Comparing the Effect of Clonidine and Dexmedetomidine on Intraoperative Bleeding in Spine Surgery

Fentanyl versus Dexmedetomidine Infusion in Head and Neck Free Flap Surgery for Comparison of Hemodynamic Parameters and Anaesthetic Requirements: A Randomised Controlled Trial

BACKGROUND

This prospective, double-blinded, randomized study aimed to compare the efficacy of dexmedetomidine and fentanyl infusions in maintaining hemodynamics during head and neck free flap surgery, as well as their impact on the relative amount of blood loss.

METHODS

Twenty patients with American Society of Anesthesiologists physical status I and II scheduled for elective head and neck free flap surgery were enrolled. The patients were randomly assigned to receive either dexmedetomidine (1 µg/kg over 10 min at anesthesia induction, followed by 0.2 to 0.75 µg/kg per hour infusion during maintenance) or fentanyl (1 to 2 µg/kg per hour infusion during maintenance). Intraoperative hemodynamic parameters, blood loss, blood transfusion requirements, surgeon satisfaction, adverse drug effects, and free flap survival up to 7 days were recorded.

RESULTS

The dexmedetomidine group achieved a mean arterial pressure (MAP) value between 60 and 70 mmHg at multiple time points (15 min, 3rd, 4th, 5th, and 6th hours), while the fentanyl group did not reach this range at any time point. The intergroup statistical analysis revealed a significant difference only at the 5th hour with (95% CI: -16.17 to -0.62) and P = 0.036. Additionally, the dexmedetomidine group exhibited lower heart rates (< 70/min) at several time points (15 min, 2nd, 3rd, 4th, 5th, and 6th hours) compared to the fentanyl group. The intergroup comparison indicated a statistically significant difference only at the 3rd hour with (95% CI: -20.94 to -0.45) and P = 0.042.

CONCLUSION

Dexmedetomidine can be a useful adjuvant of GA for inducing controlled hypotension and decreasing bleeding in free flap surgery of the head and neck region without any detrimental effect on the free flap survival.

Premedication with intranasal versus intravenous dexmedetomidine for hypotensive anesthesia during functional endoscopic sinus surgery in adults: A randomized triple-blind trial

Functional Endoscopic Sinus Surgery (FESS) has been performed under controlled hypotension to increase operating field visibility. Intranasal (IN) dexmedetomidine is easy, noninvasive, and possesses lower C max, accompanied by lower pharmacodynamic action, including hypotension, bradycardia, and sedation. This trial aimed to compare IN and intravenous (IV) dexmedetomidine for hypotensive anesthesia during FESS. This randomized, controlled, triple-blinded clinical trial involved sixty cases scheduled for FESS. Patients were divided into two equal groups by random manner. 45-60 min before anesthesia induction, group IN: received 1 μg/kg IN dexmedetomidine diluted in 10 ml of saline 0.9 % intranasally preoperative. Group IV: received 1 μg/kg dexmedetomidine diluted in 10 ml of saline 0.9 % infused over 10 min. The primary outcome was the total amount of administered atropine. The secondary outcomes included hemodynamic, through 1 h before surgery, intraoperatively and postoperatively at different time intervals. The quality of the operative field, sedation, adverse reactions and hemostatic stuffing after FESS were also assessed. The total amount of consumed atropine decreased significantly in group IN compared to group IV. Preoperative Ramsay Sedation scores at T0, T5, T50 and T60 were comparable between the two groups, while at T10, T15, T20, T30, and T40 were lower significantly in the IN group compared with the IV group. Preoperative mean arterial blood pressure at T0, T5 and T60 had comparable differences across both groups while reduced at T10 to T 45 significantly in the IV group than IN group. Both groups had comparable satisfaction, postoperative Ramsey sedation, hemostatic suffering, quality of operative field and complications. In conclusion, IN dexmedetomidine administration is relatively simple and appropriate; moreover, it decreases first-pass metabolism. Onset is prolonged relative to IV dosing; thus, it should be administered nearly 1 h before surgery and recommended in adult patients as they require minor sedation preoperatively.

Comparison of the effects of tranexamic acid, nitroglycerin, and remifentanil on the prevention of bleeding during herniated lumbar intervertebral disc surgery: A randomized clinical trial

Background

Surgery is a well-known and effective method of treating lumbar intervertebral disc herniation. The present study aimed to compare the effects of administering tranexamic acid (TXA), nitroglycerin (NTG), and remifentanil (REF) on hemorrhage prevention during herniated lumbar intervertebral disc surgery.

