Dexmedetomidine-fentanyl versus propofol-fentanyl in flexible bronchoscopy: A randomized study

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.

Tracheal stenting by rigid bronchoscopy in right lateral decubitus position in an awake patient

Rigid bronchoscopy is a common procedure for central airway obstructions (CAO). Many patients with advanced lesions causing CAO have tenuous, positionally dependent respiratory status which requires additional procedural considerations. This case report describes a 57-year-old man with high grade epithelioid angiosarcoma of the right lung and pleura who underwent placement of a tracheal stent by rigid bronchoscopy in the novel procedural conditions of right lateral decubitus, semi-sitting position with dexmedetomidine, midazolam, and propofol for moderate sedation. Dexmedetomidine, which is currently in use for flexible bronchoscopy due to its analgesic, anxiolytic, and antisialogogue properties performed ideally and should be further evaluated for this indication.

Safety and Efficacy of Dexmedetomidine for Bronchoscopy: A Systematic Review and Meta-Analysis

(1) Background: Anesthetic sedatives are widely used for bronchoscopy, and controversy surrounds the safety and efficacy of dexmedetomidine compared to other sedatives. The aim of this study is to evaluate the safety and efficacy of dexmedetomidine in bronchoscopy through a systematic review. (2) Methods: PubMed, Embase, Google Scholar, and Cochrane Library electronic databases were searched for a randomized controlled study of dexmedetomidine (Group D) or other sedative drugs (Group C) for bronchoscopy. Data extraction, quality assessment, and risk of bias analysis were performed in accordance with the preferred reporting items for systematic review and meta-analysis requirements. Meta-analysis was performed using RevMan 5.2. (3) Results: Nine studies were included, with a total of 765 cases. Compared to Group C, the incidence of hypoxemia (OR = 0.40, 95% CI (0.25, 0.64) p = 0.0001, I² = 8%) and tachycardia (OR = 0.44, 95% CI (0.26,0.74), p = 0.002, I² = 14%) were lower, but bradycardia (OR = 3.71, 95% CI (1.84, 7.47), p = 0.0002, I² = 0%) was higher in Group D; no significant difference was observed in other outcome indicators. (4) Conclusions: Dexmedetomidine reduces the incidence of hypoxemia and tachycardia during bronchoscopy but is more likely to provoke bradycardia.

The utility of a multi-orifice epidural catheter when using the "Spray-as-You-Go" technique for topical Airway Anesthesia during Flexible Bronchoscopy, a randomised trial

BACKGROUND

Lidocaine administered through the working channel of a flexible bronchoscope can provide effective local anesthesia but cannot achieve good distribution in the airway. This study was undertaken to determine whether lidocaine delivered via a multi-orifice epidural catheter (three orifices/openings) is superior to conventional method and if a better distribution and decreased the cough reflex can be achieved.

METHODS

The patients (N = 100; 50 in each group) were randomized to receive either topical airway anesthesia by the "spray-as-you-go" technique via conventional application (group C) through the working channel of the bronchoscope or via a triple-orifice epidural catheter (group E). The primary outcome measurement was the cough severity, which was documented using a 4-point scale. Bronchoscopists and nurses assessed the coughing. The visual analogue scale (VAS) score for cough, total consumption of propofol and lidocaine, requirement frequency of propofol and topical anesthesia, PACU retention time, and adverse events were also compared.

RESULTS

There was a significant difference in the median cough severity scores between the two groups (group C: 3 vs. group E: 2, P = 0.004). The median visual analogue scale (VAS) scores for the cough, were significantly higher in group C than those in group E (bronchoscopist: 3 vs. 2 P = 0.002; nurse: 3 vs. 2, P < 0.001). The incidence of cough was significantly higher in group C in the trachea, left and right bronchi. The highest respiratory rate was higher in group C than in group E (P < 0.01). Eight patients in group C and two patients in group E had an oxygen saturation below 90% during flexible bronchoscopy(FB) (P = 0.046). More patients in group C required extra topical anesthesia than in group E (P < 0.001). The total lidocaine consumption was also higher in group C than that in group E (P < 0.001).

CONCLUSIONS

Endotracheal topical anesthesia via the multi-orifice epidural catheter (three holes/openings) during flexible bronchoscopy using the "spray-as-you-go" technique was appeared to be superior to the conventional method.

