Intranasal dexmedetomidine in combination with patient-controlled sedation during upper gastrointestinal endoscopy: a randomised trial

Effect of different doses of dexmedetomidine as an adjuvant to lignocaine nebulization: A comparative study during awake flexible fiberoptic bronchoscopy

Background and Aims

Mild to moderate sedation during bronchoscopy is essential for patient safety, comfort during and after the procedure, and to facilitate the performance of the bronchoscopist. Dexmedetomidine is a highly selective, centrally acting α-2 agonist used to provide conscious sedation during various procedures. The aim of this study was to compare the efficacy of three different doses of dexmedetomidine nebulization as an adjuvant to lignocaine during bronchoscopy.

Material and Methods

Ninety American Society of Anesthesiologists physical status I/II patients, aged from 18 to 60 years, scheduled for an elective bronchoscopy, were recruited. They were divided into three groups: 30 patients in each group. Group I: The patient was nebulized with a mixture of 4 ml of 4% lignocaine and dexmedetomidine 0.5 μg/kg. Group II: The patient was nebulized with a mixture of 4% lignocaine, 4 ml, and dexmedetomidine, 1 μg/kg. Group III: The patient was nebulized with 4% lignocaine 4 ml and dexmedetomidine 1.5 μg/kg.

Results

The mean cough score was (1.17 ± 0.37), (1.40 ± 0.49), and (1.70 ± 0.75) in group III, group II, and group I, respectively. A significant difference was found between the groups. Patients were more comfortable with a statistically significant difference in the comfort score in group III as compared to group II and group I.

Conclusion

Dexmedetomidine nebulization in a dose of 1.5 μg/kg (compared to 1 μg/kg or 0.5 μg/kg) as an adjuvant to lignocaine, provides better bronchoscopy conditions and patient satisfaction.

Efficacy and safety of sedation with dexmedetomidine in adults undergoing gastrointestinal endoscopic procedures: systematic review and meta-analysis of randomized controlled trials

Background: The sedative role of dexmedetomidine (DEX) in gastrointestinal endoscopic procedures is unclear. We performed this systematic review and meta-analysis to assess the efficacy and safety of sedation with DEX during gastrointestinal endoscopic procedures with a view to providing evidence-based references for clinical decision-making. Methods: The PubMed, Embase, Cochrane Library, Web of Science, and ClinicalTrials.gov databases were searched for randomized controlled trials (RCTs) that compared DEX with different sedatives comparators (such as propofol, midazolam, and ketamine) for sedation in a variety of adult gastrointestinal endoscopic procedures from inception to 1 July 2022. Standardized mean difference (SMD) and weighted mean difference (WMD) with 95% confidence interval (CI) or pooled risk ratios (RR) with 95% CI were used for continuous outcomes or dichotomous outcomes, respectively, and a random-effect model was selected regardless of the significance of the heterogeneity. Results: Forty studies with 2,955 patients were assessed, of which 1,333 patients were in the DEX group and 1,622 patients were in the control (without DEX) group. The results suggested that the primary outcomes of sedation level of DEX are comparable to other sedatives, with similar RSS score and patient satisfaction level, and better in some clinical outcomes, with a reduced risk of body movements or gagging (RR: 0.60; 95% CI: 0.37 to 0.97; p = 0.04; I2 = 68%), and a reduced additional requirement for other sedatives, and increased endoscopist satisfaction level (SMD: 0.41; 95% CI: 0.05 to 0.77; p = 0.03; I2 = 86%). In terms of secondary outcomes of adverse events, DEX may benefit patients in some clinical outcomes, with a reduced risk of hypoxia (RR:0.34; 95% CI: 0.20 to 0.55; p < 0.0001; I2 = 52%) and cough (RR: 0.25; 95% CI: 0.12 to 0.54; p = 0.0004; I2 = 0%), no significant difference in the risk of hypotension, while an increased risk of bradycardia (RR: 3.08; 95% CI: 2.12 to 4.48; p < 0.00001; I2 = 6%). Conclusion: This meta-analysis indicates that DEX is a safe and effective sedative agent for gastrointestinal endoscopy because of its benefits for patients in some clinical outcomes. Remarkably, DEX is comparable to midazolam and propofol in terms of sedation level. In conclusion, DEX provides an additional option in sedation for gastrointestinal endoscopic procedures. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/#searchadvanced.

Effects of dexmedetomidine in non-operating room anesthesia in adults: a systematic review with meta-analysis

BACKGROUND

Dexmedetomidine (DEX) is an α2-adrenergic receptor agonist used for its sedative, analgesic, and anxiolytic effects. Non-Operating Room Anesthesia (NORA) is a modality of anesthesia that can be done under general anesthesia or procedural sedation or/and analgesia. In this particular setting, a level-2 sedation, such as the one provided by DEX, is beneficial. We aimed to study the effects and safety of DEX in the different NORA settings in the adult population.

