Comparison of Dexmedetomidine Versus Midazolam-Fentanyl Combination for Monitored Anesthesia Care During Burr-Hole Surgery for Chronic Subdural Hematoma

Local anesthesia with sedation and general anesthesia for the treatment of chronic subdural hematoma: a systematic review and meta-analysis

BACKGROUND

Surgery is the primary treatment for chronic subdural hematoma, and anesthesia significantly impacts the surgery's outcomes. A previous systematic review compared general anesthesia to local anesthesia in 319 patients. Our study builds upon this research, analyzing 4,367 cases to provide updated and rigorous evidence.

METHODS

We systematically searched five electronic databases: PubMed, Cochrane Library, Scopus, Ovid Medline, and Web of Science, to identify eligible comparative studies. All studies published until September 2023 were included in our analysis. We compared six primary outcomes between the two groups using Review Manager Software.

RESULTS

Eighteen studies involving a total of 4,367 participants were included in the meta-analysis. The analysis revealed no significant difference between the two techniques in terms of 'recurrence rate' (OR = 0.95, 95% CI [0.78 to 1.15], P = 0.59), 'mortality rate' (OR = 1.02, 95% CI [0.55 to 1.88], P = 0.96), and 'reoperation rate' (OR = 0.95, 95% CI [0.5 to 1.79], P = 0.87). Local anesthesia demonstrated superiority with a lower 'complications rate' than general anesthesia, as the latter had almost 2.4 times higher odds of experiencing complications (OR = 2.4, 95% CI [1.81 to 3.17], P < 0.00001). Additionally, local anesthesia was associated with a shorter 'length of hospital stay' (SMD = 1.19, 95% CI [1.06 to 1.32], P < 0.00001) and a reduced 'duration of surgery' (SMD = 0.94, 95% CI [0.67 to 1.2], P < 0.00001).

CONCLUSION

Surgery for chronic subdural hematoma under local anesthesia results in fewer complications, a shorter length of hospital stay, and a shorter duration of the operation.

Initial loading of dexmedetomidine and continuous propofol sedation for prevention of delayed recovery: A randomized controlled trial

BACKGROUND

Sedation with continuous dexmedetomidine and bolus midazolam administration provides a lower incidence of unacceptable patient movement during procedures but requires a longer recovery time. The authors aimed to compare recovery time and unacceptable patient movement during sedation with initial loading of dexmedetomidine followed by continuous propofol infusion with those during sedation with continuous dexmedetomidine and bolus midazolam administration.

METHODS

In this prospective randomized controlled trial, 54 patients undergoing dental surgery and requiring intravenous sedation were assigned to either the dexmedetomidine and propofol group (n = 27, dexmedetomidine administered at 6 μg/kg/h for 5 minutes, followed by continuous propofol infusion using a target-controlled infusion) or the dexmedetomidine and midazolam group (n = 27, dexmedetomidine administered at 0.2-0.7 μg/kg/h continuously after the same initial loading dose with bolus midazolam). A bispectral index of 70 through 80 was maintained during the procedure. Patient movement that interfered with the procedure and time from the end of sedation to achieving a negative Romberg sign were assessed.

RESULTS

Times from the end of sedation to achieving a negative Romberg sign in the dexmedetomidine and propofol group (median, 14 minutes [interquartile range, 12-15 minutes]) were significantly shorter (P < .001) than in the dexmedetomidine and midazolam group (median, 22 minutes [interquartile range, 17.5-30.5 minutes]). The incidence of unacceptable patient movement was comparable between groups (n = 3 in the dexmedetomidine and propofol group, n = 4 in the dexmedetomidine and midazolam group; P = .999).

CONCLUSIONS

Sedation with a single loading dose of dexmedetomidine followed by continuous propofol infusion can prevent delayed recovery without increasing unacceptable patient movement.

PRACTICAL IMPLICATIONS

The combination of dexmedetomidine and propofol may provide high-quality sedation for ambulatory dental practice. This clinical trial was registered in the University Hospital Medical Information Network Clinical Trials Registry. The registration number is UMIN000039668.

