The Analgesic Effect of Ropivacaine Combined With Dexmedetomidine for Incision Infiltration After Laparoscopic Cholecystectomy

Efficacy of dexmedetomidine combined with ropivacaine on postoperative analgesia and delirium in elderly patients with total knee arthroplasty

This study aimed to investigate the impact of dexmedetomidine combined with ropivacaine on continuous femoral nerve block (CFNB) in postoperative analgesia and delirium in elderly patients with total knee arthroplasty (TKA). A total of 120 patients who undergone TKA were randomly assigned into group D + R (dexmedetomidine combined with ropivacaine) and group R (only ropivacaine), with 60 cases in each group. The pain scores at rest and exercise at 6 h, 12 h, 24 h, and 48 h postoperatively. The occurrence of delirium on Day 1, Day 2, and Day 3 postoperatively were measured, and the sleep quality was evaluated before surgery, the night of surgery, and 24 h postoperatively to observe the occurrence of postoperative complications. The Visual analogu scale (VAS) of group D + R at 12 h, 24 h, and 48 h postoperatively were lower than those of group R in both rest and exercise states. The incidence of postoperative delirium in group D + R was lower than that in group R on Day 1 and Day 2. Pittsburgh sleep quality index (PSQI) scores in group D + R were lower than those in group R. There was no significant difference in postoperative adverse reactions between the two groups. Dexmedetomidine combined with ropivacaine improves postoperative analgesia and sleep quality, and alleviates the occurrence of postoperative delirium in elderly patients with TKA.

Periarticular infiltration used in total joint replacements: an update and review article

Periarticular infiltration following total knee and hip arthroplasty has been demonstrated to be equivalent to peripheral nerve blocks for postoperative pain management. The ideal cocktail has not been established yet. We have conducted a literature search on PubMed and Embase. Our search criteria included randomized controlled trials (RCTs) and systematic reviews (SRs). We tried to only include the most recent studies to keep the information current. The included research focused at Dexmedetomidine, Liposomal Bupivacaine, Ropivacaine, Epinephrine, Ketorolac, Morphine, Ketamine and Glucocorticosteroids. Each medication's mode of action, duration, ideal dosage, contraindications, side effects and effectiveness have been summarized in the review article. This article will help the clinician to make an informed evidence-based decision about which medications to include in their ideal cocktail.

Opioid-Free Anesthesia for Pain Relief After Laparoscopic Cholecystectomy: A Prospective Randomized Controlled Trial

Purpose

To compare the efficacies of opioid-free anesthesia (OFA) and opioid-based anesthesia (OBA) in laparoscopic cholecystectomy (LC).

Patients and Methods

A total of 150 patients who underwent 3-port LC procedures were randomly divided into an OFA group with esketamine, dexmedetomidine and lidocaine intravenous combined with local anesthetic incision infiltration or an OBA group with remifentanil combined with local anesthetic incision infiltration. The primary outcome was the consumption of rescue analgesics within 24 hrs after surgery. Secondary outcomes included time to LMA removal, time to orientation recovery, time to unassisted walking, sleep quality on the night of surgery, time to first flatus, hemodynamics during induction of general anesthesia, postoperative pain level on the visual analog scale (VAS), incidence of postoperative nausea and vomiting (PONV) and global satisfaction score (GSS) within 24 hrs after surgery.

Results

Both the consumption of rescue analgesics and the time to first flatus in the OFA group were significantly lower than those in the OBA group (P < 0.001 and P = 0.029, respectively). However, the time to LMA removal and the time to orientation recovery were significantly longer in the OFA group than in the OBA group (P < 0.001). In addition, the VAS scores at 2 hrs and 8 hrs after surgery and HR at laryngeal mask airway insertion in the OFA group were significantly lower than those in the OBA group (P = 0.002 and P = 0.001, and P =0.016, respectively).

Conclusion

OFA may be beneficial for patients undergoing LC in that it could decrease the dosage of postoperative analgesics and pain intensity and even shorten the time to first flatus after surgery.