METHODS

A systematic review with meta-analysis of randomized controlled trials was conducted. Interventions using DEX only or DEX associated with other sedative agents, in adults (18 years old or more), were included. Procedures outside the NORA setting and/or without a control group without DEX were excluded. MEDLINE, ClinicalTrials.gov, Scopus, LILACS, and SciELO were searched. The primary outcome was time until full recovery. Secondary outcomes included hemodynamic and respiratory complications and other adverse events, among others.

RESULTS

A total of 97 studies were included with a total of 6,706 participants. The meta-analysis demonstrated that DEX had a higher time until full recovery (95% CI = [0.34, 3.13] minutes, a higher incidence of hypotension (OR = 1.95 [1.25, 3.05], p = 0.003, I2 = 39%) and bradycardia (OR = 3.60 [2.29, 5.67], p < 0.00001, I2 = 0%), and a lower incidence of desaturation (OR = 0.40 [0.25, 0.66], p = 0.0003, I² = 60%).

CONCLUSION

DEX in NORA procedures in adults was associated with a lower incidence of amnesia and respiratory effects but had a long time to recovery and more hemodynamic complications.

Intranasal Dexmedetomidine for Pain Management in Older Patients: A Cross-Over, Randomized, Double-Blinded, Active-Controlled Trial

BACKGROUND

Daily care procedures provoke breakthrough pain and anxiety in palliative situations. Dexmedetomidine may be an alternative to opioids during nursing procedures for older patients.

OBJECTIVE

We aimed to compare the efficacy of intranasal dexmedetomidine with subcutaneous opioids on the intensity of pain and anxiety during comfort management procedures.

METHODS

We conducted a randomized, active-controlled, double-blind, crossover trial (NCT03151863). Patients aged ≥ 65 years were randomized to receive, 45 min before nursing care, either intranasal dexmedetomidine together with subcutaneous placebo or intranasal placebo together with a subcutaneous opioid. Each of these two interventions were administered in a cross-over design and spaced out over a 24- or 48-h period. The primary outcome was the number of patients with an Elderly Caring Pain Assessment score > 5. Secondary outcomes included pain, sedation score, and vital signs.

RESULTS

Because of difficult recruitment, the trial was interrupted after the inclusion of 24 patients. Three patients withdrew after randomization, leaving 21 patients undergoing 42 complete sessions for descriptive analyses. Of the 21 patients, 12 (57.1%) were women, and their median age was 84 years, interquartile range (75-87 years). Nine (42.9%) patients presented an Elderly Caring Pain Assessment score > 5 when receiving subcutaneous opioids, and seven (33.3%) with intranasal dexmedetomidine. Hypoxemia occurred in a single patient receiving subcutaneous opioids. No episode of bradycardia was observed.

CONCLUSIONS

Intranasal dexmedetomidine is feasible in elderly patients and may be an alternative to opioids to ensure comfort during nursing care. Future studies are needed to confirm the efficacy and safety of this procedure.

Two-center randomized controlled trial comparing oral chloral hydrate and intranasal combination of dexmedetomidine and ketamine for procedural sedation in children: study protocol

BACKGROUND

Oral chloral hydrate is widely used in pediatric sedation. Intranasal dexmedetomidine has been increasingly used for pediatric sedation; however, its improvement is warranted. The combination of dexmedetomidine with ketamine can improve onset and hemodynamic stability while maintaining sedative efficacy. This study aims to determine the efficacy and safety of intranasal combination of dexmedetomidine and ketamine compared to oral chloral hydrate.

METHODS

This is a prospective, parallel-arm, single-blinded, two-center, superiority randomized controlled trial with 1:1 allocation, designed to compare the effects of intranasal combination of dexmedetomidine and ketamine with those of oral chloral hydrate. We shall enroll 136 patients aged < 7 years old in this study. Prior to the procedure, we shall randomize each patient into the control group (oral chloral hydrate 50 mg/kg) or study group (intranasal dexmedetomidine 2 μg/kg and ketamine 3 mg/kg). The primary outcome will be the rate of achieving an adequate sedation level (6-point Pediatric Sedation State Scale 1, 2, or 3) within 15 min. In addition, we shall measure the sedation time, sedation failure rate, completion of procedure, adverse events, patient acceptance, and physician satisfaction.

DISCUSSION

This study will provide evidence of the efficacy and safety of the intranasal combination of dexmedetomidine and ketamine in comparison with oral chloral hydrate.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT04820205. Registered on 19th March 2021.

