dose, n=43) or 0.8 μg/kg (medium dose, n=46), or normal saline (vehicle control, n=45), ∼60 minutes before the end of anesthesia.

RESULTS

A transient increase in the blood pressure associated with DEX was observed; 53.5% and 91.3% of the patients in the small-dose and the medium-dose groups, respectively, required treatment. Emergence mean arterial pressure and heart rates were significantly lower in the DEX groups compared with the control group. Incidence rates of postoperative hypertension in the small-dose (16.3%) and the medium-dose groups (15.2%) were significantly lower relative to that of the control group (35.6%). Patients who received DEX had a lower Verbal Numerical Rating Scale (VNRS) score in the neurosurgical ICU than the control group, and postsurgical pain (VNRS≥4) was lower in the medium-dose group (41.3%) than in the control group (71.1%). No shivering was observed in the medium-dose group, which was significantly less than that of the other 2 groups.

CONCLUSIONS

An intraoperative bolus of DEX risks a transient increase in mean arterial pressure, but controls emergence hypertension effectively. Dose-related reductions in postsurgical pain and shivering were observed.

Postoperative Analgesia with Epidural Dexmedetomidine Compared with Clonidine following Total Abdominal Hysterectomies: A Prospective Double-blind Randomized Trial

Background and Aims:

Anesthesia for total abdominal hysterectomies is not only concerned with relieving pain during intraoperative period but also during the postoperative period. We compared clonidine and dexmedetomidine as an adjuvant to levobupivacaine for epidural analgesia with respect to onset and duration of sensory block, duration of analgesia, and adverse effects.

Materials and Methods:

A total of 80 individuals between the age of 45 and 65 years of American Society of Anesthesiologists (ASA) physical status Classes I and II who underwent total abdominal hysterectomies were randomly allocated into two groups, comprising 40 patients in each group. Group LC received 10 ml of 0.125% levobupivacaine and 2 μg/kg of clonidine while Group LD received 10 ml of 0.125% levobupivacaine and 1 μg/kg of dexmedetomidine through the epidural catheter. Onset of analgesia, time of peak effect, duration of analgesia, cardiorespiratory parameters, side effects, and need of rescue intravenous (IV) analgesics were observed. The data analysis was carried out with Z-test and Chi-square test.

Results:

The demographic profile and ASA physical classes were comparable between the groups. Group LD had early onset, early peak effect, prolonged duration, and stable cardiorespiratory parameters when compared with Group LC. Less number of patients (42.5%) in Group LD required IV rescue analgesics when compared to Group LC (70%) and was statistically significant. The side effects’ profile was also comparable.

Conclusion:

Dexmedetomidine is a better neuraxial adjuvant compared with clonidine for providing early onset and prolonged postoperative analgesia and stable cardiorespiratory parameters.

Pharmacokinetics of dexmedetomidine during analgosedation in ICU patients

Dexmedetomidine (DEX) is a fairly new alfa₂-agonist which has been increasingly used in recent years for analgosedation, mostly because it offers a unique ability of providing both moderate level of sedation and analgesia without respiratory depression. Despite of many papers published, there are still only a few concerning the PK of the drug given as long-term infusion in ICU patients. The aim of this work was to characterize the population pharmacokinetics of dexmedetomidine and to investigate the potential benefits of individualization of drug dosing based on patient characteristics in the heterogeneous group of medical and surgical patients staying in intensive care unit. This study was performed in the group of 17 males and 10 females patients with a median age of 59.5 years and median body weight of 75 kg. Blood samples for dexmedetomidine assay were collected from arterial catheter, during and after discontinuation of a standard infusion, that ranged from 24 to 102 h. The following covariates were examined to influence dexmedetomidine PK: age, sex, body weight, patients’ health status described by Sequential Organ Failure Assessment Score (SOFA), inotropes usage, and infusion duration. The dexmedetomidine PK was best described by a two-compartment model. The typical values of PK parameters were estimated as 27 L for the volume of the central compartment, 87.6 L for the volume of the peripheral compartment, 38.5 L/h (9.2 mL/min/kg for a 70 kg patient) for systemic clearance and 46.4 L/h for the distribution clearance. Those values are consistent with literature findings. We were unable to show any significant relationship between collected covariates and dexmedetomidine PK. This study does not provide sufficient evidence to support the individualization of dexmedetomidine dosing based on age, sex, body weight, SOFA, and infusion duration.