Methods

A double-blind clinical trial was conducted on 135 participants undergoing lumbar intervertebral disc surgery. A randomized block design was used for subject assignment to three groups including TXA, NTG, and REF. The hemodynamic parameters, bleeding rate, hemoglobin level, and the amount of infused propofol were measured and recorded after surgery. Data were then analyzed in SPSS software using Chi-square test and analysis of variance.

Results

The mean age of participants in the study was 42.12 ± 7.93 years, and all three groups were equal in terms of demographic characteristics (P > 0.05). The mean arterial pressure (MAP) of the TXA and NTG groups was notably higher than the REF group (P < 0.008). The mean heart rate (HR) of the TXA and NTG groups was notably higher than the REF group (P < 0.05). The propofol dosage used in the TXA group was higher than the two groups of NTG and REF (P < 0.001).

Conclusion

Among participants undergoing lumbar intervertebral disc surgery, the greatest MAP variability was observed in the NTG group. Higher mean HR and propofol consumption was observed in the NTG and TXA groups when compared to REF. No statistically significant differences were noted between groups in oxygen saturation or bleeding risk. Based on these findings, REF may be considered a preferred surgical adjunct over TXA and NTG during lumbar intervertebral disc surgery.

Opioid Sparing Analgesics in Spine Surgery

Combinations of various nonopioid analgesics have been used to decrease pain and opioid consumption postoperatively allowing for faster recovery, improved patient satisfaction, and decreased morbidity. These opioid alternatives include acetaminophen, NSAIDs, COX-2 specific inhibitors, gabapentinoids, local anesthetics, dexamethasone, and ketamine. Each of these drugs presents its own advantages and disadvantages which can make it difficult to implement universally. In addition, ambiguous administration guidelines for these nonopioid analgesics lead to a difficult implementation of standardization protocols in spine surgery. A focus on the efficacy of different pain modalities specifically within spine surgery was implemented to assist with this standardized protocol endeavor and to educate surgeons on limiting opioid prescribing in the postoperative period. The purpose of this review article is to investigate the various opioid sparing medications that have been used to decrease morbidity in spine surgery and better assist surgeons in managing postoperative pain. Methods. A narrative review of published literature was conducted using the search function in Google scholar and PubMed was used to narrow down search criteria. The keywords “analgesics,” “spine,” and “pain” were used.

Comparing the Effect of Classical and Modified Thoracolumbar Interfascial Plane Block on Postoperative Pain and IL-6 Level in Posterior Lumbar Decompression and Stabilization Surgery

Background: Ultrasound (US)-guided classical and modified thoracolumbar interfascial plane (TLIP) blocks are often used to provide adequate analgesia after lumbar spinal surgery. Postoperative pro-inflammatory interleukin 6 (IL-6) blood concentrations after lumbar spine surgery are related to postoperative pain and inflammation. Objectives: The purpose of this prospective randomized parallel controlled study was to assess postoperative pain and serum levels of pro-inflammatory IL-6 after posterior lumbar decompression and stabilization surgery with a classical and modified technique of TLIP block. Methods: This prospective randomized, single-blinded controlled pilot study was conducted on eight patients who will undergo posterior lumbar decompression and stabilization surgery. After obtaining the ethical approval and an informed consent, all subjects were randomly allocated into the classic TLIP group and the modified TLIP group. Following general anesthesia induction, 20 mL bupivacaine 0.25% was injected on each side in interfascialis plane between m. longissimus and m. iliocostalis in modified TLIP group and between m. multifidus and m. longissimus in classical TLIP group. Intraoperative hemodynamic (blood pressure and heart rate) and noxious stimulation response level (qNOX), postoperative IL-6 level, 24-hour morphine consumption, and numerical rating score were recorded and analyzed. Results: The median of IL-6 level was found to be lower in the modified TLIP group 12 hours postoperatively compared to classic TLIP (29.91 (8.56 – 87.61) vs. 46.87 (2.87 – 92.35)). The mean Numerical Rating Scale (NRS) in the modified TLIP block was comparable with the classic TLIP group, although it was lower than the classic TLIP group (2.75 ± 1.5 vs. 3.75 ± 1.7 at 6 hours and 3.5 ± 1.3 vs. 4 ± 1.6 12 hours postoperatively). However, there was no difference in intraoperative hemodynamic, Qnox value, and total postoperative morphine consumption between the two groups. Conclusions: Our study showed that modified TLIP block resulted in lower IL-6 level and NRS 12 hours postoperatively compared to classical TLIP block. However, there were no differences in total postoperative morphine consumption between the two groups.

