Role of dexmedetomidine as an anaesthetic adjuvant in breast cancer surgery as a day-care procedure: A randomised controlled study

Dexmedetomidine as an Adjuvant to Nerve Block for Cancer Surgery: A Systematic Review and Meta-Analysis

Background/Objectives: Our understanding of dexmedetomidine, as an adjuvant to nerve blocks in cancer surgery, is characterized by a current lack of compelling evidence, and it remains unknown whether the potential benefits of use outweigh the risks. The aim of the study was to evaluate the benefit and safety profiles of dexmedetomidine as an adjuvant to nerve blocks in cancer surgery. Methods: Systematic searches were conducted in MEDLINE, ScienceDirect, Cochrane Library, Springer, medRxiv, and Scopus up to 17 May 2024. Risk ratios (RR) for binary outcomes and standardized mean differences (SMDs) for continuous outcomes were quantified. Results: Twenty studies were identified. In breast cancer surgery, the use of dexmedetomidine reduced 24 h total morphine consumption (SMD = -1.99 [95% CI -3.01 to -0.98], p = 0.0001, I2 = 91%, random effects) and prolonged the requirement for morphine rescue analgesia (SMD = 2.98 [95% CI 0.01 to 5.95], p = 0.05, I2 = 98%, random effects). In abdominal cancer surgery, the dexmedetomidine group had lower total sufentanil consumption (SMD = -1.34 [95% CI -2.29 to -0.40], p = 0.005, I2 = 84%, random effects). Dexmedetomidine reduced the VAS score and decreased postoperative nausea and vomiting (PONV). No studies using dexmedetomidine reported serious adverse events. Conclusions: Using dexmedetomidine as an adjuvant to nerve blocks in cancer surgery could lower the VAS pain score and prolong the regional anesthesia duration, which would lead to a decrease in total opioid consumption and possibly contribute to fewer PONV events. Furthermore, the reports of no serious adverse events indicate its good safety profile.

Effect of dexmedetomidine on postoperative nausea and vomiting in patients under general anaesthesia: an updated meta-analysis of randomised controlled trials

OBJECTIVES

To explore the effect of dexmedetomidine (DEX) on postoperative nausea and vomiting (PONV) in adult patients after general anaesthesia.

DESIGN

Systematic review and meta-analysis.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials (RCTs) comparing the efficacy of DEX with placebo or a single drug on PONV in adult patients after general anaesthesia.

DATA SOURCES

We searched the PubMed, the Web of Science, the Cochrane Library and Embase (1 January 2000 to 30 June 2022) to select the relevant RCTs.

DATA ANALYSIS

All the relevant data were analysed by using RevMan V.5.4. Heterogeneity was tested for each outcome, and random-effect or fixed-effect models was selected according to the level of heterogeneity. The primary outcome was the incidence of PONV. The secondary outcomes were the incidence of bradycardia, perioperative opioid consumption, extubation time and the length of hospitalisation.

RESULTS

A total of 18 trials involving 2018 patients were included in this meta-analysis. Notably, 15 updated studies were not involved in the previous meta-analysis. The incidence of PONV in DEX group was lower than that in the control group (OR=0.49, 95% CI: 0.36 to 0.67) and the perioperative opioid consumption in DEX group was also decreased significantly (standard mean difference (SMD)=-1.04, 95% CI: -1.53 to -0.54). Moreover, the length of hospitalisation (SMD=-2.29, 95% CI: -4.31 to -0.28) and the extubation time (SMD=-0.75, 95% CI: -1.26 to -0.25) in DEX group were shorter. Whereas, more number of patients receiving DEX might increase the occurrence of bradycardia (OR=1.60, 95% CI: 1.13 to 2.27).

CONCLUSIONS

DEX could decrease the occurrence of PONV in adult patients under general anaesthesia and promote the recovery after surgery. However, DEX might increase the occurrence of bradycardia.

PROSPERO REGISTRATION NUMBER

CRD 42022341548.

Remifentanil combined with dexmedetomidine on the analgesic effect of breast cancer patients undergoing modified radical mastectomy and the influence of perioperative T lymphocyte subsets

OBJECTIVE

To study the analgesic effect of breast cancer patients undergoing modified radical mastectomy (MRM) and the influence of perioperative T lymphocyte subsets by remifentanil combined with dexmedetomidine.