The Effect of Two Different Dexmedetomidine Doses on the Prevention of Nausea and Vomiting in Discectomy Surgery under Spinal Anesthesia

Background

Considering the preventative effect of various medications on such complications after surgery, the present study evaluated the effect of two different dexmedetomidine doses on the prevention of nausea and vomiting in discectomy surgery.

Materials and Methods

The present controlled, double-blind clinical trial was performed on 135 patients that were candidates for discectomy surgery under spinal anesthesia, which were randomly allocated into three groups. Two different dexmedetomidine doses of 0.2 and 0.5 mcg/kg/h were intravenously administered using an infusion pump for 10 min in the first (DEX-0.2 group) and second (DEX-0.5 group) groups, respectively, with the third placebo group being used as a control group. Hemodynamic parameters, the severity of nausea and vomiting, and the incidence of complications were evaluated and recorded up to 24 h after surgery.

Results

The results of the present study revealed that, 20 min after the intervention, the severity of nausea and vomiting in the control group (with the mean of 1.95 ± 1.58) was significantly higher than that of the DEX-0.2 and DEX-0.5 groups with the means of 1.52 ± 1.11 and 1.27 ± 0.99, respectively (P = 0.010). In addition, no significant difference was found between the two dexmedetomidine doses in terms of the severity of nausea and vomiting (P > 0.05).

Conclusion

According to the results of the present study, a low dose of dexmedetomidine may be a more preferable choice as a preventive drug in the incidence of nausea and vomiting in discectomy surgery due to its lower complications, further reduction of nausea and vomiting, and more desirable hemodynamic stability.

Comparing Efficacy of Propofol and Dexmedetomidine in Conscious Sedation During Stapedotomy Surgery

Introduction

We decided to compare dexmedetomidine with propofol regarding several anesthetic and surgical aspects, during stapedotomy done under conscious sedation.

Materials and Method

Thirty patients aged 20-50 years with (American Society of Anesthesiology) ASA class I-II, were assigned to two groups of propofol and dexmedetomidine using a random number table. In dexmedetomidine group, patients received dexmedetomidine infusion (0.5 µg/kg/h) and in the control group, propofol was administered (3 mg/kg/h).Time to reach the desired Ramsey Sedation Score (RSS) and time to reach Aldrete score ≥ 9; incidence of inadvertent movement and amnesia; as well as patients' and surgeons' level of satisfaction and degree of bleeding was recorded. Data on hemodynamic variables were monitored and recorded at several intervals.

Results

The mean time taken to reach the RSS (2-4) was 10.3 ± 2.1 min in dexmedetomidine group and 3.1 ± 1.2 min in propofol group. Time to reach Aldrete score ≥ 9 for patients sedated with dexmedetomidine was 8.6 ± 2.1 min and for propofol group was 4.6 ± 1.4 min (p value < 0.05).There were also significant differences between two groups in terms of surgeon's satisfaction with sedation, and the amount of intra operative bleeding.

Conclusion

According to the results of this study, it can be concluded that dexmedetomidine is a better choice for conscious sedation than propofol. However, the time to reach the required sedation in the dexmedetomidine group was significantly longer.

Dexmedetomidine versus propofol sedation in flexible bronchoscopy: a randomized controlled trial

Background

Dexmedetomidine (DEX), is a highly selective alpha2 adrenoceptor (α2-AR) agonist, successfully used in various procedures including flexible bronchoscopy. Randomized controlled trials (RCTs) evaluating DEX sedation during bronchoscopy report equivocal results regarding respiratory and hemodynamic outcomes.

Methods

We conducted an RCT to evaluate the efficacy and safety of dexmedetomidine compared to propofol for sedation during bronchoscopy. The primary outcome was the number of desaturation events, secondary outcomes were transcutaneous Pco2 level, hemodynamic adverse events and physician and patient satisfaction.