A Comparative Study on the Effects of Ketofol, Dexmedetomidine, and Isofol in Anesthesia of Candidates for Dilatation and Curettage

Background

Dilatation and curettage (D & C) is one of the relatively common surgeries among women. Familiarity with the analgesics, along with their different uses and specific characteristics, can help to determine the best and most appropriate drug to control pain in the patients.

Objectives

This study aimed to compare the effects of ketofol, dexmedetomidine, and isofol in anesthesia of candidates for D & C.

Methods

In this double-blind clinical trial, 150 candidates for D & C surgeries with ASA class 1 and 2 were included. Patients were randomly divided into three groups. The first group received ketamine + propofol, the second group received dexmedetomidine, and the third group received isofol (isoflurane + propofol). Any hemodynamic changes or respiratory disorders, including apnea or hypoventilation, drop in the level of blood oxygen saturation, and the need for respiratory support, were recorded and compared.

Results

Hypoventilation was observed in 47 patients in isofol group, 18 in the dexmedetomidine group, and 42 in ketofol group. Also, 48 patients in the isofol group, eight in the dexmedetomidine group, and 33 in the ketofol group experienced apnea. Moreover, 17 patients in the dexmedetomidine group, 35 in the ketofol group, and eight in the isofol group experienced bradycardia. The rate of bradycardia was significantly higher in the dexmedetomidine group (70%) compared to the other two groups, and the rate of hypotension was significantly higher in the isofol group (P = 0.001).

Conclusions

According to the results, dexmedetomidine was associated with fewer complications during general anesthesia in D & C surgery.

The effect of COVID-19 derived cytokine storm on cancer cells progression: double-edged sword

OBJECTIVE

Severe acute respiratory syndrome coronavirus 2 (SARS-COV2) was first detected in Wuhan, China in December, 2019. The emerging virus causes a respiratory illness, that can trigger a cytokine storm in the body.

METHOD

Cytokine storm in patient's body is associated with severe forms of disease. It is one of the main complications of coronavirus disease-2019 (COVID-19), in which immune cells play a major role. Studies have shown immune cells in the tumor environment can be effective to induce resistance to chemotherapy in cancer patients.

RESULT

Therefore, considering the role of immune cells to induce cytokine storm in COVID-19 patients, and their role to cause resistance to chemotherapy, they are effective on disease progression and creation of severe form of disease.

CONCLUSION

By examining the signaling pathways and inducing resistance to chemotherapy in tumor cells and the cells affect them, it is possible to prevent the occurrence of severe forms of the disease in cancer patients with COVID-19; it is applicable using target therapy and other subsequent treatment strategies.

Comparison of the Effect of Propofol and Dexmedetomidine on Hemodynamic Parameters and Stress Response Hormones During Laparoscopic Cholecystectomy Surgery

Background

General anesthesia induces endocrine, immunologic, and metabolic responses. Anesthetic drugs affect the endocrine system by changing the level of stress hormones and hemodynamic variables of the patient.

Objectives

The purpose of this study was to compare the effects of propofol and dexmedetomidine on hemodynamic parameters and stress-induced hormones in laparoscopic cholecystectomy (LC) surgery.

Methods

Seventy patients of elective LC were included in this study. The patients were randomly assigned into two equal groups of propofol (75 µg/kg/min) and dexmedetomidine (0.5 µg/kg/hour) as anesthesia maintenance. Hemodynamic parameters (heart rate and mean atrial pressure), blood sugar, and serum epinephrine level were monitored and recorded from pre-anesthesia period to 10 min after entry to post-anesthesia care unit (PACU) according to a planned method.

Results

Heart rate and mean atrial pressure changes were significantly lower in dexmedetomidine group in all stages compared to propofol group (P < 0.001). Also, the rises in blood glucose and serum epinephrine levels in the dexmedetomidine group were significantly higher than in the propofol group (P < 0.001).

Conclusions

Anesthesia maintenance by dexmedetomidine showed a significant difference in hemodynamic parameters in comparison with propofol. While dexmedetomidine had better effects on controlling hemodynamic parameters, propofol showed better effects on decreasing stress hormones, and it can be suggested for LC surgery.