Dexmedetomidine as an Analgesic Agent with Neuroprotective Properties: Experimental and Clinical Aspects

Dexmedetomidine (Dexdor or Precedex®) is considered as a sedative agent which is widely used as an adjuvant in general anesthesia and critical care practice. There is extensive evidence indicating its neuroprotective properties especially in various ischemic and hemorrhagic brain injury models of animals. Clinical trials have shown that dexmedetomidine (DEX) can improve the outcome of intensive care unit (ICU) patients. Also, DEX is appropriate as a non-opioid analgesic therapy whenever minimizing opioid-related side effects is necessary. The present article reviews the recent advances in the use of DEX as a neuroprotective agent in both animal and human studies including newest findings about the mechanism of the drug as well as analgesic efficacy of this drug at all perioperative stages. In spite of the beneficial effects of the drug on the nervous system, there are potential adverse effects, such as hypotension and bradycardia, which can be treated pharmacologically and must be taken into consideration by clinicians.

Intranasal dexmedetomidine premedication in children with recent upper respiratory tract infection undergoing interventional cardiac catheterisation: A randomised controlled trial

BACKGROUND

Recent upper respiratory tract infection (URI) is a risk factor for the occurrence of peri-operative respiratory adverse events (PRAE). This risk may be higher in children with congenital heart disease (CHD), particularly in those undergoing interventional cardiac catheterisation. It is therefore essential to adapt the anaesthetic strategy in these children to prevent from the occurrence of PRAE.

OBJECTIVE

To determine whether intranasal dexmedetomidine (DEX) premedication can reduce the incidence of PRAE in children with recent URI undergoing interventional cardiac catheterisation.

DESIGN

Randomised controlled trial.

SETTING

Single-centre study based at a tertiary care centre in Shanghai, China.

PATIENTS

A total of 134 children with CHD aged 0 to 16 years with recent URI undergoing interventional cardiac catheterisation.

INTERVENTIONS

Children were randomised to receive either intranasal DEX 1.5 μg kg (DEX group) or intranasal saline (Placebo group) 30 to 45 min before anaesthesia induction.

MAIN OUTCOME MEASURES

The incidence of PRAE.

RESULTS

Intranasal DEX significantly reduced the incidence of PRAE (P = 0.001), particularly oxygen desaturation (P = 0.012). Most PRAE were observed during the emergence phase. The incidence of PRAE was comparable among the three types of left-right shunt CHD children in both groups. In children aged less than 3 years, the incidence of PRAE was significantly lower in the DEX group (P = 0.003). In contrast, the incidence of PRAE was comparable between the two groups in children aged at least 3 years. No differences in the incidence of emergence agitation, fever and vomiting between the two groups were noted.

CONCLUSION

Administration of intranasal DEX 1.5 μg kg 30 to 45 min before induction led to a reduction in the incidence of PRAE in children aged less than 3 years with recent URI undergoing interventional cardiac catheterisation.

TRIAL REGISTRATION

chictr.org.cn identifier: ChiCTR-RRC-17012519.

Control of Hemodynamic Responses and Perioperative Outcomes in Transsphenoidal Pituitary Surgery: A Qualitative Systematic Review of the Available Evidence

Transnasal transsphenoidal (TNTS) pituitary surgery is associated with short-lived but intense nociceptive stimuli which cause substantial hemodynamic perturbations that may increase blood loss and impair visualization of the surgical field. This systematic review aimed to critically appraise the clinical evidence for the efficacy and safety of various anesthetic techniques, other pharmacological modalities, and supplementary interventions by assessing intraoperative systemic hemodynamics, use of adjunct medications, quality of the surgical field, intraoperative blood loss, and recovery profiles in patients undergoing TNTS pituitary surgery. Relevant randomized clinical trials and observational studies were identified in a systematic literature search; 16 studies (13 randomized clinical trials, 3 observational studies) enrolling a total of 907 patients were identified for inclusion in this review. Propofol provided more potent hemodynamic control compared with volatile anesthetics with a sparing effect on the need for additional drugs to blunt hemodynamic responses. Recovery profiles between propofol and sevoflurane were either equivalent or favored sevoflurane, but both agents were superior to isoflurane. Regarding intraoperative analgesia, remifentanil was associated with superior hemodynamic control and recovery profiles than fentanyl. Dexmedetomidine had beneficial effects on hemodynamics, surgical field quality, recovery characteristics, and nociceptive properties compared with placebo. Although there was no clear-cut superiority of other adjunct pharmacological modalities on hemodynamic responses during surgery, regional blocks were associated with beneficial impacts on both primary and secondary outcomes. In summary, short-acting anesthetics, analgesics and dexmedetomidine seem to improve intraoperative hemodynamics, blood loss, and recovery qualities during TNTS pituitary surgery. However, definitive conclusions cannot be drawn because of methodological heterogeneity in the identified studies.