Pharmacology of Octreotide: Clinical Implications for Anesthesiologists and Associated Risks

Many patients presenting with a history of foregut, midgut neuroendocrine tumors (NETs) or carcinoid syndrome can experience life-threatening carcinoid crises during anesthesia or surgery. Clinicians should understand the pharmacology of octreotide and appreciate the use of continuous infusions of high-dose octreotide, which can minimize intraoperative carcinoid crises. We administer a prophylactic 500-μg bolus of octreotide intravenously (IV) and begin a continuous infusion of 500 μg/h for all NET patients. Advantages include low cost and excellent safety profile. High-dose octreotide for midgut and foregut NETs requires an appreciation of the pathophysiology involved in the disease, pharmacology, drug-drug interactions, and side effects.

Cochlear implantation under conscious sedation with local anesthesia; Safety, Efficacy, Costs, and Satisfaction

OBJECTIVE

To evaluate the safety, efficiency, cost effectiveness, and satisfaction of patients undergoing cochlear implantation under conscious sedation versus general anesthesia.

STUDY DESIGN

Retrospective case review of 20 patients who underwent cochlear implantation under conscious sedation which was compared to 20 age-matched patients where surgery was performed under general anesthesia.

METHODS

Perioperative times, length of stay, anesthesia drug costs, postoperative complications, and patient satisfaction were compared between the two groups.

RESULTS

Conscious sedation was associated with decreased drug costs, surgery time, and anesthesia time. Length of stay was significantly longer for patients undergoing general anesthesia. Patient satisfaction was superior with conscious sedation. Perioperative morbidity was not significantly different between the two groups.

CONCLUSION

Conscious sedation for cochlear implantation is a safe, efficient, and cost-effective alternative to general anesthesia. The efficacy of conscious sedation for cochlear implant surgery may expand the treatment of profound hearing loss to the elderly who are deemed too sick for general anesthesia or are fearful of the cognitive or medical consequences of general anesthesia.

Intravenous dexmedetomidine as an adjunct to subarachnoid block: A simple effective method of better perioperative efficacy

BACKGROUND AND AIM

Dexmedetomidine (D) is a α2 agonist, has anesthetic and analgesic-sparing property. The objective of this study was to evaluate the effect of intravenous (I.V.) dexmedetomidine on the duration of sensory and motor block, postoperative analgesia, the level of sedation and side effect.

MATERIAL AND METHODS

Sixty patients were randomly divided into two groups of thirty each. Group D received dexmedetomidine infusion @1 mcg/kg over 10 min and then @ 0.6 mcg/kg/h for rest of duration during surgery, Group C (control) received a similar volume of normal saline infusion before spinal anesthesia with 3 ml of bupivacaine 0.5%. Time of onset and regression time for sensory and motor blockade, the maximum upper level of sensory blockade, duration of postoperative analgesia, Ramsay sedation score and hemodynamic parameters were recorded. Intraoperative bradycardia and atropine requirement along with other side effect were also recorded.

RESULTS

The duration of sensorimotor block was significantly longer in D Group (341.7 ± 20.8 min for sensory block and 278.0 ± 11.0 min for motor block) as compared to control group (329.5 ± 22.1 min for sensory block and 250.0 ± 14.8 min for motor block), which was statistically significant (P < 0.05). The mean time for two dermatomal regression of sensory blockade was significantly prolonged in dexmedetomidine group (115.5 ± 8.7 min) compared to control group (95.8 ± 11.4) (P < 0.001). Intraoperative Ramsay sedation scores were significantly higher in D Group (mean - 3.4 ± 0.7, range - 2-4) as compared to C Group (mean - 2.9 ± 0.3, range - 2-4) (P < 0.001). 26.7% (8/30) cases had bradycardia that required atropine as compared to control group (2/30), and none of the patients in the dexmedetomidine group had postoperative shivering as compared to 10% in control group (P = 0.056). Statistical analysis was performed with statistical package for the social science version-20 using analysis of variance/Chi-square test/unpaired t-test, and P < 0.05 was considered statistically significant.

CONCLUSION

I.V. dexmedetomidine significantly prolongs the duration of sensory and motor block of bupivacaine spinal anesthesia. Dexmedetomidine provides an excellent sedation during surgery.