Effects of the Two Doses of Dexmedetomidine on Sedation, Agitation, and Bleeding During Pediatric Adenotonsillectomy

Background

Due to the importance of dexmedetomidine and its different dosages, here, we aimed to investigate and compare the effectiveness of the doses of 1 µg/kg and 2 µg/kg of dexmedetomidine in sedation, agitation, and bleeding in pediatrics undergoing adenotonsillectomy.

Methods

This double-blinded randomized clinical trial was performed on 105 pediatric patients that were candidates for adenotonsillectomy. Then, the patients were divided into three groups receiving dexmedetomidine at a dose of 2 µg/kg, diluted dexmedetomidine at 1 µg/kg, and normal saline. The drugs were administered 15 minutes before operations via the intravenous method. The duration of extubation, mean arterial pressure (MAP), heart rate (HR), and SPO₂ in the recovery were recorded. We also collected data regarding patients’ sedation and agitation every 15 minutes.

Results

Our data showed no significant differences between the groups of patients regarding MAP, HR, and SPO₂. However, the mean sedation score was significantly higher in patients receiving dexmedetomidine (2 µg/kg), and this score was lowest in the control group at the time of entrance to the recovery room. The patients that received dexmedetomidine at a dose of 1 µg/kg had the lowest agitation score after 45 minutes of being in the recovery room, and the patients treated with dexmedetomidine at a dose of 2 µg/kg had the lowest agitation score after 60 minutes of being in the recovery compared to other groups of patients.

Conclusions

The use of the doses of 1 µg/kg and 2 µg/kg of dexmedetomidine was associated with proper sedation and a significant reduction in agitation. The patients also had lower amounts of bleeding. We recommend that anesthesiologists should pay more attention to dexmedetomidine at a dose of 2 µg/kg, especially in pediatric surgical procedures.

Comparison of the Effect of Two Different Doses of Labetalol to Induce Controlled Hypotension on Hemodynamic Changes During Spinal Fusion Surgery

Background: Spinal fusion surgery is often associated with heavy bleeding. Labetalol is one of the most effective drugs used to control bleeding in surgery. Objectives: Here, we measured the effect of two therapeutic doses of labetalol on the amount of bleeding. Methods: This is a randomized clinical trial that was performed in 2020-2021 in Al-Zahra hospital in Isfahan, Iran, on patients that were candidates for posterior spinal fusion surgery under general anesthesia. A total number of 64 patients were entered and randomized into two groups, one receiving labetalol at the dose of 2 mg/min and another group at 4 mg/min during surgery. The amount of bleeding in patients, heart rate, blood pressure, blood oxygen saturation, hypotension or bradycardia, and the mean length of stay in the recovery room were measured and compared between the groups. Results: Extubation time (14 ± 4) and recovery time (76 ± 17) were significantly lower in patients that received labetalol (2 mg/min) compared to another group (21 ± 7 for intubation time and 116 ± 32 for recovery time (P < 0.001 for both items). Patients that received labetalol (4 mg/min) had significantly lower amounts of hemorrhage compared to other group (P = 0.001), and the surgeon's satisfaction was significantly higher in the second group (P = 0.001). The frequency of hypotension and bradycardia during the surgery were significantly higher among patients that received labetalol at the dose of 4 mg/min (P = 0.002 and P = 0.001, respectively). The patients in the group labetalol at 4 mg/min had also significantly lower systolic and diastolic blood pressure and lower mean arterial pressure (MAP) compared to the other group (P < 0.05). Conclusions: Administration of labetalol at the dose of 4 mg/min had significantly desirable effects on hemodynamics that resulted in reduced bleeding volume and blood pressures compared to labetalol at the dose of 2 mg/min.

Clinical Applications of Aspirin as a Multi-potent Drug Beyond Cardiovascular Implications: A Proof of Concept for Anesthesiologists- A Narrative Review

To the best of our knowledge, aspirin (ASA) is known as a commonly used medication worldwide. Although the cardiovascular aspects of ASA are well-established, recently, it has been identified that ASA can yield multiple extra-cardiovascular therapeutic potencies in facing neurodegenerative disorders, various cancers, inflammatory responses, and the COVID-19 pandemic. In this review, we aimed to highlight the proven role of ASA administration in the variety of non-cardiovascular diseases, particularly in the field of anesthesiology.