Chronic Subdural Hematoma Drainage Under Local Anesthesia with Sedation versus General Anesthesia and Its Outcome

BACKGROUND

Burr hole drainage is the criterion standard treatment for chronic subdural hematoma (CSDH), a common neurosurgical condition. However, apart from the surgical technique, the method of anesthesia also has a significant impact on postoperative patient outcome. Currently, there are limited studies comparing the use of local anesthesia with sedation (LA sedation) versus general anesthesia (GA) in the drainage of CSDH. The objective of this study was to compare the morbidity and mortality outcomes of using LA sedation versus GA in CSDH burr hole drainage.

METHODS

This retrospective study presents a total of 257 operations in 243 patients from 2 hospitals. A total of 130 cases were operated under LA sedation in hospital 1 and 127 cases under GA in hospital 2. Patient demographics and presenting features were similar at baseline.

RESULTS

Values are shown as LA sedation versus GA. Postoperatively, most patients recovered well in both groups with Glasgow Outcome Scale scores of 4-5 (96.2% vs. 88.2%, respectively). The postoperative morbidity was significantly increased by an odds ratio of 5.44 in the GA group compared with the LA sedation group (P = 0.005). The mortality was also significantly higher in the GA group (n = 5, 3.9%) than the LA sedation group (n = 0, 0.0%; P = 0.028). The CSDH recurrence rate was 4.6% in the LA sedation group versus 6.3% in the GA group. No intraoperative conversion from LA sedation to GA was reported.

CONCLUSIONS

This study demonstrates that CSDH drainage under LA sedation is safe and efficacious, with a significantly lower risk of postoperative mortality and morbidity when compared with GA.

Non-Coding RNAs as Regulators and Markers for Targeting of Breast Cancer and Cancer Stem Cells

Breast cancer is regarded as a heterogeneous and complicated disease that remains the prime focus in the domain of public health concern. Next-generation sequencing technologies provided a new perspective dimension to non-coding RNAs, which were initially considered to be transcriptional noise or a product generated from erroneous transcription. Even though understanding of biological and molecular functions of noncoding RNA remains enigmatic, researchers have established the pivotal role of these RNAs in governing a plethora of biological phenomena that includes cancer-associated cellular processes such as proliferation, invasion, migration, apoptosis, and stemness. In addition to this, the transmission of microRNAs and long non-coding RNAs was identified as a source of communication to breast cancer cells either locally or systemically. The present review provides in-depth information with an aim at discovering the fundamental potential of non-coding RNAs, by providing knowledge of biogenesis and functional roles of micro RNA and long non-coding RNAs in breast cancer and breast cancer stem cells, as either oncogenic drivers or tumor suppressors. Furthermore, non-coding RNAs and their potential role as diagnostic and therapeutic moieties have also been summarized.

Pharmacological interventions for the prevention of acute postoperative pain in adults following brain surgery

BACKGROUND

Pain following brain surgery can compromise recovery. Several pharmacological interventions have been used to prevent pain after craniotomy; however, there is currently a lack of evidence regarding which interventions are most effective.

OBJECTIVES

The objectives are to assess the effectiveness of pharmacological interventions for prevention of acute postoperative pain in adults undergoing brain surgery; compare them in terms of additional analgesic requirements, incidence of chronic headache, sedative effects, length of hospital stay and adverse events; and determine whether these characteristics are different for certain subgroups.

SEARCH METHODS

We searched MEDLINE, Embase, CINAHL, CENTRAL, Web of Science and two trial registries together with reference checking and citation searching on 28th of November 2018.

SELECTION CRITERIA

We included blinded and non-blinded, randomized controlled trials evaluating pharmacological interventions for the prevention of acute postoperative pain in adults undergoing neurosurgery, which had at least one validated pain score outcome measure.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. We calculated mean differences for the primary outcome of pain intensity; any pain scores reported on a 0 to 100 scale were converted to a 0 to 10 scale.

