Dexmedetomidine versus fentanyl as adjuvant to propofol: comparative study in children undergoing extracorporeal shock wave lithotripsy:

Comparison of dexmedetomidine versus fentanyl-based total intravenous anesthesia technique on the requirement of propofol, brain relaxation, intracranial pressure, neuronal injury, and hemodynamic parameters in patients with acute traumatic subdural hematoma undergoing emergency craniotomy: A randomized controlled trial

BACKGROUND

Propofol is one of the most used intravenous anesthetic agents in traumatic brain injury (TBI) patients undergoing emergency neurosurgical procedures. Despite being efficacious, its administration is associated with dose-related adverse effects. The use of adjuvants along with propofol aids in limiting its consumption, thereby mitigating the side effects related to propofol usage. This study aims to compare the safety and efficacy of dexmedetomidine-propofol versus fentanyl-propofol-based total intravenous anesthesia (TIVA) in adult TBI patients.

METHODS

A hundred patients posted for emergency evacuation of acute subdural hematoma were enrolled, and they were randomized into two groups of 50 each. Propofol-based TIVA with a Schneider target-controlled infusion model was used for induction and maintenance. Patients in Group F received fentanyl, and those in Group D received dexmedetomidine infusions as adjuvants. Advanced hemodynamic parameters were monitored. Intracranial pressure (ICP) and brain relaxation were measured after dural opening. The mean propofol consumption, number of additional fentanyl boluses, and blood samples for S100b (a biomarker of neuronal injury) were also collected.

RESULTS

The mean propofol consumption in Group D (88.7 ± 31.8 μg/kg/min) was lower when compared to Group F (107.9 ± 34.6 μg/kg/min), (P = 0.005). The mean intraoperative fentanyl requirement and postoperative S100b were significantly reduced in Group D. Subdural ICPs and brain relaxation scores were comparable. Hemodynamic parameters were well maintained in both groups.

CONCLUSION

In TBI, dexmedetomidine as an adjunct to propofol-based TIVA results in a greater reduction in total propofol consumption and intraoperative opioid requirements while maintaining hemodynamic stability when compared to fentanyl.

Comparative evaluation of dexmedetomidine and fentanyl in total intravenous anesthesia for laparoscopic cholecystectomy: A randomised controlled study

BACKGROUND AND AIMS

Laparoscopic cholecystectomy is one of the commonly performed ambulatory surgeries. The selection of anesthetic agents for ambulatory surgeries should be done bearing in mind the need for early discharge. Opioids form an integral component of total intravenous anesthesia (TIVA) but their associated side effects may result in an increased hospital stay. Hence, we planned a study to compare the opioid (fentanyl) and non-opioid (dexmedetomidine) based technique of TIVA for laparoscopic surgery.

MATERIAL AND METHODS

Ninety ASA I and II patients between 18-60 years of either sex posted for laparoscopic cholecystectomy were randomly allocated into two groups namely group D (Dexmedetomidine) and group F (Fentanyl). Patients received propofol infusion along with group specific drug infusion, after which an appropriate size proseal laryngeal mask airway was placed. The patients were assessed for discharge time from post-anesthesia care unit (PACU), on table recovery time, time to first rescue analgesia, hemodynamic parameters, incidence of postoperative nausea and vomiting (PONV) and any other complication.

RESULTS

Demographic profile of both the groups was comparable. Group D had longer on table recovery time (13.00 ± 2.34 min vs 6.29 ± 2.46 min; P < 0.001) and time to discharge from PACU (6.80 ± 3.96 min vs 2.36 ± 1.67 min; P < 0.001) compared to group F. Group F had better hemodynamic stability compared to group D. In group D, 77% patients required rescue analgesia in first one hour post surgery, unlike 22% in group F. No patient in group D had PONV.

CONCLUSION

Opioid based technique (Fentanyl) of TIVA is superior over non-opioid based (dexmedetomidine) technique with faster recovery, early discharge, decreased postoperative pain scores and better hemodynamic stability. PONV is observed with opioids which can be treated successfully with antiemetics.