Effect of dexmedetomidine in the prophylactic endoscopic injection sclerotherapy for oesophageal varices: a study protocol for prospective interventional study

Background

Dexmedetomidine (DEX) is a novel, highly selective α2-adrenoceptor agonist that elicits sedative, amnestic, sympatholytic and analgesic effects in patients. Several Japanese investigators have reported the clinical usefulness of DEX for sedation in endoscopic therapies for gastrointestinal malignancies; however, there have been limited data regarding the usefulness and safety of DEX for sedation during endoscopic procedures for oesophageal varices (OVs), such as endoscopic injection sclerotherapy (EIS). In this prospective, single-arm interventional study, we aimed to elucidate these issues.

Methods

Patients who require two or more sessions of prophylactic EIS for the treatment of OVs will be enrolled in this prospective interventional study. EIS procedures include two methods: (1) sedation during endoscopic procedures will be performed using conventional methods (pentazocine (PNZ) and midazolam (MDZ)), and (2) sedation during endoscopic procedures will be performed using PNZ, low-dose MDZ and DEX. These two methods were randomly assigned in the first and second EIS. The effect and safety of these two procedures with respect to patient sedation are to be compared with the degree of sedation evaluated using the Bispectral Index monitoring system (Aspect Medical Systems, Norwood, Massachusetts, USA).

Ethics and dissemination

This study received approval from the Institutional Review Board at Hyogo College of Medicine (approval no. 2324). The authors are committed to publishing the study results as widely as possible in peer-reviewed journals, and to ensuring that appropriate recognition is provided to everyone who is working on this study.

Trial registration number

UMIN000026688; Pre-results.

Effect of Two Different Doses of Dexmedetomidine on Stress Response in Laparoscopic Pyeloplasty: A Randomized Prospective Controlled Study

Background

Clonidine, opioids, β-blockers, and dexmedetomidine have been tried to attenuate stress responses during laparoscopic surgery. We evaluated the efficacy of dexmedetomidine in two different doses in attenuating stress responses on patients undergoing laparoscopic pyeloplasty.

Subjects and Methods

Ninety patients were assigned to one of the three groups: Group A, Group B, and Group C. Group B received dexmedetomidine 1 mcg/kg as loading dose, followed by 0.7 mcg/kg/h for maintenance; Group C received dexmedetomidine 0.7 mcg/kg as a loading dose, followed by 0.5 mcg/kg/h for maintenance. Group A received normal saline. Stress responses were assessed by the variations in heart rate (HR), mean arterial pressure (MAP), blood glucose levels, and serum cortisol levels. One-way analysis of variance test was applied. Multiple comparisons between groups were done with post hoc Bonferroni test.

Results

The HR and MAP were found to be higher in Group A. The difference was statistically significant (P < 0.05) during intubation, carbon dioxide insufflation, and extubation when compared with Groups B and C. Blood glucose levels at postintubation and at extubation were higher in Group A and statistically significant (P < 0.05) when compared with Groups B and C. Serum cortisol levels at postintubation, during midsurgery, and 2 h after extubation were higher in Group A and statistically significant (P < 0.05) when compared with Groups B and C. However, HR, MAP, blood glucose levels, and serum cortisol levels were similar in dexmedetomidine groups.

Conclusions

Dexmedetomidine decreases stress response and provides good condition for maintenance of anesthesia. Dexmedetomidine when used in lower dose in Group C decreases stress response comparable to higher dose in Group B.

Dexmedetomidine as an adjuvant to local anesthetics in brachial plexus blocks: A meta-analysis of randomized controlled trials

BACKGROUND

Brachial plexus block (BPB) for upper extremity surgery provides superior analgesia, but this advantage is limited by the pharmacological duration of local anesthetics. Dexmedetomidine (DEX) as a local anesthetics adjuvant for BPB has been utilized to prolong the duration of the nerve block in some randomized controlled trials (RCTs) but is far from unanimous in the efficacy and safety of the perineural route. Hence, an updated meta-analysis was conducted to assess the efficacy and safety of DEX as local anesthetic adjuvants on BPB.

METHODS

A search in electronic databases was conducted to collect the RCTs that investigated the impact of adding DEX to local anesthetics for BPB. Sensory block duration, motor block duration, onset time of sensory and motor block, time to first analgesic request, the common adverse effects were analyzed.