MAIN RESULTS

We included 42 completed studies (3548 participants) and identified one ongoing study. Nonsteroidal anti-inflammatories (NSAIDs) Nonsteroidal anti-inflammatories (NSAIDs) reduce pain up to 24 hours (0 to 6 hours, MD -1.16, 95% CI -1.57 to -0.76; 12 hours, MD -0.62, 95% CI -1.11 to -0.14; 24 hours, MD -0.66, 95% CI -1.18 to -0.13; 6 studies, 742 participants; all high-quality evidence). Results for other outcomes were imprecise (additional analgesic requirements: MD 1.29 mg, 95% CI -5.0 to 2.46, 4 studies, 265 participants; nausea and vomiting RR 1.34, 95% CI 0.30 to 5.94, 2 studies, 345 participants; both low-quality evidence). Dexmedetomidine reduces pain up to 12 hours (0 to 6 hours, MD -0.89, 95% CI -1.27 to -0.51, moderate-quality evidence; 12 hours, MD -0.81, 95% CI -1.21 to -0.42, low-quality evidence). It did not show efficacy at 24 hours (MD -0.08, 95% CI -0.32 to 0.16; 2 studies, 128 participants; low-quality evidence). Dexmedetomidine may decrease additional analgesic requirements (MD -21.36 mg, 95% CI -34.63 to -8.1 mg, 2 studies, 128 participants, low-quality evidence). Results for other outcomes were imprecise (nausea and vomiting RR -0.43, 95% CI 0.06 to 3.08, 3 studies, 261 participants; hypotension RR 0.5, 95% CI 0.05 to 5.28, 3 studies, 184 participants; both low-quality evidence). Scalp blocks may reduce pain up to 48 hours (0 to 6 hours, MD -0.98, 95% CI -1.66 to -0.3, 10 studies, 414 participants; 12 hours, MD -0.95, 95% CI -1.53 to -0.37, 8 studies, 294 participants; 24 hours, MD -0.78, 95% CI -1.52 to -0.05, 9 studies, 433 participants, all low-quality evidence; 48 hours, MD -1.34, 95% CI -2.57 to -0.11, 4 studies, 135 participants, very low-quality evidence. When studies with high risk of bias were excluded, significance remained at 12 hours only. Scalp blocks may decrease additional analgesia requirements (SMD -1.11, 95% CI -1.97 to -0.25, 7 studies, 314 participants). Results for other outcomes were imprecise (nausea and vomiting RR 0.66, 95% CI 0.33 to 1.32, 4 studies, 165 participants, very low-quality evidence). Scalp Infiltration may reduce pain postoperatively but efficacy was inconsistent, with a significant effect at 12 and 48 hours only (12 hours, MD -0.71, 95% CI -1.34 to -0.08, 7 studies, 309 participants, low-quality evidence; 48 hours, MD - 1.09, 95% CI -2.13 to - 0.06, 3 studies, 128 participants, moderate-quality evidence). No benefit was observed at other times (0 to 6 hours, MD -0.64, 95% CI -1.28 to -0.00, 9 studies, 475 participants, moderate-quality evidence; 24 hours, MD -0.39, 95% CI -1.06 to 0.27,6 studies, 260 participants, low-quality evidence. Scalp infiltration may reduce additional analgesia requirements MD -9.56 mg, 95% CI -15.64 to -3.49, 6 studies, 345 participants, very low-quality evidence). When studies with high risk of bias were excluded, scalp infiltration lost the pain benefit at 12 hours and effects on additional analgesia requirements, but retained the pain-reducing benefit at 48 hours (MD -0.56, 95% CI -1.20 to -0.32, 2 studies, 100 participants, very low-quality evidence). Results for other outcomes were imprecise (nausea and vomiting, RR 0.74, 95% CI 0.48 to 1.41, 4 studies, 318 participants, low-quality evidence). Pregabalin or gabapentin may reduce pain up to 6 hours (2 studies, 202 participants), MD -1.15,95% CI -1.66 to -0.6, 2 studies, 202 participants, low-quality evidence). One study examined analgesic efficacy at 12 hours showing significant benefit. No analgesia efficacy was shown at later times (24 hours, MD -0.29, 95% CI -0.78 to -0.19; 48 hours, MD - 0.06, 95% CI -0.86 to 0.77, 2 studies, 202 participants, low-quality evidence). Additional analgesia requirements were not significantly less (MD -0.37 (95% CI -1.10 to 0.35, 3 studies, 234 participants, low-quality evidence). Risk of nausea and vomiting was significantly reduced (RR 0.51, 95% CI 0.29 to 0.89, 3 studies, 273 participants, low-quality evidence). Results for other outcomes were imprecise (additional analgesia requirements: MD -0.37, 95% CI -1.10 to 0.35, 3 studies, 234 participants, low-quality evidence). Acetaminophen did not show analgesic benefit (0 to 6 hours, MD -0.35, 95% CI -1.00 to 0.30; 12 hours, MD -0.51, 95% CI -1.04 to 0.03, 3 studies, 332 participants, moderate-quality evidence; 24 hours, MD -0.34, 95% CI -1.20 to 0.52, 4 studies, 439 participants, high-quality evidence). Results for other outcomes remained imprecise (additional analgesia requirements, MD 0.07, 95% CI -0.86 to 0.99, 4 studies, 459 participants, high-quality evidence; length of hospitalizations, MD -3.71, 95% CI -14.12 to 6.7, 2 studies, 335 participants, moderate-quality evidence).