Results

Overall, 63 patients were included, 30 and 33 in the DEX and propofol groups, respectively. The number of desaturation events was similar between groups, median (IQR) 1 (0–1) and 1 (0–2) in the DEX and control groups, respectively (P = 0.29). Median desaturation time was 1 (0–2) and 1 (0–3) minutes in the DEX and control groups, respectively (P = 0.48). Adverse events included hypotension, 33% vs 21.1% in intervention and control groups, respectively (P = 0.04), bradycardia, cough, and delayed recovery from sedation. Total adverse events were 22 and 7 in DEX and propofol groups, respectively (P = 0.009).

Conclusion

Dexmedetomidine sedation during bronchoscopy did not show differences in oxygen saturation and transcutaneous CO2 level in comparison to propofol. Moreover, DEX sedation required a significantly higher number of rescue boluses, due to inadequate sedation and was associated with a higher rate of adverse events.

Trial registration NCT04211298, registration date: 26.12.2019.

Clinical usefulness of intermediate-dose dexmedetomidine (0.75 μg/kg) in flexible bronchoscopy - A prospective, randomized, double-blinded study

BACKGROUND:

Dexmedetomidine, although an effective drug for conscious sedation during flexible bronchoscopy, has occasional side effects on the cardiovascular system which need to be addressed.

MATERIALS AND METHODS:

Patients between 18 and 65 years, requiring diagnostic flexible bronchoscopy, found eligible, after screening, were randomized to either receive 0.75 μg/kg intravenous dexmedetomidine over 10 min or intravenous midazolam 0.035 mg/kg over 1 min. Composite score was used as the primary outcome measure. Additional parameters recorded were: Hemodynamic variables, oxygen saturation, Ramsay sedation score, for pain intensity and distress Numerical Rating Scale, number of rescue medication doses, ease of doing bronchoscopy, Visual Analog Scale score for cough and response of the patient 24 h after bronchoscopy.

RESULTS:

In each group, 24 patients were enrolled. The composite score was in the ideal category in 24 patients in dexmedetomidine group and 21 in midazolam group, at nasopharynx (P = 0.234). The corresponding values at the level of trachea were 23 and 16 (P = 0.023). In dexmedetomidine group, patient response after 24 h of bronchoscopy showed quality of sedation to be excellent in 0 subjects, good in 13, fair in 9 and poor in 2 and discomfort to be nil in 7, mild 10, moderate in 7 and severe in 0. The corresponding values in midazolam group for quality of sedation were 0, 4, 14, 6, and for discomfort 0, 10, 14, 0. The Visual Analog Scale (VAS) for cough revealed a mean score of 0.800 and 1.812 (P = 0.011) during and 2.092 and 3.542 (P = 0.016) 24 h after bronchoscopy in the respective study groups.

CONCLUSION:

Low-dose dexmedetomidine (0.75 μg/kg single dose) appears to provide better patient comfort and equivalent safety profile when compared with midazolam.

Bronchoscopy during COVID-19 pandemic, ventilatory strategies and procedure measures

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has changed bronchoscopy practices worldwide. Bronchoscopy is a high-risk aerosol-generating procedure with a potential for direct SARS-CoV-2 exposure and hospital-acquired infection. Current guidelines about personal protective equipment and environment considerations represent key competencies to minimize droplets dispersion and reduce the risk of transmission. Different measures should be put in field based on setting, patient's clinical characteristics, urgency and indications of bronchoscopy. The use of this technique in SARS-CoV-2 patients is reported primarily for removal of airway plugs and for obtaining microbiological culture samples. In mechanically ventilated patients with SARS-CoV-2, bronchoscopy is commonly used to manage complications such as hemoptysis, atelectasis or lung collapse when prone positioning, physiotherapy or recruitment maneuvers have failed. Further indications are represented by assistance during percutaneous tracheostomy. Continuous positive airway pressure, non-invasive ventilation support and high flow nasal cannula oxygen are frequently used in patient affected by Coronavirus Disease-2019 (COVID-19): management of patients' airways and ventilation strategies differs from bronchoscopy indications, patient's clinical status and in course or required ventilatory support. Sedation is usually administered by the pulmonologist (performing the bronchoscopy) or by the anesthetist depending on the complexity of the procedure and the level of sedation required. Finally, elective bronchoscopy for diagnostic indications during COVID-19 pandemic should be carried on respecting rigid standards which allow to minimize potential viral transmission, independently from patient's COVID-19 status. This narrative review aims to evaluate the indications, procedural measures and ventilatory strategies of bronchoscopy performed in different settings during COVID-19 pandemic.