Effect of a Local Anesthetic Injection Kit on Pain Relief and Postoperative Recovery After Transumbilical Single-Incision Laparoscopic Cholecystectomy

Purpose

This study was conducted to explore whether incisional infiltration using a local anesthetic injection kit could better relieve postoperative pain and enhance the quality of recovery compared with ultrasound-guided rectus sheath block (RSB) or conventional local anesthetic infiltration in patients undergoing transumbilical single-incision laparoscopic cholecystectomy (SILC).

Patients and Methods

A total of 60 patients undergoing SILC with American Society of Anesthesiology functional status scores of I-II were randomized into the rectus sheath block group (RSB group), conventional local wound infiltration group (LAI-I group) and incisional infiltration using a local anesthetic injection kit group (LAI-II group). The primary outcomes were the patient-controlled intravenous analgesia (PCIA) demand frequency within 48 hours after the operation and postoperative pain measured by a visual analog scale (VAS) at 2 h, 4 h, 8 h, 24 h, and 48 h after surgery. Secondary outcomes were the total procedure times, cumulative consumption of anesthetic drugs, duration of surgery, duration and awaking time of anesthesia, early recovery indicator and side effects.

Results

The PCIA demand frequency in LAI-II group was significantly lower compared with patients in the RSB and LAI-I group (both P < 0.001). Moreover, the total procedure times in LAI-I and LAI-II group was significantly shorter than that in the RSB group (P < 0.001, respectively), but it was comparable between LAI-I and LAI-II group (P = 0.471). Though lower at 2h and 4h postoperative in LAI-II group, pain scores at each time point had no statistical differences among three groups. There were no significant differences among three groups for other outcomes as well.

Conclusion

The effect of ultrasound-guided RSB and conventional local anesthetic infiltration in SILC patients were found to be similar in terms of relieving postoperative pain and promoting recovery. Incisional infiltration using a local anesthetic injection kit can significantly reduce the demand frequency of PCIA, which serves as a rescue analgesic.

Effect and Mechanism of Lidocaine Pretreatment Combined with Dexmedetomidine on Oxidative Stress in Patients with Intracranial Aneurysm Clipping

This study aimed to explore the effect and mechanism of lidocaine pretreatment combined with dexmedetomidine on oxidative stress in patients with intracranial aneurysm clipping. Many studies have used various drugs such as lidocaine to explore the effect and mechanism of lidocaine pretreatment. A total of 80 patients with intracranial aneurysm clipping surgery were randomly divided into 4 groups: the single lidocaine group, single dexmedetomidine group, lidocaine combined with dexmedetomidine group, and control group. The thread embolism method was used to establish a stable intracranial aneurysm model of Hashimoto rats. Fifty adult rats were randomly divided into a sham operation group, ligation of the left common carotid artery and bilateral posterior branch of renal artery, lidocaine group, dexmedetomidine group, and lidocaine combined with dexmedetomidine group. The colorimetric method was used to determine the oxidative stress indicators in brain tissue: MDA content, SOD activity, and T-AOC content. The western blot method characterized the protein levels related to oxidative stress: nNOS, iNOS, and NADPH oxidase subunits p22phox, gp91phox, and p47phox. The differences in each index between the groups were statistically significant (P < 0.05). Animal experiment results revealed that the content of MDA in the brain tissue of rats in the LD group was significantly lower than that in the single-drug group and sham group. The T-AOC and SOD concentrations in the LD group were significantly higher than those in the single-drug group and sham group, and the differences between the groups were statistically significant (P < 0.05). The protein expression of the LD group was significantly lower than that of the drug-alone group and model group, and the difference between groups was statistically significant (P < 0.05). To sum up, lidocaine pretreatment combined with dexmedetomidine can effectively maintain the hemodynamic stability of patients with intracranial aneurysm clipping and reduce postoperative oxidative stress response. Its mechanism of action may be related to the inhibition of oxidative stress damage mediated by nNOS, iNOS, and p22phox, gp91phox, and p47phox in the hippocampus. Our study has significant and applicable medical aspects in lidocaine pretreatment combined with dexmedetomidine on oxidative stress in patients.