RESULTS

Eighteen trails (1014 patients) were included with 515 patients receiving perineural DEX. The addition of DEX prolonged the duration of sensory block (WMD 257 minutes, 95%CI 191.79-322.24, P < 0.001), motor block (WMD 242 minutes, 95%CI 174.94-309.34, P < 0.001), and analgesia (WMD 26 6 minutes, 95%CI 190.75-342.81, P < 0.001). Perineural DEX also increased the risk of bradycardia (OR=8.25, 95%CI 3.95-17.24, P < 0.001), hypotension (OR = 5.62, 95%CI 1.52-20.79, P < 0.01), and somnolence (OR = 19.67, 95%CI 3.94-98.09, P < 0.001). There was a lack of evidence that perineural DEX increased the risk of other adverse events.

CONCLUSIONS

DEX is a potential anesthetic adjuvant that can facilitate better anesthesia and analgesia when administered in BPB. However, it also increased the risk of bradycardia, hypotension, and somnolence. Further research should focus on the efficacy and safety of the preneural administration of DEX.

The efficacy of dexmedetomidine-remifentanil versus dexmedetomidine-propofol in children undergoing flexible bronchoscopy: A retrospective trial

Flexible bronchoscopy has been more and more used for diagnosis and management diseases of respiratory system in pediatrics. Previous studies have reported that remifentanil (RF) and propofol are safe and effective for flexible bronchoscopy in adults, however, there have no trials evaluate the efficacy of DEX-RF versus dexmedetomidine-propofol in children undergoing flexible bronchoscopy.We divided 123 children undergoing flexible bronchoscopy with DEX-RF or dexmedetomidine-propofol into 2 groups: Group DR (n = 63, DEX infusion at 1.0 μg kg for 10 minutes, then adjusted to 0.5-0.7 μg kg h; RF infusion at 1.0 μg kg for 5 minutes, then adjusted to 0.05-0.2 μg kg min), Group DP (n = 60, DEX infusion at 1.0 μg kg for 10 minutes, then adjusted to 0.5-0.7 μg kg h; propofol infusion at 10 μg kg for 5 minutes, then adjusted to 0.05-0.1 μg kg min). Ramsay sedation scale of the 2 groups was maintained at 3. Anesthesia onset time; total number of intraoperative patient movements; hemodynamics; total cumulative dose of DEX; amount of and time to first-dose rescue midazolam and lidocaine; postoperative recovery time; adverse events; and bronchoscopist satisfaction score were recorded.Anesthesia onset time was significantly shorter in DP (8.22 ± 2.48 vs 12.25 ± 6.43 minutes, respectively, for DP, DR, P = 0.015). The perioperative hemodynamic profile was more stable in DR than DP group. More children moved during flexible bronchoscopy in DP group (P = 0.009). Total dose of rescue midazolam and lidocaine was significantly higher in DR than in DP (P < 0.001). Similarly, the time to first dose of rescue midazolam and lidocaine was significantly longer in DP than in DR (P < 0.001). Total cumulative dose of DEX was more in DR than DP group (P < 0.001). The time to recovery for discharge from the postanesthesia care unit (PACU) was significantly shorter in DP than in DR group (P < 0.001). The bronchoscopist-satisfaction scores were higher for DR than DP (P = 0.036). There were significant differences between the 2 groups in terms of the overall incidence of hypertension, tachycardia, and hypoxemia (P < 0.05).Although underwent longer recovery time and more incidence of rescue scheme, DEX-RF resulted in more stable hemodynamic profiles and bronchoscopist-satisfaction scores, lesser patient movements, and can hence be more effectively used in children undergoing flexible bronchoscopy than dexmedetomidine-propofol.

Comparison between two doses of dexmedetomidine added to bupivacaine for caudal analgesia in paediatric infraumbilical surgeries

Background and Aims:

Caudal block (CB) with adjuvants is routinely used in children for anaesthesia. We evaluated the efficacy of the α2 adrenergic agonist, dexmedetomidine at two different doses as an adjuvant to bupivacaine in CB.

Methods:

This study was conducted on ninety children. Control group BD0 received 0.25% bupivacaine 1 ml/kg, whereas, the study groups BD1 and BD2 received 1 μg/kg and 2 μg/kg dexmedetomidine, respectively, with 0.25% bupivacaine 1 ml/kg as a single shot CB. Adequacy of the block, haemodynamic changes, duration of analgesia and side effects were compared. Analysis of Variance was used for between-group comparisons of numerical variables. Student's t-test and Mann–Whitney U-test were used for quantitative data.