Dexmedetomidine sedation for endobronchial ultrasound-guided transbronchial needle aspiration, a randomised controlled trial

Background and aim

Appropriate sedation is important to the success of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). Dexmedetomidine is a sedative agent that operates via the α2 adrenergic agonist, which provides sleep-like sedation with little respiratory suppression. This study compared the efficacy and safety of dexmedetomidine sedation with propofol in cases of EBUS-TBNA.

Methods

Patients requiring EBUS-TBNA were randomly assigned dexmedetomidine sedation (D, n=25) or propofol sedation (P, n=25). Vital signs, diagnostic yield and the bispectral index (BIS) were recorded throughout the bronchoscopic procedure and recovery period. The tolerance and cooperation of the patients were evaluated using questionnaires.

Measurements and results

The lowest mean arterial blood pressure in group D (79.2±9.9 versus 72.5±12.9 mmHg, p=0.049) exceeded that in group P, the lowest heart rate was lower (60.9±10.2 versus 71.4±11.8 beats·min⁻¹, p=0.006) and the mean BIS during sedation was significantly higher (84.1±8.3 versus 73.6±5.7, p<0.001). Patients in group D were more likely to report perceiving procedure-related symptoms and express an unwillingness to undergo the bronchoscopy again, if indicated (41.1 versus 83.3%, p=0.007). One subject in group D aborted EBUS-TBNA due to intolerance. Many of the variables in the two groups were similar, including the proportion of hypoxaemic events, recovery times, patient cooperation and diagnostic yield.

Conclusions

The effects of dexmedetomidine on haemodynamics were in line with its pharmacodynamic features. Patients who received dexmedetomidine were more likely than those who received propofol to perceive the procedures. Overall, dexmedetomidine did not prove inferior to propofol sedation in terms of patient cooperation or diagnostic yield.

Compared to propofol sedation for EBUS-TBNA, dexmedetomidine provided patients lighter sedation with lower heart rates and less decrease in blood pressure. The recovery times, hypoxaemia, cooperation and diagnostic yield in the two groups were similar.https://bit.ly/33qgEj3

Comparison of midazolam and low-dose dexmedetomidine in flexible bronchoscopy: A prospective, randomized, double-blinded study

BACKGROUND

Dexmedetomidine is a clinically useful drug for providing sedation, but concern regarding its cardiovascular side effect profile can limit its widespread use during routine diagnostic flexible bronchoscopy (FB).

MATERIALS AND METHODS

Patients between 18 and 65 years of age, who required diagnostic FB, were screened. Eligible patients were randomized to either receive 0.5 μg/kg intravenous dexmedetomidine over 10 min or intravenous midazolam 0.035 mg/kg over 1 min. If required, rescue medication (intravenous midazolam 0.5 mg bolus) was administered. The primary outcome measure was the composite score. Other parameters observed were numerical rating scale, hemodynamic variables, oxygen saturation, number of doses of rescue medication, visual analog scale score for cough, ease of bronchoscopy, Ramsay Sedation Score, and postprocedure patient response after 24 h of bronchoscopy.

RESULTS

A total of 54 patients were enrolled, 27 in each group. Total composite score (mean ± standard deviation) in dexmedetomidine and midazolam group at nasopharynx was 7.04 ± 2.19 and 6.59 ± 1.55 (P = 0.387), respectively. The corresponding values at the level of trachea were 9.22 ± 3.69 and 8.63 ± 2.13 (P = 0.475). In the dexmedetomidine group, patient response after 24 h of bronchoscopy showed the quality of sedation to be excellent in three patients, good in 10, fair in 11, and poor in 3 and discomfort to be nil in 14, mild 7, moderate in 3, and severe in 3. The corresponding values in the midazolam group for the quality of sedation were 0, 9, 18, 0 and for discomfort 10, 16, 1, 0. Other parameters did not reveal any statistically significant difference.

CONCLUSION

Dexmedetomidine at a dose of 0.5 μg/kg may provide clinically useful conscious sedation, comparable to midazolam.