Efficacy and safety of dexmedetomidine as an adjuvant to local wound infiltration anaesthesia: A meta-analysis with trial sequential analysis of 23 randomised controlled trials

To further identify the real efficacy and safety of dexmedetomidine as an adjuvant to local wound infiltration anaesthesia, we conducted this meta‐analysis. The systematic search strategy was performed using PubMed, Embase, Cochrane Library, and Chinese databases. As a result, a total of 23 RCTs (1445 patients) were included. Patients receiving dexmedetomidine combined with local anaesthetics had a lower rescue analgesia rate [risk ratio (RR): 0.48; 95% confidence interval (CI): 0.36‐0.65] and lower rescue analgesic consumption [weighted mean difference (WMD): −10.80 mg; 95%CI: −13.28 to −8.31 mg] than patients receiving local anaesthetics alone. The dexmedetomidine‐related adverse reactions included bradycardia (RR: 1.33; 95%CI: 0.32‐5.56) and hypotension (RR: 3.00; 95%CI: 0.49‐18.42). In addition, the time to first analgesic request (WMD: 296.16 minutes; 95%CI: 165.69 minutes ~ 426.63 minutes), incidence of postoperative nausea and vomiting (PONV) and pain scores at 4 hours postoperatively were also significantly lower in patients receiving dexmedetomidine combined with local anaesthetics. This meta‐analysis demonstrated that the use of dexmedetomidine as an adjuvant to wound infiltration is effective for reducing the rescue analgesia rate, rescue analgesic consumption and PONV. In addition, limited evidence shows that dexmedetomidine can prolong postoperative analgesia for approximately 5 hours. Further investigations on dexmedetomidine‐related adverse reactions and the dose–response effect of dexmedetomidine in wound infiltration are warranted.

Adjuncts to local anesthetic wound infiltration for postoperative analgesia: a systematic review

Local anesthetics (LAs) are commonly infiltrated into surgical wounds for postsurgical analgesia. While many adjuncts to LA agents have been studied, it is unclear which adjuncts are most effective for co-infiltration to improve and prolong analgesia. We performed a systematic review on adjuncts (excluding epinephrine) to local infiltrative anesthesia to determine their analgesic efficacy and opioid-sparing properties. Multiple databases were searched up to December 2019 for randomized controlled trials (RCTs) and two reviewers independently performed title/abstract screening and full-text review. Inclusion criteria were (1) adult surgical patients and (2) adjunct and LA agents infiltration into the surgical wound or subcutaneous tissue for postoperative analgesia. To focus on wound infiltration, studies on intra-articular, peri-tonsillar, or fascial plane infiltration were excluded. The primary outcome was reduction in postoperative opioid requirement. Secondary outcomes were time-to-first analgesic use, postoperative pain score, and any reported adverse effects. We screened 6670 citations, reviewed 126 full-text articles, and included 89 RCTs. Adjuncts included opioids, non-steroidal anti-inflammatory drugs, steroids, alpha-2 agonists, ketamine, magnesium, neosaxitoxin, and methylene blue. Alpha-2 agonists have the most evidence to support their use as adjuncts to LA infiltration. Fentanyl, ketorolac, dexamethasone, magnesium and several other agents show potential as adjuncts but require more evidence. Most studies support the safety of these agents. Our findings suggest benefits of several adjuncts to local infiltrative anesthesia for postoperative analgesia. Further well-powered RCTs are needed to compare various infiltration regimens and agents.