METHODS

80 breast patients were divided into control group and research group based on the anesthesia protocol. Patients in control group was given remifentanil for anesthesia induction and maintenance, and patients in research group was given remifentanil and dexmedetomidine for anesthesia induction and maintenance. We compared the anesthesia time, operation time, surgical blood loss, postoperative wake-up time, extubation time, incidence of adverse reactions, VAS score and T lymphocyte subsets in peripheral blood in the two groups of patients.

RESULTS

The baseline data including age, height, weight and BMI, ASA classification, stage of breast cancer, frequency of neoadjuvant therapy, and surgical characteristics including anesthesia time, operation time and bleeding volume all have no significant difference between two groups (P > 0.05). Compared to control group, the time of wake up and extubation in patients of research group were all significantly decreased (P < 0.05), and significantly decreased MBP and HR after loading dose of dexmedetomidine in research group (P < 0.05). The VAS scores of patients at 4, 8, 12, 16, 20 and 24 h after surgery in the research group are all significantly lower than those in the control group (P < 0.05). Before induction of anesthesia, there was no significant difference in the ratio of CD4+, CD8+ and CD4+/CD8+ T lymphocytes in peripheral blood between the two groups (P > 0.05). At 1 h during operation and 24 h after operation, the ratio of CD4+ and CD4+/CD8+ cells in the research group was significantly higher than these of the control group (P < 0.05), while the ratio of CD8+ cells was lower than that of the control group (P < 0.05).

CONCLUSION

For breast cancer patients undergoing MRM, the use of remifentanil combined with dexmedetomidine can enhance postoperative analgesia and reduce postoperative immunosuppression.

Perioperative Breast Analgesia: a Systematic Review of the Evidence for Perioperative Analgesic Medications

PURPOSE OF REVIEW

Breast surgery is common and may result in significant acute as well as chronic pain. A wide range of pharmacologic interventions is available including opioids, non-steroidal anti-inflammatory drugs (NSAIDs), N-methyl-D-aspartate (NMDA) receptor antagonists, anticonvulsants, and other non-opioids with analgesic properties. We present a review of the evidence for these pharmacologic interventions. A literature search of the MEDLINE database was performed via PubMed with combined terms related to breast surgery, anesthesia, and analgesia. Articles were limited to randomized controlled trial (RCT) design, adult patients undergoing elective surgery on the breast (not including biopsy), and pharmacologic interventions only. Article titles and abstracts were screened, and risk of bias assessments were performed.

RECENT FINDINGS

The search strategy initially captured 7254 articles of which 60 articles met the full inclusion criteria. Articles were organized according to intervention: 6 opioid agonists, 14 NSAIDs and acetaminophen, 4 alpha-2 agonists, 7 NMDA receptor antagonists, 6 local anesthetics, 7 steroids, 15 anticonvulsants (one of which also discussed an NMDA antagonist), 1 antiarrhythmic, and 2 serotonin reuptake inhibitors (one of which also studied an anticonvulsant). A wide variety of medications is effective for perioperative breast analgesia, but results vary by agent and dose. The most efficacious are likely NSAIDs and anticonvulsants. Some agents may also decrease the incidence of chronic postoperative pain, including flurbiprofen, gabapentin, venlafaxine, and memantine. While many individual agents are well studied, optimal combinations of analgesic medications remain unclear.

Prediction of total hospital expenses of patients undergoing breast cancer surgery in Shanghai, China by comparing three models

BACKGROUND

Breast cancer imposes a considerable burden on both the health care system and society, and becomes increasingly severe among women in China. To reduce the economic burden of this disease is crucial for patients undergoing the breast cancer surgery, hospital managers, and medical insurance providers. However, few studies have evidenced the prediction of the total hospital expenses (THE) for breast cancer surgery. The aim of the study is to predict THE for breast cancer surgery and identify the main influencing factors.

METHODS

Data were retrieved from the first page of medical records of 3699 patients undergoing breast cancer surgery in one tertiary hospital from 2017 to 2018. Multiple liner regression (MLR), artificial neural networks (ANNs), and classification and regression tree (CART) were constructed and compared.

RESULTS

The dataset from 3699 patients were randomly divided into training and test sets at a 70:30 ratio (2599 and 1100 records, respectively). The average total hospital expenses were 12520.54 ± 7844.88 ¥ (US$ 1929.20 ± 1208.11). MLR results revealed six factors to be significantly associated with THE: age, LOS, type of disease, having medical insurance, minimally invasive surgery, and receiving general anesthesia. After comparing three models, ANNs was the best model to predict THEs in patients undergoing breast cancer surgery, and its strong predictive performance was also validated.