Dexmedetomidine with sufentanil in intravenous patient-controlled analgesia for relief from postoperative pain, inflammation and delirium after esophageal cancer surgery

BACKGROUND AND AIMS

Postoperative pain can cause serious adverse reactions that severely affect postoperative outcome. The present study evaluated the effect of dexmedetomidine (DEX) added to sufentanil in intravenous patient-controlled analgesia (PCA) on the relief of pain and inflammatory responses during postoperative recovery of patients undergoing a combined thoracoscopic-laparoscopic esophagectomy (TLE).

METHODS

Sixty patients undergoing TLE were randomly allocated to receive 1 μg/ml of sufentanil alone (Group S) or 1 μg/ml of sufentanil plus 2.5 μg/ml of DEX (Group D) for postoperative intravenous (IV) PCA. Postoperative pain relief, cumulative PCA requirements, inflammatory marker levels, delirium and recovery were assessed.

RESULTS

A joint DEX and sufentanil regimen significantly reduced the area under the curve of numerical rating scores for pain at rest (NRSR) and coughing (NRSC) at 1-48 h postoperatively (P = 0.000) that were associated with lower PCA-delivered cumulative sufentanil consumption and less PCA frequency until 48 h postoperatively (P < 0.05 and P < 0.0001, respectively). The simultaneous administration of DEX and sufentanil significantly reduced plasma IL-6 and TNF-α concentrations and increased IL-10 level (P < 0.0001, P = 0.0003 and P = 0.0345, respectively), accompanied by better postoperative delirium categories and health statuses of patients (P = 0.024 and P < 0.05, respectively). There was no hypotension, bradycardia, respiratory depression or oversedation in Group D.

CONCLUSION

Patients receiving DEX in addition to IV PCA sufentanil for TLE exhibited better postoperative analgesia, fewer inflammatory responses and lower postoperative delirium categories and better health statuses.

Intranasal dexmedetomidine for attenuation of hemodynamic response to laryngoscopy and intubation in adults

Background : To evaluate effectiveness of intranasal dexmedetomidine for attenuation of hemo-dynamic response to laryngoscopy and intubation in adults. Design and setting : This prospective randomized study included 90 American Society of Anesthesiologists (ASA) status I, adult patients of either sex, aged between 18-60 years, and undergoing elective surgery under general anesthesia requiring endotracheal intubation. Methods : Patients were randomly assigned to one of three groups of 30 each, to receive either intranasal saline (Group C), intranasal dexmedetomidine 1µg/kg (Group D 1 ) or intranasal dexmedetomidine 2µg/kg (Group D 2) , administered 30 minutes before the induction of anesthesia. Anesthesia technique was standardized for all patients taking part in the study. Main outcome measures : Primary outcome studied was attenuation of hemodynamic response to laryngoscopy and intubation. Secondary parameters studied were sedation score and dose of propofol required at induction. Results : There was a statistically significant rise in heart rate and systolic, diastolic and mean arterial pressures at 1, 3, and 5 minutes of intubation in group C as compared to groups D 1 and D 2 . Sedation score was significantly higher in groups D 1 and D 2 (p<0.0001). Propofol requirement was significantly lower in groups D 1 and D 2 (p<0.0001). Intranasal dexmedetomidine 2µg/kg was associated with higher a incidence of bradycardia. Conclusion : Intranasal dexmedetomidine (1µg/kg and 2µg/kg) effectively diminishes hemodynamic changes associated with laryngoscopy and intubation in adult patients undergoing elective surgery. Intranasal dex-medetomidine 2µg/kg is associated with significant bradycardia. Intranasal dexmedetomidine also provides effective preoperative sedation and decreases the dose of propofol required for induction of anesthesia.

The clinical effect of dexmedetomidine combined with parecoxib sodium on sedation, antianxiety and prevention of intubation stress in patients undergoing functional endoscopic sinus surgery: a randomised controlled trial

Background

To investigate the effect of intravenous injection of dexmedetomidine combined with parecoxib sodium on sedation and anxiety and stress response of tracheal intubation in patients undergoing functional endoscopic sinus surgery.

Methods

One hundred twenty patients undergoing endoscopic sinus surgery were randomly divided into four groups: group DP, group D, group P and group N. The blood pressure (BP), heart rate (HR), blood oxygen saturation (SPO2), EEG, bispectral index (BIS), Ramsay sedation score and state anxiety questionnaire (SAI) were recorded before administration (T0), 10 min (T1), 20 min (T2) and 30 min (T3) after administration. After 30 min, endotracheal intubation was performed after anesthesia induction. The BP, HR, SPO2 were recorded 1 min before intubation (T4), intubation (T5), 3 min (T6) after intubation, 5 min (T7) after intubation, and blood samples were collected from patients before administration and after intubation 2 min to detect serum cortisol (Cor), adrenalin (E) norepinephrine (NE) and blood glucose (BS).