Results:

The demography was comparable. Anal sphincter 5 min after administration of the CB was relaxed in 89.3%, 82.1% and 75% of cases in BD0, BD1 and BD2 groups, respectively. The sphincter was relaxed at the end of surgery in all the cases. Comparable haemodynamics was noted with significantly prolonged duration of analgesia in the groups BD1 (964.2 ± 309 min) and BD2 (1152.6 ± 380.4 min) compared to control (444.6 ± 179.4 min). While no complications were encountered in groups BD0 and BD1, bradycardia was observed in four cases of BD2 group with accompanied hypotension in one of them.

Conclusion:

Dexmedetomidine as an adjuvant to bupivacaine improves the quality of CB, provides good operating conditions and increases the duration of post-operative analgesia. We conclude that 1 μg/kg is as effective as 2 μg/kg of dexmedetomidine and with a better safety profile.

Nitroglycerine, esmolol and dexmedetomidine for induced hypotension during functional endoscopic sinus surgery: A comparative evaluation

Background and Aim:

Induced hypotension limits intra-operative blood loss to provide better visibility of the surgical field and diminishes the incidence of major complications during functional endoscopic sinus surgery (FESS). We aimed at comparing nitroglycerine, esmolol and dexmedetomidine for inducing controlled hypotension in patients undergoing FESS.

Material and Methods:

One hundred and fifty American Society of Anesthesiologists physical status I or II adult patients undergoing FESS under general anesthesia were randomly allocated to three groups of 50 patients each. Group E received esmolol in a loading and maintenance dose of 1 mg/kg over 1 min and 0.5-1.0 mg/kg/h, respectively. Group D received a loading dose of dexmedetomidine 1 μg/kg over 10 min followed by an infusion 0.5-1.0 μg/kg/h, and group N received nitroglycerine infusion at a dose of 0.5-2 μg/kg/min so as to maintain mean arterial pressure (MAP) between 60 and 70 mmHg in all the groups. The visibility of the surgical field was assessed by surgeon using Fromme and Boezaart scoring system. Hemodynamic variables, total intra-operative fentanyl consumption, emergence time and time to first analgesic request were recorded. Any side-effects were noted. The postoperative sedation was assessed using Ramsay Sedation Score.

Result:

The desired MAP (60-70 mmHg) could be achieved in all the three study groups albeit with titration of study drugs during intra-operative period. No significant intergroup difference was observed in Fromme's score during the intra-operative period. The mean total dose of fentanyl (μg/kg) used was found to be significantly lower in group D compared to groups E and N (1.2 ± 0.75 vs. 3.6 ± 1.3 and 2.9 ± 1.1 respectively). The mean heart rate was significantly lower in group D compared to groups E and N at all times of measurement (P < 0.05). The MAP was found to be significantly lower in group D compared to groups E and N after infusion of study drugs, after induction, just after intubation and 5 min after intubation (P < 0.05). The Ramsay Sedation Scores were significantly higher in group D (score 3 in 46%) when compared to group E (score 2 in 50%) and group N (score 2 in 54%) (P < 0.001). The emergence time was significantly lower in group E and group N compared to group D. Time to first analgesic request was significantly longer in group D.

Conclusion:

Dexmedetomidine and esmolol provided better hemodynamic stability and operative field visibility compared to nitroglycerin during FESS. Dexmedetomidine provides an additional benefit of reducing the analgesic requirements and providing postoperative sedation.

Dexmedetomidine versus midazolam as adjuvants to intrathecal bupivacaine: A clinical comparison

BACKGROUND AND AIMS

Trials are being carried out to identify an adjuvant to intrathecal bupivacaine that preferably potentiates postoperative analgesia. This prospective, randomized, double-blind study was aimed to compare the onset and duration of sensory and motor block, postoperative analgesia and adverse effects of dexmedetomidine or midazolam given with 0.5% hyperbaric bupivacaine for spinal anesthesia.