CONCLUSIONS

To reduce the THEs, more attention should be paid to related factors of LOS, major and minimally invasive surgeries, and general anesthesia for these patient groups undergoing breast cancer surgery. This may reduce the information asymmetry between doctors and patients and provide more reliable cost, practical inpatient medical consumption standards and reimbursement standards reference for patients, hospital managers, and medical insurance providers ,respectively.

Comparison of effect of intraperitoneal instillation of additional dexmedetomidine or clonidine along with bupivacaine for post-operative analgesia following laparoscopic cholecystectomy

Background and Aims

Despite advances in minimally invasive surgery, postoperative pain remains a concern after laparoscopic cholecystectomy. This study aims to compare the effect of intraperitoneal instillation of bupivacaine with alpha-2 agonists (dexmedetomidine and clonidine) for postoperative analgesia.

Methods

One hundred and eight patients scheduled for elective laparoscopic cholecystectomy were randomised to receive either 20 mL of 0.5% bupivacaine (Group B), 20 mL of 0.5% bupivacaine with dexmedetomidine 1 μg/kg (Group BD) or 20 mL of 0.5% bupivacaine with clonidine 1 μg/kg (Group BC). Study drug made to equal volume (40 mL) was instilled before the removal of trocar at the end of surgery. Standard general endotracheal anaesthesia with intra-abdominal pressure of 12-14 mm Hg during laparoscopy was followed uniformly. The primary objective of our study was the magnitude of pain. One way analysis of variance (ANOVA) for continuous variables and Chi-square test for categorical variables was used.

Results

The Numerical Rating Scale (NRS) scores for pain intensity did not show any statistical significance at any of the pre-defined time points. Time to first request for analgesia was shortest in group BC (64.0 ± 60.6 min) when compared to the other groups (B, 78.8 ± 83.4 min; BD, 112.2 ± 93.4 min; P < 0.05). Total amount of rescue fentanyl given in groups BD (16.8 ± 29.0 μg) and BC (15 ± 26.4 μg) was significantly less than B (35.7 ± 40.0 μg); P < 0.05).

Conclusion

The addition of alpha-2 agonists to bupivacaine reduces the post-operative opioid consumption, and dexmedetomidine appears to be superior to clonidine in prolonging time to first analgesic request.

Effect of dexmedetomidine on hemodynamic responses to tracheal intubation: A meta-analysis with meta-regression and trial sequential analysis

STUDY OBJECTIVE

An uncontrolled adrenergic response during tracheal intubation may lead to life-threatening complications. Dexmedetomidine binds to α2-receptors and may attenuate this response. The primary aim of our meta-analysis is to investigate dexmedetomidine efficacy in attenuating sympathetic response to tracheal intubation, compared with placebo or no dexmedetomidine, in terms of heart rate and blood pressure at intubation.

DESIGN

Meta-analysis with meta-regression and trial sequential analysis.

SETTING

Systematic search from inception until December 1, 2020 in the following databases: Pubmed, Scopus, the Cochrane Central Register of Controlled Trials, EMBASE and Google Scholar.

INTERVENTIONS

All randomized controlled trials investigating intravenous dexmedetomidine as premedication in adult patients undergoing tracheal intubation were included in our study. Studies were included without any language or publication date restriction. A trial sequential analysis and a post-hoc meta-regression were performed on the main outcomes.

MEASUREMENTS

Hemodynamic parameters and heart rate at tracheal intubation, dose of anesthetic needed for induction of anesthesia, total anesthetic requirement throughout the operative procedure, postoperative pain and percentage of patients requiring analgesics at 24 postoperative hours, postoperative nausea and vomiting, intraoperative and postoperative bradycardia, hypotension, dizziness, shivering and/or respiratory depression.

MAIN RESULTS

Ninety-nine included studies randomized 6833 patients. During laryngoscopy, all hemodynamic parameters were significantly greater in the no dexmedetomidine group. In particular, in the dexmedetomidine group, systolic blood pressure differed by -21.8 mm Hg (95% CI -26.6 to -17.1, p-value < 0.001, I² 97%), mean arterial pressure by -12.8 mm Hg (95% CI -15.6 to -10.0, p-value < 0.001, I² 98%), and heart rate by -16.9 bpm (95% CI -19.8 to -13.9, p-value < 0.001, I² 98%).

CONCLUSIONS

Patients receiving premedication with dexmedetomidine for tracheal intubation, compared with no dexmedetomidine, have a lower blood pressure and heart rate, however, the risk of bradycardia and hypotension is relevant and its use during daily practice should be cautiously evaluated for each patient.