The effects of different doses of dexmedetomidine on the requirements for propofol for loss of consciousness in patients monitored via the bispectral index: a double-blind, placebo-controlled trial

BACKGROUND

The α₂-adrenergic agonist dexmedetomidine (DEX) is a sedative and can be used as an adjunct to hypnotics. The study sought to evaluate the effects of different doses of DEX on the requirements for propofol for loss of consciousness (LOC) in patients monitored via the bispectral index (BIS).

METHODS

In this randomized, double-blind, three arm parallel group design and placebo-controlled trial, 73 patients aged between 18 and ~ 65 years with a BMI range of 18.0-24.5 kg·m^- 2 and an American Society of Anesthesiologists (ASA) grade I or II who were scheduled for general anesthesia at the General Hospital of Ningxia Medical University were included in this study. Anesthesiologists and patients were blinded to the syringe contents. All patients were randomly assigned in a 1:1:1 ratio to receive a 0.5 μg·kg^- 1 DEX infusion (0.5 μg·kg^- 1 DEX group; n = 24), a 1.0 μg·kg^- 1 DEX infusion (1.0 μg·kg^- 1 DEX group; n = 25) or a saline infusion (control group; n = 24) for 10 min. Propofol at a concentration of 20 mg·kg^- 1·h^- 1 was then infused at the end of the DEX or saline infusion. The propofol infusion was stopped when the patient being infused lost consciousness. The primary endpoint were propofol requirements for LOC and BIS value at LOC.

RESULTS

The data from 73 patients were analyzed. The propofol requirements for LOC was reduced in the DEX groups compared with the control group (1.12 ± 0.33 mg·kg^- 1 for the 0.5 μg·kg^- 1 DEX group vs. 1.79 ± 0.39 mg·kg^- 1 for the control group; difference, 0.68 mg·kg^- 1 [95% CI, 0.49 to 0.87]; P = 0.0001) (0.77 ± 0.27 mg·kg^- 1 for the 1.0 μg·kg^- 1 DEX group vs. 1.79 ± 0.39 mg·kg^- 1 for the control group; difference, 1.02 mg·kg^- 1 [95% CI, 0.84 to 1.21]; P = 0.0001). The propofol requirements for LOC was lower in the 1.0 μg·kg^- 1 DEX group than the 0.5 μg·kg^- 1 DEX group (0.77 ± 0.27 mg·kg^- 1 vs. 1.12 ± 0.33 mg·kg^- 1, respectively; difference, 0.34 mg·kg^- 1 [95% CI, 0.16 to 0.54]; P = 0.003). At the time of LOC, the BIS value was higher in the DEX groups than in the control group (67.5 ± 3.5 for group 0.5 μg·kg^- 1 DEX vs. 60.5 ± 3.8 for the control group; difference, 7.04 [95% CI, 4.85 to 9.23]; P = 0.0001) (68.4 ± 4.1 for group 1.0 μg·kg^- 1 DEX vs. 60.5 ± 3.8 for the control group; difference, 7.58 [95% CI, 5.41 to 9.75]; P = 0.0001).

CONCLUSION

The study showed that DEX (both 0.5 and 1.0 μg·kg^- 1 DEX) reduced the propofol requirements for LOC. DEX pre-administration increased the BIS value for LOC induced by propofol.

CLINICAL TRIAL REGISTRATION

The study was registered at ClinicalTrials.gov (trial ID: NCT02783846 on May 26, 2016).

Comparison of opioid-based and opioid-free TIVA for laparoscopic urological procedures in obese patients

BACKGROUND AND AIMS

Perioperative pain management in an obese patient is challenging. The incidence of respiratory depression is higher in obese patients and is exaggerated with opioids. We evaluated the efficacy of opioid-free anesthesia with propofol, dexmedetomidine, lignocaine, and ketamine in obese patients undergoing urological laparoscopic procedures with reference to postoperative analgesic consumption, hemodynamic stability, and respiratory depression.