AUTHORS' CONCLUSIONS

There is high-quality evidence that NSAIDs reduce pain up to 24 hours postoperatively. The evidence for reductions in pain with dexmedetomidine, pregabalin or gabapentin, scalp blocks, and scalp infiltration is less certain and of very low to moderate quality. There is low-quality evidence that scalp blocks and dexmedetomidine may reduce additional analgesics requirements. There is low-quality evidence that gabapentin or pregabalin may decrease nausea and vomiting, with the caveat that the total number of events for this comparison was low.

Dexmedetomidine and Midazolam Sedation Reduces Unexpected Patient Movement During Dental Surgery Compared With Propofol and Midazolam Sedation

PURPOSE

Owing to its unpredictability, unexpected patient movement is one of the most important problems during surgery while under monitored anesthesia care with sedation. The purpose of this study was to compare unexpected patient movement during dental surgery while under dexmedetomidine and propofol sedation.

MATERIALS AND METHODS

The authors designed and implemented a prospective randomized controlled trial. Patients undergoing dental surgery requiring intravenous sedation were randomly assigned to dexmedetomidine and midazolam (dexmedetomidine group) or propofol and midazolam (propofol group) sedation. In each group, midazolam 0.02 mg/kg was administered in conjunction with continuous administration of dexmedetomidine or propofol to maintain a bispectral index value of 70 to 80. Unexpected patient movement interfering with the procedure was defined as acceptable, defined as no body movement or only 1 controllable movement, or unacceptable, defined as at least 2 controllable movements or any uncontrollable movement. The primary outcome was unexpected patient movement, and the secondary outcome was defined as snoring and cough reflex. Other variables included demographic and procedural characteristics. Continuous or ordinal variables were analyzed using the Student t test or Mann-Whitney test. Dichotomous or categorical variables were analyzed using the χ² test or Fisher exact test. A P value less than.05 was considered statistically significant.

RESULTS

Eighty-eight patients were enrolled in the study (dexmedetomidine group, n = 44; propofol group, n = 44). There were no relevant differences between groups for demographics and baseline variables. Intraoperative unacceptable patient movement occurred more commonly in the propofol group (n = 13; 30%) than in the dexmedetomidine group (n = 4; 9%; P = .015). Intraoperative snoring occurred more commonly in the dexmedetomidine than in the propofol group (P = .045). Incidence and number of cough reflexes were comparable between groups.

CONCLUSION

Dexmedetomidine and midazolam sedation decreases unexpected patient movement during dental surgery compared with propofol and midazolam sedation.