Results

There was no significant difference in Ramsay sedation score before anesthesia, but the Ramsay sedation score in group D、DP was significantly higher than that in group P and group N, the BIS, BP, HR and anxiety scores were significantly lower than those in the group P and group N (p < 0.05). There was no significant difference in Ramsay sedation score, BIS value, anxiety score and BP, HR between group D and group DP (p > 0.05). Compared with T4, there was no significant difference in BIS and BP, HR in group D, group DP and group P (p > 0.05), but the BIS, BP and HR in group N were significantly higher than T4, (p < 0.05). Three minutes after intubation there was no statistical difference in the changes of Cor, E, NE and BS values compared with before intubation in group P and group DP (p > 0.05), but the changes of Cor, E, NE and BS values were significantly lower than that in group N (p < 0.05). Compared with T0, the values of NE, E, Cor, BS decreased in group D, DP and P at T4, group DP decreased more significantly than group D (p < 0.05). while the NE, E, Cor, BS of T6 are at the same level as the base value. In group N, the NE, E, Cor, BS of T4 were at the same level of T0, but significantly higher at T6.And at T6, NE and E in group D, P and N were significantly different from those in group DP (p < 0.05).

Conclusion

Preoperative intravenous infusion of dexmedetomidine combined with parecoxib sodium by functional nasal endoscopy can not only calm and resist anxiety, but also better prevent stress response of endotracheal intubation, which is a safe and effective way of preoperative medication.

Trial registration

ChiCTR-OPN-17010444. Prospectively registered on 16 January 2017.

The Use of Intranasal Dexmedetomidine and Midazolam for Sedated Magnetic Resonance Imaging in Children: A Report From the Pediatric Sedation Research Consortium

OBJECTIVE

The objective of this study was to describe the use of intranasal dexmedetomidine (IN DEX) for sedated magnetic resonance imaging (MRI) examinations in children. The use of IN DEX for MRI in children has not been well described in the literature.

MATERIALS AND METHODS

The Pediatric Sedation Research Consortium (PSRC) is a collaborative and multidisciplinary group of sedation practitioners dedicated to understanding and improving the process of pediatric sedation. We searched the 2007 version of the PSRC database solely for instances in which IN DEX was used for MRI diagnostic studies. Patients receiving intravenous medications were excluded. Patient demographics, IN DEX dose, adjunct medications and dose, as well as procedure completion, complications, interventions, and monitoring providers were analyzed.

RESULTS

A total of 224 sedation encounters were included in our primary analysis. There were no major adverse events. Most sedations (88%) required no intervention. Registered nurses were the monitoring provider in over 99% of cases. The median (interquartile range) dose of dexmedetomidine was 3 (2.5-3) mcg/kg. Adjunctive midazolam was used in 219/224 (98%) of the cases. All procedures were completed.

CONCLUSIONS

This report from the PSRC shows that IN DEX in combination with midazolam is an effective medication regimen for children who require an MRI with sedation.

Dexmedetomidine Attenuates Myocardial Ischemia-Reperfusion Injury in Diabetes Mellitus by Inhibiting Endoplasmic Reticulum Stress

OBJECTIVE

With the increasing incidence of diabetes mellitus (DM) combined with myocardial ischemia, how to reduce myocardial ischemia-reperfusion injury in DM patients has become a major problem faced by clinicians. We investigated the therapeutic effects of dexmedetomidine (DEX) on myocardial ischemia-reperfusion injury in DM rats and its effect on endoplasmic reticulum stress.

METHODS

SD rats with SPF grade were randomly divided into 6 groups: non-DM rats were divided into the sham operation group (NDM-S group), ischemia-reperfusion group (NDM-IR group), and dexmedetomidine group (NDM-DEX group); DM rats were divided into the diabetic sham operation group (DM-S group), diabetes-reperfusion group (DM-IR group), and diabetes-dexmedetomidine (DM-DEX) group, with 10 rats in each group. Then the effects of DEX on the changes of CK-MB and cTnT levels were examined. The effects of myocardial pathological damage and myocardial infarct size were detected. The apoptosis of cardiomyocytes was detected. The apoptosis of heart tissue cells was also tested through the expressions of cleaved caspase-3, Bcl-2, and Bax proteins. The expression of endoplasmic reticulum stress-related proteins GRP78, CHOP, ERO1α, ERO1β, and PDI was examined. The hypoxia/reoxygenation (H/R) injury cell model was established, the effects of DEX, DEX+ ERS agonist on cell apoptosis was also detected.