MATERIAL AND METHODS

A total of 80 patients, scheduled for vaginal hysterectomies, were randomly allocated to Group D (n = 40) to receive intrathecally 3.0 mL 0.5% hyperbaric bupivacaine +5 ug dexmedetomidine in 0.5 mL of normal saline; and Group M (n = 40) to receive 3 mL of 0.5% hyperbaric bupivacaine +2 mg midazolam in 0.4 mL (5 mg/mL) +0.1 mL normal saline. The onset, duration of sensory and motor block, time to first postoperative analgesia and side effects were noted. Power and Sample size (PS) version 3.0.0.34 was used for power and sample size calculation. Statistical analysis was performed using Microsoft (MS) Office Excel software with the Student's t-test and Chi-square test (level of significance P = 0.05).

RESULTS

Duration of sensory, motor blockade and time to the first requirement of analgesia were significantly higher in Group D. Postoperative visual analog scale was significantly less in Group D than Group M. Both groups were similar with respect to sedation, hemodynamic variables and side-effects.

CONCLUSION

Intrathecal dexmedetomidine was better adjuvant than midazolam as it produces significantly longer duration of sensory block, reduced doses of postoperative analgesic agents with comparable side-effects.

The Influence of Dexmedetomidine on Ultrasound-induced Pulmonary Capillary Hemorrhage in Rats

The use of xylazine, a veterinary sedative, with ketamine for rat anesthesia has been shown to enhance the pulmonary capillary hemorrhage (PCH) effect of diagnostic ultrasound. This study was undertaken to assess whether the sedative/analgesic dexmedetomidine, commonly used in the intensive care unit, can also enhance ultrasound-induced PCH. Female Sprague Dawley rats were anesthetized with various combinations of ketamine plus xylazine or dexmedetomidine. The dosage of dexmedetomidine was reduced for some groups to doses relevant to human clinical usage. The right thorax of all rats was shaved and depilated for ultrasound transmission and the rats were scanned with diagnostic ultrasound using a 7.6-MHz linear array in a 38°C de-gassed water bath. There was no significant difference in PCH results for the recommended anesthetic dosages of ketamine plus xylazine and ketamine plus 500 μg/kg dexmedetomidine. The varied doses of dexmedetomidine enhanced the PCH, even for the lowest dose of 4 μg/kg, equivalent to a low human dose of 0.64 μg/kg. There was no significant difference in PCH for 500 μg/kg dexmedetomidine with or without ketamine. Further research is needed to identify and characterize other factors that may modify the patient risk from ultrasound-induced PCH.

Dexmedetomidine in gastrointestinal endoscopic procedures

Gastrointestinal endoscopy is the gold standard in the examination and the treatment of the diseases of gastrointestinal system, but the disadvantage of being painful process. At this point the sedative and analgesic agents may be important. Dexmedetomidine is a new sedoanalgesic agent which is alternative to benzodiazepines and opioids. It has analgesia, amnesia, sedative and anxiolytic properties. The use of dexmedetomidine as the sole anesthetic agent and as the adjuvant analgesic agent has been published but has not been approved because of the inconsistency of efficacy and safety. The author has been collected the published papers in the literature. This article is aimed to describe the use of dexmedetomidine in various gastrointestinal endoscopic procedures.

Dexmedetomidine versus midazolam for sedation during endoscopy: A meta-analysis

Patients undergoing endoscopy frequently require sedation, which commonly includes the administration of midazolam or dexmedetomidine. Previous meta-analyses have mainly focused on comparing the effects of these two drugs in intensive care unit patients. In the present study, randomized controlled trials (RCTs) that compared the sedative and clinical effectiveness of these two drugs in patients undergoing endoscopy were searched in a number of databases. The meta-analysis showed that dexmedetomidine demonstrated a significantly lower rate of respiratory depression and adverse events compared with those presented upon midazolam administration. A significant difference was also observed in the sedation potency of the sedatives. The current controlled data suggest that dexmedetomidine may be an alternative to midazolam in the sedation for endoscopy. However, more high-quality and well-designed studies are required to further evaluate this conclusion.

Anaesthesia for laparoscopic surgery: General vs regional anaesthesia

The use of laparoscopy has revolutionised the surgical field with its advantages of reduced morbidity with early recovery. Laparoscopic procedures have been traditionally performed under general anaesthesia (GA) due to the respiratory changes caused by pneumoperitoneum, which is an integral part of laparoscopy. The precise control of ventilation under controlled conditions in GA has proven it to be ideal for such procedures. However, recently the use of regional anaesthesia (RA) has emerged as an alternative choice for laparoscopy. Various reports in the literature suggest the safety of the use of spinal, epidural and combined spinal-epidural anaesthesia in laparoscopic procedures. The advantages of RA can include: Prevention of airway manipulation, an awake and spontaneously breathing patient intraoperatively, minimal nausea and vomiting, effective post-operative analgesia, and early ambulation and recovery. However, RA may be associated with a few side effects such as the requirement of a higher sensory level, more severe hypotension, shoulder discomfort due to diaphragmatic irritation, and respiratory embarrassment caused by pneumoperitoneum. Further studies may be required to establish the advantage of RA over GA for its eventual global use in different patient populations.