Discharge readiness after minor gynaecological surgeries comparing dexmedetomidine and ketamine premedication in bispectral index (BIS) guided propofol-based anaesthesia

Background and Aims:

Dexmedetomidine and ketamine are commonly used pre-medicants to propofol. Previous literature shows a delay in recovery with their use without any clarity on discharge. This study was planned to find out whether adding these premedicants to Bispectral index (BIS) guided propofol anaesthesia led to delayed discharge in minor gynaecological surgeries.

Methods:

Totally, 120 adult females belonging to American Society of Anesthesiologists (ASA) physical status I and II undergoing minor gynaecological surgeries under general anaesthesia were randomly allocated to receive 1 μg/kg dexmedetomidine (Group D), 0.5 mg/kg ketamine (Group K) and normal saline (Group P) as premedication. Propofol 1% was used for induction and maintenance of anaesthesia keeping BIS between 55 and 70. After the procedure, patients were assessed primarily for discharge readiness using Modified Post Anaesthesia Discharge Scoring System (MPADSS).The secondary outcomes were Modified Aldrete Score (MAS), total dose of propofol used and haemodynamics.

Results:

The percentage of patients ready for discharge were 22.5%, 30% and 15%at 1 hour in group D, K and P, respectively (p = 0.275). Median MAS was 5, 4 and 6 respectively for group D, K and P immediately post-surgery (p = 0.000). The mean dose of propofol used was 69.75 ± 12.56 mg in group D and 135.25 ± 9.2 mg in group P (p = 0.001). There were significant haemodynamic variations in group D (16.4% fall in heart rate at 5 minutes and 24.18% fall in mean arterial pressure at 15 minutes).

Conclusion:

Premedication with dexmedetomidine and ketamine in propofol anaesthesia does not delay discharge. However, stable haemodynamics and good analgesia with ketamine make it a better option.

Dexmedetomidine as an adjuvant for patients undergoing breast cancer surgery: A meta-analysis

BACKGROUND

The goal of this study was to comprehensively evaluate the analgesic and antiemetic effects of adjuvant dexmedetomidine (DEX) for breast cancer surgery using a meta-analysis.

METHODS

Electronic databases were searched to collect the studies that performed randomized controlled trials. The effect size was estimated by odd ratio (OR) or standardized mean difference (SMD). Statistical analysis was performed using the STATA 13.0 software.

RESULTS

Twelve published studies involving 396 DEX treatment patients and 395 patients with control treatment were included. Pooled analysis showed that the use of DEX significantly prolonged the time to first request of analgesia (SMD = 1.67), decreased the postoperative requirement for tramadol (SMD = -0.65) and morphine (total: SMD = -2.23; patient-controlled analgesia: SMD = -1.45) as well as intraoperative requirement for fentanyl (SMD = -1.60), and lower the pain score at 1 (SMD = -0.30), 2 (SMD = -1.45), 4 (SMD = -2.36), 6 (SMD = -0.63), 8 (SMD = -2.47), 12 (SMD = -0.81), 24 (SMD = -1.78), 36 (SMD = -0.92), and 48 (SMD = -0.80) hours postoperatively compared with the control group. Furthermore, the risks to develop postoperative nausea/vomiting (PONV) (OR = 0.38) and vomiting (OR = 0.54) were significantly decreased in the DEX group compared with the control group. The pain relief at early time point (2, 6, 12, 24 hours postoperatively) and the decrease in the incidence of PONV were especially obvious for the general anesthesia subgroup (P < .05) relative to local anesthesia subgroup (P >.05).

CONCLUSION

DEX may be a favorable anesthetic adjuvant in breast cancer surgery, which could lower postoperative pain and the risk to develop PONV. DEX should be combined especially for the patients undergoing general anesthesia.

Safety and Efficacy of Dexmedetomidine in Breast Surgeries: A Systematic Review and Meta-Analysis

PURPOSE

Pain control during and after breast surgery is still a challenging task. Dexmedetomidine (DEX) is considered as a sedative agent that is widely used perineurally or intravenously as an adjuvant in general anesthesia and critical care medicine practice. The aim of this study is to evaluate the efficacy of perineural DEX and intravenous (IV) DEX and their effects on postoperative complications in breast surgeries.

DESIGN

Systematic review and meta-analysis.

METHODS

The present study systematically reviewed all identified randomized controlled trials for efficacy and safety of IV and perineural use of DEX in breast surgeries. Databases were searched for articles published before October 2019.