MATERIAL AND METHODS

In this prospective, randomized, blinded controlled study, patients were randomized to receive either opioid-based (opioid group) or opioid-free (opioid-free group) anesthesia. Postoperative pain was assessed using visual analog score (VAS) 30 min after recovery, hourly for 2 h and every 4 hourly for 24 h. The primary outcomes studied were respiratory depression, mean analgesic consumption and time to rescue analgesia. Intraoperative hemodynamic parameters, mean SpO2, respiratory rate and postanesthesia care unit (PACU) discharge time were secondary objectives.

RESULTS

There were no differences in the demographic and intraoperative hemodynamic profile between the groups. Incidence of respiratory depression, defined as fall in saturation, was more in opioid-based group. Postoperative analgesic requirement (225 ± 48.4 vs 63.6 ± 68.5 mg of tramadol with P value of <0.001) and PACU discharge times (18.1 ± 5.4 vs 11.7 ± 4.3 hours with P value of <0.001) were significantly less in the opioid-free group.

CONCLUSIONS

Opioid-free anesthesia is a safer and better form of anesthesia in obese patients undergoing laparoscopic urological procedures as there is a lower requirement of postoperative analgesia.

Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018

Supplemental Digital Content is available in the text.

Dexmedetomidine versus Magnesium Sulfate in Anesthesia for Cochlear Implantation Surgery in Pediatric Patients

Context:

Cochlear implantation surgery represents a great advance in ENT surgeries. Special anesthetic managements were required to provide bloodless surgical field and monitoring of the facial nerve.

Aims:

We aimed to compare both dexmedetomidine and magnesium sulfate as regards their efficacy in inducing deliberate hypotension and providing better quality of the surgical field during cochlear implantation in pediatrics.

Settings and Design:

Prospective, randomized double-blinded study.

Subjects and Methods:

Forty-six pediatric patients aging 1.5–2.5 years of either sex with American Society of Anesthesiologists physical status classes I and II were randomized into dexmedetomidine (D) group (n = 23) and magnesium sulfate (M) group (n = 23). In the D group, after induction of anesthesia but before the surgery, a bolus dose of 0.4 μg/kg slowly infused over 10 min, then continuous infusion by a rate of 0.4 μg/kg/h until the end of surgery. In M group, after induction of anesthesia but before the surgery, magnesium sulfate 10% (50 mg/kg) was given slowly, then continuous infusion by a rate of 10 mg/kg/h during the whole surgery. Intraoperative hemodynamics, quality of surgical field, fentanyl consumption, blood loss, operative time, FLACC pain scores, and adverse effects were compared in both groups.

Statistical Analysis Used:

Data were presented as mean ± standard deviation, ranges, numbers, and percentages as appropriate. Comparison of demographic data and time of surgery was done by Student's t-test. Two-way analysis of variance with correction for repeated measurements was used for heart rate and blood pressure comparison. Mann–Whitney U-test was used for nonparametric measurements.

Results:

Surgical field score and blood loss were better in D group than M group. Fentanyl consumption was less in D group than M group. Heart rate and mean atrial blood pressure were lower in D group except in the initial times than M group.

Conclusions:

In our study, both drugs were effective in achieving hypotensive anesthesia in pediatrics; however, dexmedetomidine proved to have superior effect on the surgical field and blood loss compared to magnesium sulfate with no intra- and post-operative complications for cochlear implantation surgery.

Procedural sedation and analgesia for pediatric shock wave lithotripsy: a 10 year experience of single institution