Nebulized dexmedetomidine-lidocaine inhalation as a premedication for flexible bronchoscopy: a randomized trial

Background

Dexmedetomidine plus opioid infusion after topical anaesthesia with nebulized lidocaine for cough suppression is a commonly used method for flexible bronchoscopy. Recently, the use of dexmedetomidine as an additive to local anaesthetics has been reported to have several advantages over conventional intravenous administration. However, there are no data regarding the use of nebulized dexmedetomidine-lidocaine for topical anaesthesia as a premedication for flexible bronchoscopy. Therefore, this study compared the tolerability and safety of nebulized dexmedetomidine with that of conventional intravenous administration in patients undergoing bronchoscopy with moderate sedation.

Methods

Sixty patients requiring flexible bronchoscopy were randomly assigned to three groups: (I) nebulized dexmedetomidine + lidocaine, n=20; (II) intravenous dexmedetomidine + nebulized lidocaine, n=20; and (III) nebulized lidocaine alone (no dexmedetomidine), n=20. The patients' coughing scores were assessed and graded. Our primary hypothesis was that nebulized dexmedetomidine-lidocaine could reduce the incidence of moderate to severe coughing. The secondary endpoints were the rates of glottis closure, complete jaw relaxation and limb movement during the procedure; the elapsed time until recovery; and the dosages of vasoconstrictors and atropine.

Results

The incidence of moderate to severe coughing was 15% in the nebulized dexmedetomidine group, 50% in the intravenous dexmedetomidine group and 55% in the no dexmedetomidine group. The nebulized dexmedetomidine group had the lowest incidence of moderate to severe coughing (P=0.019). Nebulized dexmedetomidine showed a protective effect for reducing coughing compared with intravenous dexmedetomidine [P=0.008, odds ratio (OR): 0.273, 95% confidence interval (CI): 0.089-0.833]. No differences in the rates of complete jaw relaxation and limb movement during the procedure were observed among the three groups (all P>0.05). The rates of glottis closure were similar (20%, 25%, and 35%; P>0.05). The elapsed time until recovery in the nebulized dexmedetomidine group was significantly shorter than that in the intravenous dexmedetomidine group (10.60±1.39 vs. 15.10±1.45, P<0.001). The vasoconstrictor dosages were significantly lower in the nebulized dexmedetomidine group than in the intravenous dexmedetomidine group (P<0.001).

Conclusions

Nebulized dexmedetomidine-lidocaine inhalation as a premedication for flexible bronchoscopy was well tolerated during bronchoscopies performed under moderate sedation and was associated with a reduced incidence of moderate to severe coughing, a shorter recovery time and reduced vasoconstrictor consumption.

Effect of dexmedetomidine combined with lumbar anesthesia on Th1/Th2 in maternal patients and neonates undergoing caesarean section

The selection of anesthetic method and drugs is of utmost importance for patients undergoing caesarean section. The application of anesthetic drugs may affect the immune system of the maternal patient and neonate. Therefore, the present study aimed to analyze the effect of dexmedetomidine combined with lumbar anesthesia on type 1 T-helper cells (Th1) and Th2 cytokines in mothers and their neonates undergoing caesarean section. A total of 60 females with full-term pregnancies and an American Society of Anesthesiologists grade I or II who received caesarean section were selected and equally divided in a randomized manner into a control group receiving lumbar epidural anesthesia and a combination group treated by dexmedetomidine combined with lumbar epidural anesthesia. The visual analogue scale (VAS) score, adverse reactions, traction response and the neonates' Apgar score were compared between the two groups. The levels of interleukin-2 (IL-2), tumor necrosis factor-α (TNF-α), IL-4 and IL-10 in the blood of mothers and neonates were detected by reverse transcription-quantitative PCR and ELISA. The results indicated no statistically significant difference in the Apgar score between the two groups. The VAS scores, adverse reactions, reduced traction response, as well as IL-2 and TNF-α expression, in the mothers of the combination group were significantly decreased, while IL-4 and IL-10 were obviously elevated compared with those in the controls (P<0.05). Furthermore, IL-2 and TNF-α levels were markedly declined, whereas IL-4 and IL-10 expression was apparently enhanced in the neonates from the combination group compared with those in the control group (P<0.05). In conclusion, dexmedetomidine in addition to lumbar epidural anesthesia reduces the VAS score, adverse reactions and traction response, and promotes the conversion of Th1 cytokines to Th2 cytokines in mothers/nonates after caesarean section.