RESULTS

The myocardial damage of DM-IR was more severe than that of NDM-IR rats. DEX could reduce the expression of CK-MB and cTnT, reduce pathological damage, and reduce scar formation and improve fibrosis. DEX can reduce the expression of GRP78, CHOP, ERO1α, ERO1β, and PDI proteins in vivo and in vitro. And the effect of DEX on cell apoptosis could be blocked by ERS agonist.

CONCLUSION

DEX attenuates myocardial ischemia-reperfusion injury in DM rats and H/R injury cell, which is associated with the reduction of ERS-induced cardiomyocyte apoptosis.

Effects of Dexmedetomidine Combined with Sufentanil on Postoperative Delirium in Young Patients After General Anesthesia

Background

This study was designed to evaluate the effects of combined usage of dexmedetomidine (DEX) and sufentanil on young patients with postoperative delirium (POD) after general anesthesia.

Material/Methods

We randomized 100 young patients with POD into 4 groups: Group D, Group S, Group DS1, and Group DS2, with loading and maintenance doses of DEX and/or sufentanil administered according to the experimental protocol. Hemodynamic variables, standard visual analogue scale (VAS) scores, sedation agitation scale (SAS) scores, stress hormones, and inflammatory biomarkers were assessed at 5 time-points: baseline (T₁); 1 h (T₂), 2 h (T₃), 4 h (T₄), and 8 h (T₅) after completion of the loading dose.

Results

At T₃–T₅, hemodynamic indicators in group D were obviously higher than in the other groups (P<0.05). At T₂–T₅, the VAS and SAS scores were noticeably lower than those at T₁ in each group (P<0.05). The VAS and SAS scores were remarkably higher in group D than those in the other groups (P<0.05). Compared with DS1, the incidence of respiratory distress decreased and the incidence of POD increased in group DS2. Compared to T₁, plasma concentrations of epinephrine, norepinephrine, IL-6, and TNF-α all decreased at T₂ and T₅ (P<0.05).

Conclusions

DEX and sufentanil decrease the incidence of POD, ameliorate the abnormities of hemodynamic indicators, and decrease VAS scores, SAS scores, stress hormones, and inflammatory biomarkers, but increase the incidence of respiratory distress. DEX combined with sufentanil may play a synergistic reaction in causing respiratory distress, but remarkably decreases the incidence of POD.

Neuroprotective effect of bispectral index-guided fast-track anesthesia using sevoflurane combined with dexmedetomidine for intracranial aneurysm embolization

Dexmedetomidine has sedative, anxiolytic, analgesic, anti-sympathetic, and anti-shivering effects. Dexmedetomidine might be effective in combination with sevoflurane for anesthesia, but prospective randomized controlled clinical trials with which to verify this hypothesis are lacking. In total, 120 patients who underwent embolization of an intracranial aneurysm were recruited from Anhui Provincial Hospital and Renmin Hospital of Wuhan University of China and randomly allocated to two groups. After intraoperative administration of 2% to 3% sevoflurane inhalation, one group of patients received pump-controlled intravenous injection of 1.0 μg/kg dexmedetomidine for 15 minutes followed by maintenance with 0.3 μg/kg/h until the end of surgery; the other group of patients only underwent pump-controlled infusion of saline. Bispectral index monitoring revealed that dexmedetomidine-assisted anesthesia can shorten the recovery time of spontaneous breathing, time to eye opening, and time to laryngeal mask removal. Before anesthetic induction and immediately after laryngeal mask airway removal, the glucose and lactate levels were low, the S100β and neuron-specific enolase levels were low, the perioperative blood pressure and heart rate were stable, and postoperative delirium was minimal. These findings indicate that dexmedetomidine can effectively assist sevoflurane for anesthesia during surgical embolization of intracranial aneurysms, shorten the time to consciousness and extubation, reduce the stress response and energy metabolism, stabilize hemodynamic parameters, and reduce adverse reactions, thereby reducing the damage to the central nervous system. This trial was registered at the Chinese Clinical Trial Registry (http://www.chictr.org.cn/) (registration number: ChiCTR-IPR-16008113).

Intranasal dexmedetomidine in termination of first trimester pregnancy of suction evacuation

BACKGROUND AND AIM

Deep sedation without intubation for termination of first trimester pregnancy of suction evacuation entails use of sedatives such as propofol or a combination of propofol and sulfentanil, with unwanted complications. Dexmedetomidine is an α2-adrenoreceptor agonist which provides sedation, anxiolysis and analgesia, without any of the complications associated with the popular sedatives.