Comparison of Intraoperative Infusion of Remifentanil Versus Fentanyl on Pain Management in Patients Undergoing Spine Surgery: A Double Blinded Randomized Clinical Trial

Background

Remifentanil is an ultra-short-acting opioid which facilitates hemodynamic management. However, there are concerns about postoperative Remifentanil hyperalgesia because of its potent fast onset and offset.

Objectives

The aim of this study was to determine visual analog scale (VAS), postoperative pain, and morphine used in two groups after spine surgery.

Methods

In this randomized clinical trial study, 60 patients aged 18 - 60 years old, according to the American Society of Anesthesiology (ASA) I - II, who underwent spinal canal stenosis or scoliosis surgery, were divided into two groups. In the control group, patients received 0.07 - 0.1 µg/kg/h intraoperative Fentanyl infusion, and in the intervention group 0.1 - 0.2 µg/kg/min remifentanil was infused during the surgery. Both groups received 15 mg/kg intravenous Acetaminophen 20 minutes before the end of the surgery. Postoperative pain score and morphine consumption were measured 6, 12, 24, and 48 hours after discharge from the post-anesthesia care unit (PACU).

Results

During the first 12 hours, VAS and morphine consumption were significantly higher in remifentanil group (P < 0.001). However, no significant difference was found between the two groups in morphine consumption 12 - 48 hours after surgery.

Conclusions

These findings suggest that Remifentanil infusion during surgery may increase postoperative pain. Also, VAS and morphine consumption were higher during the first 12 hours.

Effect of Different Loading Doses of Dexmedetomidine on Controlled Hypotension and the Incidence of Bradycardia During Rhinoplasty: A Clinical Trial

Controlled hypotension, with a mean arterial pressure (MAP) of 60 mmHg - 70 mmHg, provides a bloodless and visible surgical field during rhinoplasty. It has been shown that dexmedetomidine, an α2-adrenoreceptor agonist, is a suitable choice in this regard. One of the disadvantages of this drug is the possibility of severe bradycardia during infusion. Therefore, we compared lower intravenous (IV) loading doses to determine whether the hypotensive effect of the drug was preserved and the bradycardia incidence decreased. In this randomized, double-blinded clinical trial, 81 patients aged 18 to 50 years with the American Society of Anesthesiologists physical status (ASA-PS) class I and II, scheduled for rhinoplasty randomly received 1.0, 0.9, and 0.8 µg/kg (named as groups 1.0, 0.9, and 0.8, respectively) of IV dexmedetomidine before the induction of anesthesia followed by infusion (0.3 - 0.7 µg/kg/h) during operation. The patients' heart rate (HR), MAP, the requirements for nitroglycerin (NTG) and extra fentanyl, as well as the incidence of bradycardia, were recorded. Bleeding and visibility of the surgical field were scored by the surgeon using a 6-point visual scale. MAPs, HRs, and consumption of NTG and extra fentanyl were similar in the studied groups. The surgical field was more visible and bloodless in group 1.0 compared to group 0.8 (P < 0.001); the differences were not significant between groups 1.0 and 0.9 (P = 0.605). The incidence (P = 0.027) and the severity of bradycardia (P = 0.017) were higher in the groups with higher loading doses. We concluded that dexmedetomidine is an acceptable agent to provide controlled hypotension. A loading dose of 0.9 µg/kg, but not 0.8 µg/kg, provides similar surgical field conditions as the dose of 1 µg/kg. Furthermore, despite the decrease in the incidence of bradycardia, the hypotensive effect of the drug is preserved.

Adjuvant Drugs for Peripheral Nerve Blocks: The Role of Alpha-2 Agonists, Dexamethasone, Midazolam, and Non-steroidal Anti-inflammatory Drugs

Adjuvant drugs for peripheral nerve blocks are a promising solution to acute postoperative pain and the transition to chronic pain treatment. Peripheral nerve blocks (PNB) are used in the brachial plexus, lumbar plexus, femoral nerve, sciatic nerve, and many other anatomic locations for site-specific pain relief. However, the duration of action of a PNB is limited without an adjuvant drug. The use of non-opioid adjuvant drugs for single-shot peripheral nerve blocks (sPNB), such as alpha-2 agonists, dexamethasone, midazolam, and non-steroidal anti-inflammatory drugs, can extend the duration of local anesthetics and reduce the dose-dependent adverse effects of local anesthetics. Tramadol is a weak opioid that acts as a central analgesic. It can block voltage-dependent sodium and potassium channels, cause serotonin release, and inhibit norepinephrine reuptake and can also be used as an adjuvant in PNBs. However, tramadol's effectiveness and safety as an adjuvant to local anesthetic for PNB are inconsistent. The effects of the adjuvants on neurotoxicity must be further evaluated with further studies to delineate the safety in their use in PNB. Further research needs to be done. However, the use of adjuvants in PNB can be a way to help control postoperative pain.