Protocol registration

PROSPERO (CRD42018103851) (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=103851)

Examination of the sedative and analgesic effects of gabapentin and dexmedetomidine in patients undergoing laparoscopic cholecystectomy surgery: A randomized controlled trial

Introduction:

At present, laparoscopic surgery is a very common method, especially for the removal of the gallbladder, because pain and anxiety following surgery is a major problem in surgical operations. Various studies have demonstrated the effectiveness of gabapentin and dexmedetomidine in reducing pain intensity after surgery. The present study is aimed at examining the sedative and analgesic effects of gabapentin and dexmedetomidine in patients undergoing laparoscopic cholecystectomy.

Methods:

This was a double-blinded clinical trial involving 40 patients who were candidates for laparoscopic cholecystectomy. The patients were randomly allotted in two groups of dexmedetomidine (n = 20) and gabapentin (n = 20). Then, pain intensity based on the visual analog scale (VAS) and sedation level based on the Ramsay Sedation Scale (RSS) were measured at the curtained times. As the data were not normally distributed, the Mann–Whitney U test was used to analyze the data, and the significance level was set at 0.05.

Results:

Across the follow-up points, more reduction in pain intensity was observed in the dexmedetomidine group as compared with the gabapentin group. The available dissimilarities between these two groups in pain decrement at the recovery room and 3 h after being discharged from the recovery room were not significant (P ≥ 0.414). In addition, across all the time points, there was considerable growth in sedation in the dexmedetomidine group in comparison with the gabapentin group (P < 0.024). This finding indicated that dexmedetomidine was more effective than gabapentin in creating sedation.

Conclusion:

Compared with gabapentin, dexmedetomidine leads to more pain reduction after surgery and better sedation during and after surgery.

Gallbladder Retrieval From Epigastric Versus Umbilical Port in Laparoscopic Cholecystectomy: A PRISMA-Compliant Meta-Analysis

Purpose. To date, no evidence supports the retrieval of the gallbladder through a specific trocar site, and this choice is left to surgeons’ preference. The aim of this meta-analysis was to investigate the influence of the trocar site used to extract the gallbladder on postoperative outcomes. Methods. According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a literature search of PubMed, Google Scholar, Cochrane Library, and EMBASE databases was performed. Terms used were: (“gallbladder” OR “cholecystectomy”) AND “umbilical” AND (“epigastric” OR “subxiphoid”). Randomized trials comparing the gallbladder retrieval from different trocar sites were considered for further analysis. Results. Literature search revealed 145 articles, of which 7 matched inclusion criteria and reported adequate data about postoperative pain, operative time, port-site infections, and hernias. A total of 876 patients were included, and the gallbladder was extracted through epigastric or umbilical trocar site in 441 and in 435 patients, respectively. A statistically significant difference among groups was noted in terms of postoperative pain at 1, 6, 12, and 24 hours in favor of the umbilical trocar site ( P < .001). No significant differences were noted in postoperative hernia and infection rate, nor in terms of operative time. Conclusions. This meta-analysis shows a statistically significant reduction in terms of postoperative pain at 1, 6, 12, and 24 hours after surgery when the gallbladder is extracted through the umbilical port. Retrieval time, infections, and hernias rate implicate no contraindication for the choice of a specific trocar site to extract specimens. Despite limitations of this study, the umbilical trocar should be favored as the first choice to retrieve the gallbladder.

Protective efficacy of combined use of parecoxib and dexmedetomidine on postoperative hyperalgesia and early cognitive dysfunction after laparoscopic cholecystectomy for elderly patients

Purpose:

To investigate efficacy of combined use of parecoxib and dexmedetomidine on postoperative pain and early cognitive dysfunction after laparoscopic cholecystectomy for elderly patients.

Methods:

The present prospective randomized controlled study included a total of 80 patients who underwent laparoscopic cholecystectomy surgery during January 2016 to November 2017 in our hospital. All patients were randomly divided into 4 groups, the parecoxib group, the dexmedetomidine group, the parecoxib and dexmedetomidine combined group, and the control group. Demographic data and clinical data were collected. Indexes of heart rate (HR), mean arterial pressure (MAP), levels of jugular venous oxygen saturation (SjvO2) and jugular venous oxygen pressure (PjvO2) were recorded at different time points before and during the surgery. The mini-mental state examination (MMSE) score, Ramsay score and Visual Analogue Score (VAS) were measured.