FINDINGS

Twelve trials were identified including 803 patients undergoing breast surgery. Although administration of IV DEX and its use with pectoral nerve (Pecs) block significantly postponed time for first analgesic request and decreased pain score at 1 and 12 hours after surgery, paravertebral use of DEX had no statistically significant effect. Pooled data about perineural DEX showed no significant effect on postoperative nausea and vomiting (PONV), whereas IV DEX significantly reduced PONV. Pooled analysis also showed that DEX administration did not significantly affect postoperative complications, such as postoperative itching, bradycardia, and pneumothorax in patients undergoing breast surgery.

CONCLUSIONS

The results showed that unlike paravertebral DEX, both DEX use with Pecs blocks and IV DEX were effective in control of postoperative pain in patients undergoing breast surgeries. Unlike perineural DEX, IV DEX significantly reduced PONV.

Intranasal dexmedetomidine combined with local anesthesia for conscious sedation during breast lumpectomy: A prospective randomized trial

Breast lumpectomy is usually performed under general or local anesthesia. To the best of our knowledge, whether conscious sedation with intranasal dexmedetomidine and local anesthesia is an effective anesthetic technique has not been studied. Thus, the present study aimed to investigate the effectiveness of conscious sedation with intranasal dexmedetomidine combined with local anesthesia in breast lumpectomy, and to identify its optimal dose. A prospective randomized, double-blinded, placebo-controlled, single-center study was designed, and patients undergoing breast lumpectomies were recruited based on the inclusion and exclusion criteria. All patients were randomly allocated to four groups: i) Local anesthesia with 0.9% intranasal saline (placebo); local anesthesia with ii) 1 µg.kg⁻¹; iii) 1.5 µg.kg⁻¹; or iv) 2 µg.kg⁻¹ intranasal dexmedetomidine. The sedation status, pain relief, vital signs, adverse events, and satisfaction of patient and surgeon were recorded. Patients in the three dexmedetomidine groups were significantly more sedated and experienced less pain compared with the placebo group 45 min after intranasal dexmedetomidine administration and during 30 min in the post-anesthesia care unit. Patients in the 1.5 µg.kg⁻¹ group were more sedated compared with the 1 µg.kg⁻¹ group (without reaching statistical significance), whereas the 1.5 µg.kg⁻¹ group exhibited a similar level of sedation 45 min after intranasal dexmedetomidine administration compared with the 2 µg.kg⁻¹ group. In addition, patients in the 1 and 1.5 µg.kg⁻¹ group experienced no adverse hemodynamic effects. Patient and surgeon satisfaction were greater in the 1.5 µg.kg⁻¹ group compared with the 1 and 2 µg.kg⁻¹ groups. Taken together, the results of the present study suggested that conscious sedation with intranasal dexmedetomidine and local anesthesia may be an effective anesthetic for breast lumpectomy surgery, and that the optimal dose for intranasal dexmedetomidine administration may be 1.5 µg.kg⁻¹, as it resulted in good sedation and patient satisfaction without adverse effects.

Effects of serum from breast cancer surgery patients receiving perioperative dexmedetomidine on breast cancer cell malignancy: A prospective randomized controlled trial

Adrenergic receptors (ARs) have gained attention for their involvement in breast cancer (BC) progression. Dexmedetomidine, a selective α₂ -AR agonist, has been reported to increase the malignancy of BC cells in vitro or stimulate tumor growth in mice. However, clinical evidence is lacking. Clinical research in this area is important as dexmedetomidine is widely used in BC surgery patients. Here we allocated 24 women with primary BC to the dexmedetomidine group (who received a total dose of 2 μg kg^-1 dexmedetomidine perioperatively) or to the control group (who received the same volume of normal saline). Venous blood was obtained from all patients immediately upon entering the operating room and 24 hours postoperatively. Serum was then exposed to MCF-7 cells at a concentration of 10% for 24 hours. Cell proliferation, migration, and invasion were analyzed using EdU, Transwell, and Matrigel methods, respectively. We found that postoperative serum from those who received dexmedetomidine was associated with significantly increased cell proliferation, migration, and invasion compared with preoperative serum when used to culture MCF-7 cells. The mean percentage change from post to preoperative values in these cell functions was significantly larger in the dexmedetomidine group than in the control group (proliferation, 30.44% vs 8.45%, P = .0024; migration, 15.90% vs 3.25%, P = .0015; invasion, 8.17% vs 2.13%, P = .04). In conclusion, these findings suggest that in patients undergoing surgery for primary BC, perioperative administration of dexmedetomidine might influence the serum milieu in a way that favors the malignancy of MCF-7 cells. Clinical trial registration: NCT03108937.