Efficacy of Dexmedetomidine Infusion Without Loading Dose on Hemodynamic Variables and Recovery Time During Craniotomy: A Randomized Double-blinded Controlled Study

Background

Maintaining hemodynamic stability during intracranial surgery is one of the most important tasks. There is no general agreement regarding which anesthetics are optimal for craniotomy. Propofol and short-acting opioids are usually used, but their use is not without side effects. Recently, dexmedetomidine has been considered a safe alternative in different surgeries.

Objectives

We aimed to assess the efficacy of 0.5 µg/kg/h dexmedetomidine infusion without loading dose as an adjunct to general anesthesia for craniotomy.

Methods

A prospective, randomized, double-blinded, parallel-group, placebo-controlled trial was conducted. Setting: Single university teaching hospital’s operating rooms and postoperative intensive care unit. Patients: A total of 50 patients scheduled for elective supratentorial craniotomy participated in this study. Interventions: Patients were randomly divided into either control group (group C) and Dexmedetomidine group (group D). Main outcome measure: Intraoperative hemodynamics measurements at specific timings.

Results

We found that dexmedetomidine had significantly maintained mean arterial blood pressure and heart rate (P-value < 0.001); with lower intraoperative fentanyl and propofol consumption in group D (132 ± 35 µg and 14 ± 30 mg, respectively) when compared to group C (260 ± 38 µg and 534 ± 66 mg, respectively). Finally, a lesser sedation level was noticed in the dexmedetomidine group, together with a significantly lesser recovery time of 10.3 ± 4 min.

Conclusions

Dexmedetomidine infusion without loading dose could be an efficacious and safe agent in achieving hemodynamic stability with intraoperative opioid-sparing effect and lesser recovery time.

To Compare the Efficacy of Dexmedetomidine Versus Labetalol in Providing Controlled Hypotension in Functional Endoscopic Sinus Surgery

Background

Functional endoscopic sinus surgery (FESS) is a surgical intervention for sinus diseases. Bleeding is a common concern during FESS. Hemodynamic stability and quality surgical field visibility help to achieve the best outcomes.

Objectives

The present study primarily intended to compare the effectiveness of dexmedetomidine versus labetalol in providing controlled hypotension during FESS and then to assess the quality of the surgical field.

Methods

The current research was conducted as a prospective randomized double-blinded clinical study. Sixty patients of the American Society of Anesthesiologists grade I or II status undergoing FESS under general anesthesia were divided into two groups, each with 30 members. Patients receiving dexmedetomidine and labetalol were named as group D and L, respectively. The study intended to manage mean arterial pressure (MAP) between 65 - 75 mmHg. The visibility of the operative field was evaluated using Fromme and Boezaart scoring system. Total intraoperative fentanyl consumption and postoperative first analgesic request time were recorded.

Results

The MAP target was achieved in both groups. Intergroup differences concerning MAP were observed in both D (75.0 ± 2.0) and L (82.4 ± 5.2) groups (P-value < 0.05). Scores for blood loss were significantly lower in the D group (1.3 ± 0.3) compared to the L group (2.1 ± 0.3) (P-value < 0.05). There was no intergroup difference concerning the mean heart rate (group D; 70.8 ± 4.2, and group L; 73.4 ± 4.4). The total dose of fentanyl consumed was found to be significantly lower in the group D (41.9 ± 5.8) compared to group L (59.9 ± 5.3) (P-value < 0.05). The first analgesic request time was significantly longer in the group D (50.2 ± 9.1) compared to group L (24.8 ± 5.1) (P-value < 0.05).

Conclusions

Dexmedetomidine provided better hemodynamic stability and operative field visibility as compared to labetalol during FESS.