METHODS

A total number of 90 patients were randomized to three groups: 1. group P, treated with intranasal saline, intravenous saline and propofol; 2. group DP, treated with intranasal dexmedetomidine, intravenous saline and propofol; and 3. group SP, treated with intranasal saline, intravenous sulfentanil and propofol. The primary outcome was the consumption of propofol, and the secondary outcomes were numeric rating scale (NRS) anxiety score, NRS pain score of uterine cramping, amount of blood loss, use of oxytocin and NRS satisfaction scores of obstetric and gynecological (ob/gyn) physicians and patients.

RESULTS

The consumption of propofol, NRS pain score of uterine cramping after surgery, NRS anxiety score, and amount of blood loss in group DP were significantly lower than those in group P and group SP. Ob/gyn physicians' satisfaction score in group DP was significantly higher compared with group SP and group P.

CONCLUSION

Sedation with intranasal dexmedetomidine (1 μg/kg) provided effective analgesia and anxiolysis, reduced consumption of propofol and lower blood loss in termination of first trimester pregnancy of suction evacuation. Compared with propofol or the combination of propofol and sulfentanil, intranasal dexmedetomidine was associated with higher satisfaction score of ob/gyn physicians. No unforeseen perioperative respiratory and cardiovascular adverse events occurred.

REGISTRY NUMBER FOR CLINICAL TRIALS

ChiCTR-IPR-14005654.

Dexmedetomidine in perioperative acute pain management: a non-opioid adjuvant analgesic

Many nociceptive, inflammatory, and neuropathic pathways contribute to perioperative pain. Although opioids have long been a mainstay for perioperative analgesia, other non-opioid therapies, and dexmedetomidine, in particular, have been increasingly used as part of a multimodal analgesic regimen to provide improved pain control while minimizing opioid-related side effects. This article reviews the evidence supporting the preoperative, intraoperative, and postoperative efficacy of dexmedetomidine as an adjuvant, and the efficacy of intravenous, spinal canal, and nerve block analgesia with dexmedetomidine for perioperative acute pain treatment. While there have not been any large-scale clinical trials conducted, the current body of evidence suggests that dexmedetomidine is suitable for use as an adjuvant analgesic at all perioperative stages. However, there are potential adverse effects, such as hypotension and bradycardia, which must be taken into consideration by clinicians.

When to Pick the Nose: Out-of-Hospital and Emergency Department Intranasal Administration of Medications

The intranasal route for medication administration is increasingly popular in the emergency department and out-of-hospital setting because such administration is simple and fast, and can be used for patients without intravenous access and in situations in which obtaining an intravenous line is difficult or time intensive (eg, for patients who are seizing or combative). Several small studies (mostly pediatric) have shown midazolam to be effective for procedural sedation, anxiolysis, and seizures. Intranasal fentanyl demonstrates both safety and efficacy for the management of acute pain. The intranasal route appears to be an effective alternative for naloxone in opioid overdose. The literature is less clear on roles for intranasal ketamine and dexmedetomidine.

Computer-Assisted and Patient-Controlled Sedation Platforms

As the number and complexity of endoscopic procedures increase, the role of sedation has been integral in patient and physician satisfaction. This article discusses the advances of computer-assisted and patient-controlled platforms. These computer-assisted and patient-controlled platforms use different anesthetics and analgesics, all with the intent of achieving improved consistency in the level of sedation, appropriate to the needs of patients, while also improving patient safety. These systems have been around for decades; however, few are approved for use in the United States, and several still require further study before broad clinical application.

Intranasally Administered Adjunctive Dexmedetomidine Reduces Perioperative Anesthetic Requirements in General Anesthesia

PURPOSE

Intranasal dexmedetomidine is an effective sedative for premedication and is regularly used to reduce preoperative tension and anxiety in children. This study aimed to assess the effect of intranasally adjunctive dexmedetomidine on perioperative sedative and analgesic requirements in adults.

MATERIALS AND METHODS

Patients were randomly divided into four groups to receive preoperative administration of saline, intranasal dexmedetomidine 1 μg/kg and 2 μg/kg, and intravenous dexmedetomidine 1 μg/kg, respectively. Propofol and remifentanil were target-controlled infused to maintain intraoperative bispectral index at 45-55 and blood pressure at baseline value±20%. Sufentanil was administered to maintain postoperative visual analogue scale ≤3. Perioperative anesthetics requirements were compared using nonparametric tests.

RESULTS

Intranasal dexmedetomidine significantly attenuated propofol requirements for anesthesia induction and maintenance in a dose-dependent manner. Patients given intranasal dexmedetomidine 2 μg/kg required less remifentanil for anesthesia maintenance. The first postoperative request for sufentanil analgesia was delayed in patients given intranasal dexmedetomidine 2 μg/kg. The anesthetics-sparing effect of intranasal dexmedetomidine was significantly weaker than intravenous dexmedetomidine at the same dose of 1 μg/kg. The incidences of adverse events, including hemodynamic instability and delayed recovery, were comparable with and without intranasal dexmedetomidine.