Results:

Levels of both SjvO2 and PjvO2 were significantly higher in parecoxib group, dexmedetomidine group and the combined group than the control group. Meanwhile, levels of both SjvO2 and PjvO2 in the combined group were the highest. VAS scores were significantly lower in the combined group than all other groups, and total patient controlled intravenous analgesia (PCIA) pressing times within 48 h after surgery were the lowest in the combined group. Both Ramsay and MMSE scores were the highest in the combined group compared with other groups, while were the lowest in the control group.

Conclusion:

The combined use of parecoxib and dexmedetomidine could reduce the postoperative pain and improve the postoperative sedation and cognitive conditions of patients after laparoscopic cholecystectomy.

Effects of adding dexmedetomidine to local infiltration of bupivacaine on postoperative pain in pediatric herniorrhaphy: a randomized clinical trial

Background

Postoperative pain is a major problem, especially in children, as their tolerance level is lower and several drugs are contraindicated in childhood. This study aimed to compare the effect of dexmedetomidine added to local infiltration of bupivacaine for postoperative pain relief in children undergoing inguinal herniorrhaphy.

Methods

This double-blind, randomized clinical trial included 60 children aged 6–72 months undergoing unilateral herniorrhaphy at selected hospitals in Shiraz, Iran, randomly allocated into two groups, 30 in each group. One group received 1 µg/kg dexmedetomidine plus local infiltration of 0.2 ml/kg bupivacaine 0.5% at the incision site before surgery (BD), and the other group received bupivacaine and normal saline (BO). Analgesic requirements, emergence time, and nausea/vomiting, postoperative pain and sedation scores were assessed for 4 h after the operation. Heart rate (HR), systolic blood pressure (SBP), and oxygen saturation (SaO₂) were recorded at baseline, and at 10 and 20 min after injection.

Results

Eighty percent were boy in each group; mean age was 22.75 ± 18.63 months. SaO₂ and SBP were not different between the groups, while HR was significantly lower in the Group BD at 10 and 20 min after injection (P < 0.05). Group BD had a lower pain score at 1 and 2 h after the operation, a higher sedation score at the first three time intervals, and longer emergence time than Group BO (all P < 0.001). Group BD had a lower pain score at 1 and 2 h after the operation (P < 0.001, P < 0.047 respectively).

Conclusions

Addition of dexmedetomidine to local infiltration of bupivacaine in children undergoing herniorrhaphy significantly reduced postoperative pain and increased sedation.

Efficacy of dexmedetomidine as an adjuvant to local wound infiltration anaesthesia in abdominal surgery: A meta-analysis of randomised controlled trials

To assess the efficacy and safety of dexmedetomidine (DEX) as an adjuvant to local wound infiltration anaesthesia in abdominal surgery, we conducted this meta-analysis. First, the systematic search strategy was performed on PubMed, Embase, and Cochrane Library and five randomised controlled trials (RCTs) involving 294 patients were included. Then, the outcome data were extracted from the studies and their effect sizes were calculated using Review Manager 5. As a result, the addition of DEX significantly reduced visual analogy scores at 6 hours after surgery (mean difference = -0.53[-0.82, -0.25], P < .001), 12 hours after surgery (mean difference = -0.39 [-0.73, -0.05]; P = .03), and 24 hours after surgery (mean difference = -0.20 [-0.29, -0.11], P < .001) and reduced total analgesic consumption within 24 hours after surgery (mean difference = -4.92 [-9.00, -0.84]; P = .02) compared with placebo groups. However, there was no difference in the incidence of postoperative nausea and vomiting (risk ratio = 0.68 [0.41, 1.14]; P = .14). In summary, DEX as a local anaesthetic adjuvant added for local wound infiltration anaesthesia in abdominal surgery could reduce visual analogy scores and postoperative analgesic consumption without changing incidence of postoperative nausea and vomiting.