Guidelines for diagnostic flexible bronchoscopy in adults: Joint Indian Chest Society/National College of chest physicians (I)/Indian association for bronchology recommendations

Flexible bronchoscopy (FB) is commonly performed by respiratory physicians for diagnostic as well as therapeutic purposes. However, bronchoscopy practices vary widely across India and worldwide. The three major respiratory organizations of the country supported a national-level expert group that formulated a comprehensive guideline document for FB based on a detailed appraisal of available evidence. These guidelines are an attempt to provide the bronchoscopist with the most scientifically sound as well as practical approach of bronchoscopy. It involved framing appropriate questions, review and critical appraisal of the relevant literature and reaching a recommendation by the expert groups. The guidelines cover major areas in basic bronchoscopy including (but not limited to), indications for procedure, patient preparation, various sampling procedures, bronchoscopy in the ICU setting, equipment care, and training issues. The target audience is respiratory physicians working in India and well as other parts of the world. It is hoped that this document would serve as a complete reference guide for all pulmonary physicians performing or desiring to learn the technique of flexible bronchoscopy.

The comparison of propofol and midazolam for bronchoscopy: A meta-analysis of randomized controlled studies

BACKGROUND

Propofol and midazolam are widely used for the sedation of bronchoscopy. This systematic review and meta-analysis is conducted to compare the efficacy of propofol and midazolam for bronchoscopy.

METHODS

The databases including PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases are systematically searched for collecting the randomized controlled trials (RCTs) regarding the efficacy of propofol and midazolam for bronchoscopy.

RESULTS

This meta-analysis has included 4 RCTs. Compared with midazolam intervention in patients undergoing bronchoscopy, propofol intervention is associated with remarkably reduced recovery time [standard mean difference (SMD) = -0.74; 95% confidence interval (95% CI) = -1.04 to -0.45; P < .00001], but demonstrates no significant impact on operation time (SMD = -0.01; 95% CI = -0.16 to 0.13; P = .87), induction time (SMD = -0.58; 95% CI = -1.19 to 0.03; P = .06), lowest oxyhemoglobin saturation (SpO2, SMD = 0.24; 95% CI = -0.09 to 0.58; P = .15), SpO2 <90% [risk ratio (RR) = 1.02; 95% CI = 0.82-1.25; P = .88), and major arrhythmias (RR = 0.56; 95% CI = 0.26-1.19; P = .13).

CONCLUSION

Propofol sedation is able to reduce recovery time and shows similar safety compared with midazolam sedation during bronchoscopy.

Anesthetic Considerations for Mediastinal Staging Procedures for Lung Cancer

Tumor staging is critical for the treatment of lung malignancies. Invasive techniques of lung tumor staging can be accomplished via mediastinoscopy, endobronchial ultrasound, and video-assisted thoracoscopy. Anesthesiologists taking care of patients undergoing mediastinal staging procedures might face different challenges. In this narrative review, the authors summarize the literature on the anesthetic considerations for mediastinal staging procedures.

Significant Bradycardia in Critically Ill Patients Receiving Dexmedetomidine and Fentanyl

Purpose

To report a case series of three patients who developed significant bradycardia while receiving the combination of dexmedetomidine and fentanyl for sedation and analgesia.

Materials and Methods

This is a case series of patients obtained from a mixed medical, surgical, and cardiac ICU in a community teaching hospital. Three intubated patients receiving fentanyl and dexmedetomidine infusion developed sudden bradycardia requiring intervention. In all three cases, adjustments to therapy were required.

Results

All three patients experienced significant bradycardia, with a heart rate less than 50 bpm, and one patient briefly developed asystole. In Case  1, the fentanyl infusion rate was reduced by 67% and the dexmedetomidine infusion rate was reduced by 25%. In Case  2, the sedation was changed to midazolam, and in Case  3, both fentanyl and dexmedetomidine were discontinued. In all three cases, there were no further incidences of significant bradycardia following intervention.

Conclusions

Fentanyl used in combination with dexmedetomidine can result in clinically significant bradycardia. Further study is warranted to identify risk factors and elucidate the mechanisms that result in life-threatening bradycardia.