CONCLUSION

Intranasal administration of dexmedetomidine can reduce perioperative anesthetic requirements, and a dose of dexmedetomidine 2 μg/kg produces a better effect in adults. The anesthetics-sparing effect of intranasal dexmedetomidine 1 μg/kg is less than that with the same intravenous dose of dexmedetomidine.

Dexmedetomidine in gastrointestinal endoscopic procedures

Gastrointestinal endoscopy is the gold standard in the examination and the treatment of the diseases of gastrointestinal system, but the disadvantage of being painful process. At this point the sedative and analgesic agents may be important. Dexmedetomidine is a new sedoanalgesic agent which is alternative to benzodiazepines and opioids. It has analgesia, amnesia, sedative and anxiolytic properties. The use of dexmedetomidine as the sole anesthetic agent and as the adjuvant analgesic agent has been published but has not been approved because of the inconsistency of efficacy and safety. The author has been collected the published papers in the literature. This article is aimed to describe the use of dexmedetomidine in various gastrointestinal endoscopic procedures.

Dexmedetomidine-fentanyl Compared With Midazolam-fentanyl for Conscious Sedation in Patients Undergoing Lumbar Disc Surgery

PURPOSE

Patients undergoing awake lumbar disc surgery need adequate sedation and analgesia. This study investigated whether use of a dexmedetomidine-fentanyl (DF) regimen could be superior to midazolam-fentanyl (MF) for these patients.

METHODS

Sixty patients scheduled for elective lumbar laminotomy and discectomy were randomly assigned to receive either DF or MF for conscious sedation. Patient-controlled intravenous analgesia with fentanyl was used for postoperative pain management. Hemodynamic and respiratory changes, sedation scores, pain scores, fentanyl consumption, patient satisfaction, postoperative hospital stay, and adverse events were assessed.

FINDINGS

The patient and surgical characteristics, sedation levels, and pain scores were similar in the 2 groups. Compared with the MF group, heart rate was lower in the DF group at six time points from skin incision to 15 minutes in the postanesthesia care unit (PACU), they are skin incision, 15 min after the beginning of surgery, 30 min after the beginning of surgery, skin closure, entering PACU, and 15 min in PACU (P = 0.016, 0.002, 0.000, 0.000, 0.000, and 0.001, respectively), whereas pulse oxygen saturation was higher at 3 time points from 15 minutes after the beginning of surgery to skin closure (P = 0.022, 0.026, and 0.025, respectively). The intraoperative, postoperative, and total consumption of fentanyl were lower in the DF group (total: mean difference = -69.3 µg; 95% CI, = -114.3 to -24.4; P = 0.003). No significant differences were found for adverse events, postoperative hospital stay, or satisfaction between the 2 groups.

IMPLICATIONS

Although awake lumbar disc surgery can be performed successfully under sedation with either MF or DF combination, the latter may be a better alternative because of less consumption of opioid analgesics. ChiCTR.org identifier: ChiCTR-TRC-13003645.

Intranasal Dexmedetomidine on Stress Hormones, Inflammatory Markers, and Postoperative Analgesia after Functional Endoscopic Sinus Surgery

Background. A strong ongoing intraoperative stress response can cause serious adverse reactions and affect the postoperative outcome. This study evaluated the effect of intranasally administered dexmedetomidine (DEX) in combination with local anesthesia (LA) on the relief of stress and the inflammatory response during functional endoscopic sinus surgery (FESS). Methods. Sixty patients undergoing FESS were randomly allocated to receive either intranasal DEX (DEX group) or intranasal saline (Placebo group) 1 h before surgery. Stress hormones, inflammatory markers, postoperative pain relief, hemodynamic variables, blood loss, surgical field quality, body movements, and satisfaction were assessed. Results. Plasma epinephrine, norepinephrine, and blood glucose levels were significantly lower in DEX group as were the plasma IL-6 and TNF-α levels (P < 0.05). The weighted areas under the curve (AUCw) of the VAS scores were also significantly lower in DEX group at 2–12 h after surgery (P < 0.001). Furthermore, hemodynamic variables, blood loss, body movements, discomfort with hemostatic stuffing, surgical field quality, and satisfaction scores of patients and surgeons were significantly better (P < 0.05) in DEX group. Conclusions. Patients receiving intranasal DEX with LA for FESS exhibited less perioperative stress and inflammatory response as well as better postoperative comfort with hemostatic stuffing and analgesia.