Anesthesia in the Elderly Patient Undergoing Otolaryngology Head and Neck Surgery

Geriatric patients undergoing surgery have a whole set of specific physiologic changes, perioperative needs, and postoperative complications. This review presents an overview of the basic concepts and the evolving challenges pertaining to the care of geriatric patients undergoing otolaryngologic procedures from the perspective of the anesthesiologist.

Use of Dexmedetomidine Along With Local Infiltration Versus General Anesthesia for Burr Hole and Evacuation of Chronic Subdural Hematoma (CSDH)

BACKGROUND

In neurosurgery, chronic subdural hematoma (CSDH) is a very common clinical entity. Both general anesthesia (GA) and local anesthesia with or without sedation are used for the surgical treatment of CSDH. Sedation with dexmedetomidine has been safely used for various diagnostic and therapeutic procedures. However, its effectiveness against GA has not been evaluated for surgical treatment of CSDH. We tried to compare dexmedetomidine sedation technique with the GA technique for surgical treatment of CSDH.

MATERIALS AND METHODS

In this prospective-randomized study, 76 patients undergoing surgery for CSDH were divided into 2 groups using computer-generated randomized tables; Dex group ([n=38]; received IV bolus of dexmedetomidine 1 mcg/kg over 10 min followed by maintenance infusion 0.5 mcg/kg/h) and GA group ([n=38; of which 4 patients were dropped out]; received endotracheal intubation with balanced anesthesia).

RESULTS

Both anesthesia techniques (Dex group; n=35/38 [92.1%] and GA group; n=34/34 [100%]) were successfully used for surgical treatment of CSDH. Significantly less time for anesthesia onset (14.2±4.2 vs. 20.5±3.4 min, P=0.001), total duration of surgery (77.1±23.9 vs. 102.7± 24.8 min, P=0.001), and recovery from anesthesia (7.4±5.9 vs. 13.2±6.5 min, P=0.004) was observed in the Dex group compared with GA group. Perioperative hemodynamic fluctuations were more common in the GA group as against the Dex group. Postoperative complications (n=2 vs. 9, P=0.021) and length of hospital stay (1.05±0.23 vs. 1.79±2.1 d, P=0.007) were significantly less in the Dex group as against the GA group.

CONCLUSIONS

Dexmedetomidine sedation with local anesthesia is a safe and effective technique for burr hole and evacuation of CSDH. It is associated with significantly shorter operative time, lesser hemodynamic fluctuations, postoperative complications, and length of hospital stay, thus it is a better alternative to GA.

Comparative Evaluation of Dexmedetomidine and Propofol Along With Scalp Block on Haemodynamic and Postoperative Recovery for Chronic Subdural Haematoma Evacuation Under Monitored Anaesthesia Care

OBJECTIVE

Chronic subdural haematoma (CSDH) is a common neurosurgical problem, and treatment includes evacuation of the haematoma by burr hole drainage. Commonly, these procedures are performed under local anaesthesia, general anaesthesia or, recently, with monitored anaesthesia care (MAC). We compared dexmedetomidine- and propofol-based sedation along with scalp nerve block for burr hole evacuation of CSDH.

METHODS

In this prospective randomised study, 62 patients were divided into the following two groups of 31 patients each: Group D and Group P. Group D received dexmedetomidine 1 μg kg-1 over 10 minutes as a loading dose, followed by 0.2-0.7 μg kg-1 hr-1. Group P received propofol 1 mg kg-1 over 10 minutes as a loading dose, followed by 1-3 mg kg-1 hr-1. The heart rate (HR) and blood pressure were measured at different intervals. The recovery parameter and satisfaction score were also recorded.

RESULTS

There were no significant differences noted in the demographic profile. A significant decrease in HR compared to preoperative value was seen in Group D compared to Group P. Blood pressure values were statistically significantly lower in both study groups, compared to preoperative values during the whole procedure and after surgery (p<0.05). Time to achieve modified Aldrete score of 9-10 was not significantly different between the groups (p=0.354). Surgeon satisfaction was significantly better in Group D compared to Group P (p<0.05), but patient satisfaction was similar between the groups (p=0.364).