Effect of ultrasound-guided peripheral nerve blocks of the abdominal wall on pain relief after laparoscopic cholecystectomy

Purpose: The aim of this study was to compare the effect of an ultrasound-guided transversus abdominis plane block (TAPB) and rectus sheath block (RSB) combination, an ultrasound-guided posterior TAP block combined with the local anesthetic infiltration (LAI) and LAI alone on pain relief after laparoscopic cholecystectomy (LC). Patients and methods: One hundred eighty patients who were American Society of Anesthesiologists class Ι or Π were included in this randomized, double-blind, non-inferiority study. All patients underwent three-port LC and were divided into 3 groups. The LAI group had ropivacaine mixed with dexmedetomidine injected around the trocar entrance site preoperatively. The TL group underwent ultrasound-guided posterior TAPB combined with LAI, and the TR group underwent ultrasound-guided TAPB combined with RSB. Postoperative pain was evaluated at the first, 4th, 8th, 24th, and 48th hours. If the visual analogue scale (VAS) score (including incisional pain, visceral pain or shoulder pain) was >3, intravenous dezocine (0.05 mg/kg) was injected slowly. Sleep quality, total consumption of dezocine and time to unassisted walking were recorded. The Global Satisfaction Score (GSS) for analgesia was also assessed within 48 hrs. Results: No difference was found in sleep quality, time to unassisted walking, or requirement for dezocine. We also found no difference in VAS scores at each time point within 48 hrs after LC among the 3 groups, but the GSS for analgesia in the LAI group was significantly increased within 48 hrs compared with the other two groups. Conclusion: Ultrasound-guided peripheral nerve blocks of the abdominal wall can significantly relieve postoperative pain in patients undergoing LC; however, patients receiving LAI expressed more satisfaction than patients in whom other methods were used. LAI is an easy and effective method that can be recommended for routine clinical practice in LC patients who are not converted to an open procedure.

Intranasal Low-Dose Dexmedetomidine Reduces Postoperative Opioid Requirement in Patients Undergoing Hip Arthroplasty Under General Anesthesia

BACKGROUND

Patients undergoing total hip arthroplasty (THA) need substantial amount of opioids for postoperative pain management, which necessitates opioid-sparing modalities. Dexmedetomidine is a novel alpha-2-adrenoceptor-activating drug for procedural sedation. In addition to its sedative effect, dexmedetomidine has analgesic and antiemetic effects. We evaluated retrospectively the effect of intraoperatively administered intranasal low-dose dexmedetomidine on postoperative opioid requirement in patients undergoing THA.

METHODS

We included 120 patients with American Society of Anesthesiologists status 1-2, age between 35 and 80 years, and scheduled for unilateral primary THA under general anesthesia with total intravenous anesthesia. Half of the patients received 50 μg of intranasal dexmedetomidine after anesthesia induction, while the rest were treated conventionally. Postoperative opioid requirements were calculated as morphine equivalent doses for both groups. The impact of intranasal dexmedetomidine on postoperative hemodynamics and length of stay was evaluated.

RESULTS

The cumulative postoperative opioid requirement was significantly reduced in the dexmedetomidine group compared with the control group (26.3 mg, 95% confidence interval 15.6-36.4, P < .001). The cumulative dose was significantly different between the groups already at 12, 24, and 36 h postoperatively (P = .01; P = .001; P < .001, respectively). Dexmedetomidine group had lower mean arterial pressure in the postanesthesia care unit compared with the control group (P = .01). There was no difference in the postanesthesia care unit stay or postoperative length of stay between the two groups (P = .47; P = .10, respectively).

CONCLUSION

Compared with the control group, intraoperative use of intranasal low-dose dexmedetomidine decreases opioid consumption and sympathetic response during acute postoperative period in patients undergoing THA.