The aim of this study was to evaluate anesthesia practice for pediatric extracorporeal shock wave lithotripsy (ESWL) according to the age groups and discuss the anesthetic management of these patients. Pediatric patients treated with ESWL because of urolithiasis under anesthesia in our department between December 2007 and January 2017 were evaluated retrospectively. A total of 251 patients were divided into two groups as Group PS: preschool children (<6 years) and Group S: school children (≥6 years). Groups were compared according to ketamine and midazolam doses, extra anesthetic agent requirement, duration of procedure, procedural and postprocedural complications due to anesthesia, as well as mean number of sessions and calculus diameter. A total of 408 sessions of ESWL were applied to 251 children included in the study. Overall, mean age of the patients was 4.5 ± 3.2 years (7 months-14 years). In school children (Group S), mean ketamine and midazolam doses were significantly higher than the preschool group (p < 0.01 and p = 0.04, respectively). There was no statistically significant difference in additional anesthetic agent requirement (p = 0.35) as well as mean number of SWL sessions (p = 0.23), duration of anesthesia (p = 0.93), stone size (p = 0.20), and stone laterality (p = 0.71) in both preschool and school children. No severe complications were observed in both groups. In pediatric ESWL patients, ketamine-midazolam combination is an effective and safety choice for outpatient anesthesia. Appropriate dose adjustment in a monitorized and well-equipped setting is essential.

General anesthesia with a native airway for patients with mucopolysaccharidosis type III

BACKGROUND

Mucopolysaccharidosis type III is a progressive disease with worsening airway, pulmonary, and cardiac involvement that may complicate anesthetic care.

AIM

To prospectively evaluate the incidence of airway issues and complications during magnetic resonance imaging (MRI) and lumbar puncture (LP) during general anesthesia with a native airway for patients with mucopolysaccharidosis type III.

METHOD

The study was a part of the natural history study. Anesthesia was induced with sevoflurane, which was discontinued after intravenous access was obtained. General anesthesia with a native airway was provided by dexmedetomidine and propofol. Dexmedetomidine (0.5 μg·kg^-1 ) was administered over 5 min followed by a continuous infusion at 0.5 μg·kg^-1 ·h^-1 . A continuous infusion of propofol was started at 150 μg·kg^-1 ·min^-1 . A bolus dose of propofol (1 mg·kg^-1 ) was administered and the propofol infusion was increased as needed. Airway management and vital signs were recorded for the entire procedure until discharge.

RESULTS

Twenty-five patients (6.9 ± 3.1 years) received total of 43 MRI and LP procedures in the cohort. No patient failed sedation. Although mask induction with sevoflurane was not clinically problematic, upper airway obstruction was noted during 14 procedures (33%). This required the application of continuous positive airway pressure, temporary oral airway placement, jaw thrust, or shoulder roll. Airway dynamics improved once the anesthesia was transitioned to intravenous anesthetic agents. Although a small shoulder roll was needed to improve airway patency for 11 cases (26%), a large shoulder roll tended to make the upper airway obstruction worse. Oxygen desaturation (≤90%) was noted during MRI in three cases (7%).

CONCLUSION

A combination of dexmedetomidine and propofol provided effective general anesthesia with a native airway during the procedures. Although upper airway obstruction was noted, it resolved with simple airway maneuvers without further airway intervention.

Efficacy of intranasal dexmedetomidine versus oral midazolam for paediatric premedication

Background and Aims:

Premedication is an integral component of paediatric anaesthesia which, when optimal, allows comfortable separation of the child from the parent for induction and conduct of anaesthesia. Midazolam has been accepted as a safe and effective oral premedicant. Dexmedetomidine is a selective alpha-2 agonist with sedative and analgesic effects, which is effective through the transmucosal route. We compared the efficacy and safety of standard premedication with oral midazolam versus intranasal dexmedetomidine as premedication in children undergoing elective lower abdominal surgery.

Methods:

This was a prospective randomised double-blinded trial comparing the effects of premedication with 0.5 mg/kg oral midazolam versus 1 μg/kg intranasal dexmedetomidine in children between 2 and 12 years undergoing abdominal surgery. Sedation scores at separation and induction were the primary outcome measures. Behaviour scores and haemodynamic changes were secondary outcomes. Student's t-test and Chi-square were used for analysis of the variables.

Results:

Sedation scores were superior in Group B (dexmedetomidine) than Group A (midazolam) at separation and induction (P < 0.001). The behaviour scores at separation, induction and wake up scores at extubation were similar between the two groups. The heart rate and blood pressure showed significant differences at 15, 30 and 45 min in Group B but did not require pharmacological intervention for correction.