The role of exogenous Fibrinogen in cardiac surgery: stop bleeding or induce cardiovascular disease

The surgical treatment contributes to broad variety of cardiovascular diseases (CVD). Due to many involved factors in preoperative bleeding, it is almost difficult to perform better Haemostatic approach. Fibrinogen is a major blood glycoprotein and a coagulation factor which decreases postoperative bleeding. It has a potential role in platelet activation and bleeding inhibition; it may reflect the inflammatory responses and be related to the endothelial dysfunction. Fibrinogen can act as a pro-inflammatory element via increasing some inflammatory markers including IL-6, tumor necrosis factor-α (TNF-α), monocyte chemo attractant protein (MCP-1), macrophage inflammatory protein-1 (MIP-1a and b), matrix metalloproteinase (MMP-1 and MMP-9) and Toll-like Receptors (TLRs); through activation of these factors, fibrinogen may induce some inflammatory mechanisms such as focal adhesion kinase (FAK), mitogen-activated protein kinases (MAPK) and nuclear factor κB (NF-κB) pathways. It may cause endothelial dysfunction by increasing P and E-selection, intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1) levels which activate MAPK and NF-κB pathways. This factor is also associated with increased exocytosed von Willebrand factor (vWF) as well as activation of Rho-GTPase mechanism. All of these data demonstrate the dual role of fibrinogen in cardiac surgeries, bleeding inhibition and CVD. Therefore, identifying the CVD factors is helpful for designing preventive strategies and alternative drugs.

Tranexamic Acid for Blood Loss after Transforaminal Posterior Lumbar Interbody Fusion Surgery: A Double-Blind, Placebo-Controlled, Randomized Study

Background

Transforaminal lumbar interbody fusion (TLIF) may result in significant blood loss and an increase in blood transfusion. Though tranexamic acid (TXA) is widely studied for the hemostasis of arthroplasty, there is little information on the use of TXA for TLIF surgery.

Methods

This prospective randomized, double-blind, placebo-controlled trial was conducted to study the influence of TXA (intravenous bolus of 10 mg/kg 15 minutes before skin incision followed by intravenous infusion of 6-8 mg/kg/h up to a total dose of 15 mg/kg during the surgery) on the blood loss and Enhanced Recovery After Surgery (ERAS) after TLIF surgery. 40 patients were randomized into two groups: TXA group (tranexamic acid) and control group (placebo). Baseline characteristics were comparable between the TXA group and the control group before the surgery. Outcomes assessed included blood loss, total postoperative drainage, time for drainage removal, time to ambulation, hospital stay after surgery, postoperative hemoglobin (Hb) one day after surgery, and adverse events.

Results

Compared to patients in the control group after TLIF surgery, patients in the TXA group have significantly reduced intraoperative hemorrhage and time to ambulation after surgery but show similar hospital stay, postoperative drainage, time for drainage removal, postoperative Hb one day after surgery, and adverse events.

Conclusions

TXA shows important ability in controlling blood loss and promoting the ERAS after TLIF surgery.

Comparative In Vitro Study of Various α2-Adrenoreceptor Agonist Drugs for Ticagrelor Reversal

Ticagrelor, an antiplatelet adenosine diphosphate (ADP)-P2Y₁₂ receptor antagonist, increases the risk of bleeding. Its management is challenging because platelet transfusion is ineffective and no specific antidote is currently available. Epinephrine, a vasopressor catecholamine prescribed during shock, restores platelet functions inhibited by ticagrelor through stimulation of α_2A-adrenoreceptors. It subsequently inhibits cyclic adenosine monophosphate (cAMP) pathway and PI3K signaling. However, since epinephrine may expose a patient to deleterious hemodynamic effects, we hypothesized that other α₂-adrenoreceptor agonist drugs used in clinical practice with fewer side effects could reverse the antiplatelet effects of ticagrelor. We compared in vitro the efficacy of clonidine, dexmedetomidine, brimonidine, and norepinephrine with epinephrine to restore ADP- and PAR-1-AP-induced washed platelet aggregation inhibited by ticagrelor, as well as resulting platelet cAMP levels. In ticagrelor-free samples, none of the α₂-adrenoreceptor agonists induced aggregation by itself but all of them potentiated ADP-induced aggregation. Compared with epinephrine, norepinephrine, and brimonidine partially restored ADP- and fully restored PAR-1-AP-induced aggregation inhibited by ticagrelor while clonidine and dexmedetomidine were ineffective. Indeed, this lack of effect resulted from a lower decrease in cAMP concentration elicited by these partial α₂-adrenoreceptor agonists, clonidine, and dexmedetomidine, compared with full α₂-agonists. Our results support the development of specific full and systemic α₂-adrenoreceptor agonists for ticagrelor reversal.