CONCLUSION

Dexmedetomidine-based sedation compared to propofol, along with scalp block for MAC in patients undergoing burr hole evacuation of CSDH is associated with haemodynamic stability and greater surgeon satisfaction.

The Safety and Efficacy of Dexmedetomidine vs. Sufentanil in Monitored Anesthesia Care during Burr-Hole Surgery for Chronic Subdural Hematoma: A Retrospective Clinical Trial

Background: Chronic subdural hematoma (CSDH) is a very common clinical emergency encountered in neurosurgery. While both general anesthesia (GA) and monitored anesthesia care (MAC) can be used during CSDH surgery, MAC is the preferred choice among surgeons. Further, while dexmedetomidine (DEX) is reportedly a safe and effective agent for many diagnostic and therapeutic procedures, there have been no trials to evaluate the safety and efficacy of DEX vs. sufentanil in CSDH surgery.

Objective: To evaluate the safety and efficacy of DEX vs. sufentanil in MAC during burr-hole surgery for CSDH.

Methods: In all, 215 fifteen patients underwent burr-hole surgery for CSDH with MAC and were divided into three groups: Group D1 (n = 67, DEX infusion at 0.5 μg·kg⁻¹ for 10 min), Group D2 (n = 75, DEX infusion at 1 μg·kg⁻¹ for 10 min), and Group S (n = 73, sufentanil infusion 0.3 μg·kg⁻¹ for 10 min). Ramsay sedation scale (RSS) of all three groups was maintained at 3. Anesthesia onset time, total number of intraoperative patient movements, hemodynamics, total cumulative dose of DEX, time to first dose and amount of rescue midazolam or fentanyl, percentage of patients converted to alternative sedative or anesthetic therapy, postoperative recovery time, adverse events, and patient and surgeon satisfaction scores were recorded.

Results: The anesthesia onset time was significantly less in group D2 (17.36 ± 4.23 vs. 13.42 ± 2.12 vs. 15.98 ± 4.58 min, respectively, for D1, D2, S; P < 0.001). More patients in groups D1 and S required rescue midazolam to achieve RSS = 3 (74.63 vs. 42.67 vs. 71.23%, respectively, for D1, D2, S; P < 0.001). However, the total dose of rescue midazolam was significantly higher in group D1 (2.8 ± 0.3 vs. 1.9 ± 0.3 vs. 2.0 ± 0.4 mg, respectively, for D1, D2, S; P < 0.001). The time to first dose of rescue midazolam was significantly longer in group D2 (17.32 ± 4.47 vs. 23.56 ± 5.36 vs. 16.55 ± 4.91 min, respectively, for D1, D2, S; P < 0.001). Significantly fewer patients in groups S and D2 required rescue fentanyl to relieve pain (62.69 vs. 21.33 vs. 27.40%, respectively, for D1, D2, S; P < 0.001). Additionally, total dose of rescue fentanyl in group D1 group was significantly higher (212.5 ± 43.6 vs. 107.2 ± 35.9 vs. 98.6 ± 32.2 μg, respectively, for D1, D2, S; P < 0.001). Total number of patient movements during the burr-hole surgery was higher in groups D1 and S (47.76 vs. 20.00 vs. 47.95%, respectively, for D1, D2, S; P < 0.001). Four patients in D1 and five in S converted to propofol. The time to recovery for discharge from the PACU was significantly shorter in group D2 (16.24 ± 4.15 vs. 12.48 ± 3.29 vs. 15.91 ± 3.66 min, respectively, for D1, D2, S; P < 0.001). Results from the patient and surgeon satisfaction scores showed significant differences favoring group D2 (P < 0.05). More patients in groups D1 and S showed higher levels of the overall incidence of tachycardia and hypertension, and required higher doses of urapidil and esmolol (P < 0.05). Six patients experienced respiratory depression in group S.

Conclusion: Compared with sufentanil, DEX infusion at 1 μg·kg⁻¹ was associated with fewer intraoperative patient movements, fewer rescue interventions, faster postoperative recovery, and better patient and surgeon satisfaction scores and could be safely and effectively used for MAC during burr-hole surgery for CSDH.