Conclusion:

Intranasal dexmedetomidine at a dose of 1 μg/kg produced superior sedation scores at separation and induction but normal behavioural scores in comparison to oral midazolam in paediatric patients.

Is unilateral transversus abdominis plane block an analgesic alternative for ureteric shock wave lithotripsy?

Background:

Various sedative and analgesic techniques have been used during shock wave lithotripsy (SWL).

Aim:

This study aimed at evaluating the efficacy of ultrasound-guided unilateral transversus abdominis plane (TAP) block as an analgesic technique alternative during ureteric SWL.

Settings and Design:

Prospective randomized comparative study.

Materials and Methods:

Fifty patients scheduled for ureteric SWL were randomly allocated into two equal groups: Group (F) received 1.5 mcg/kg fentanyl intravenous and group (T) received unilateral TAP block with injection of 25 ml of bupivacaine 0.25% (62.5 mg).

Statistical Analysis:

Statistical analysis was performed using SPSS program version 19 and EP16 program.

Results:

The visual analog scale was significantly less in group (T) than in group (F) both intra-operatively (at 10, 20, 30, and 40 min) and postoperatively (at 10 min intervals in the postanesthesia care unit [PACU]) (P < 0.001). Rescue analgesia with pethidine during the procedure and in the PACU was less (P < 0.001) in the group (T) than group (F) with a median of 20 mg versus 55 mg, respectively. The higher sedation scores observed in group (F) at 15, 25, and 35 min during the procedure, and at 20 min during the PACU time were statistically highly significant (P < 0.001), but only significant at 10 min (P = 0.03) and 30 min (P = 0.007) during the PACU time. There was also highly significant decrease (P < 0.001) in the time of PACU stay in group (T) (38.2 ± 6.6 min) compared with group (F) (89.2 ± 13.39 min). We recorded 6 patients in group (F) (24%) who have developed respiratory depression (respiratory rate < 10 breaths/min) compared to 0% in group (T) (P = 0.022). In addition, in group (F) nausea was noted in 8 patients (32%) and vomiting in 6 patients (24%), which was statistically significant when compared to group (T) (0%) (P = 0.01 and 0.022, respectively).

Conclusion:

Ultrasound-guided unilateral TAP block is an effective alternative analgesic technique during ureteric SWL.

Opioid-free total intravenous anesthesia with propofol, dexmedetomidine and lidocaine infusions for laparoscopic cholecystectomy: a prospective, randomized, double-blinded study

BACKGROUND AND OBJECTIVES

Intraoperative use of opioids may be associated with postoperative hyperalgesia and increased analgesic consumption. Side effects due to perioperative use of opioids, such as postoperative nausea and vomiting may delay discharge. We hypothesized that total intravenous anesthesia consisting of lidocaine and dexmedetomidine as an opioid substitute may be an alternative technique for laparoscopic cholecystectomy and would be associated with lower fentanyl requirements in the postoperative period and less incidence of postoperative nausea and vomiting.

METHODS

80 Anesthesiologists I-II adults were scheduled for elective laparoscopic cholecystectomy. Patients were randomly allocated into two groups to have either opioid-free anesthesia with dexmedetomidine, lidocaine, and propofol infusions (Group DL) or opioid-based anesthesia with remifentanil, and propofol infusions (Group RF). All patients received a standard multimodal analgesia regimen. A patient controlled analgesia device was set to deliver IV fentanyl for 6h after surgery. The primary outcome variable was postoperative fentanyl consumption.

RESULTS

Fentanyl consumption at postoperative 2nd hour was statistically significantly less in Group DL, compared with Group RF, which were 75 ± 59 μg and 120 ± 94 μg respectively, while it was comparable at postoperative 6th hour. During anesthesia, there were more hypotensive events in Group RF, while there were more hypertensive events in Group DL, which were both statistically significant. Despite higher recovery times, Group DL had significantly lower pain scores, rescue analgesic and ondansetron need.

CONCLUSION

Opioid-free anesthesia with dexmedetomidine, lidocaine and propofol infusions may be an alternative technique for laparoscopic cholecystectomy especially in patients with high risk for postoperative nausea and vomiting.