Dexmedetomidine as an adjuvant to levobupivacaine in supraclavicular brachial plexus block: A novel anesthetic approach

Aims and Objectives:

Supplementation of dexmedetomidine produces a dose-dependent sedation, anxiolysis and analgesia without respiratory depression. This study was conducted to evaluate the possible effect of dexmedetomidine as an adjuvant to levobupivacaine for supraclavicular brachial plexus block in upper limb surgery.

Settings and Design:

Tertiary care institute, Department of Anaesthesiology and Intensive Care, a placebo-controlled study.

Materials and Methods:

After obtaining Ethical Committee approval, a randomized, double-blind, placebo-controlled study was conducted on sixty American Society of Anesthesiologists physical status I and II patients in the age group of 18–60 years, divided randomly into two groups, Group I received 30 ml of 0.5% levobupivacaine with 1 ml of isotonic sodium chloride solution and Group II received 30 ml of 0.5% levobupivacaine and 1 ml (100 mcg) of dexmedetomidine for supraclavicular brachial plexus block. The onset and duration of sensory and motor blockade, duration of analgesia (DOA) and any adverse effects were noted. At the end of the study, data were compiled and analyzed using appropriate statistical tests. The value of P < 0.05 was considered significant.

Results:

Demographic profile was comparable in both the groups. The time to onset of sensory and motor block was 10.54 ± 2.333 min and 12.21 ± 2.529 min in Group I while it was 3.24 ± 0.951 min and 2.83 ± 1.197 min in Group II, respectively. The duration of sensory and motor block was 7.79 ± 2.007 h and 9.18 ± 1.701 h in Group I, and it was 16.31 ± 2.606 h and 17.52 ± 2.098 h in Group II, respectively. The DOA was 678.68 ± 20.492 min in Group I and 1273.79 ± 83.139 min in Group II. On statistical comparison, these values were highly significant (P < 0.001). Side effects such as nausea, vomiting, hypoxemia, pruritis, or urinary retention were not observed in either of the groups.

Conclusion:

Dexmedetomidine shortens the onset time for sensory and motor block significantly and prolongs DOA as well when used with levobupivacaine for supraclavicular brachial plexus block, without increasing the incidence of any adverse effects.

Comparison of dexmedetomidine and clonidine as an adjuvant to ropivacaine for epidural anesthesia in lower abdominal and lower limb surgeries

BACKGROUND

The quality and duration of analgesia is improved when a local anesthetic is combined with alpha 2 adrenergic agonist. Though, the effects of clonidine on local anesthetics have been extensively studied, there are limited studies demonstrating the effects of epidural dexmedetomidine on local anesthetics. The aim of our study is to compare the effect of clonidine and dexmedetomidine when used as an adjuvant to epidural ropivacaine in lower abdominal and lower limb surgeries.

MATERIALS AND METHODS

Patients were randomized into two groups-group ropivacaine with clonidine (RC) received 15 ml of 0.75% ropivacaine with 1 μg/kg clonidine and group ropivacaine with dexmedetomidine (RD) received 15 ml of 0.75% ropivacaine with 1 μg/kg dexmedetomidine epidurally. Onset of sensory analgesia using cold swab, onset of motor blockade using Bromage scale, time to 2 dermatome regression of sensory level, time to first demand for analgesia, sedation using Ramsay sedation scale, intra operative hemodynamic parameters and complications were assessed.

RESULTS

The onset (RD-8.53 ± 1.81, RC-11.93 ± 1.96) and duration of sensory blockade (RD-316 ± 31.5, RC-281 ± 37, sedation were found to be significantly better in the dexmedetomidine group. No significant difference was found in terms of onset of motor blockade and hemodynamic changes.

CONCLUSION

Dexmedetomidine at doses of 1 μg/kg is an effective adjuvant to ropivacaine for epidural anesthesia, which is comparable to clonidine.