Effects of Intraoperative Dexmedetomidine Infusion on Postoperative Pain after Craniotomy: A Narrative Review

Craniotomy involves procedures with high incidences of postoperative pain. Dexmedetomidine, a highly selective a2-adrenoreceptor agonist, has been shown to be beneficial in neuroanaesthesia. The purpose of this narrative review was to assess the effect and safety of dexmedetomidine given intraoperatively during anaesthesia compared to placebo and demonstrate the effect on acute postoperative pain in adult patients undergoing craniotomy. Literature published from 1996 until 2021 were analysed through a search of PubMed, Medline and Embase. Randomised controlled trials investigating intraoperative administration of Dexmedetomidine with evaluation of postoperative pain were included. Medical Subject Headings terms and free-text words were used to identify articles related to the intraoperative use of Dexmedetomidine and postcraniotomy pain. Thirteen distinct randomized controlled trials with 882 recruited patients undergoing craniotomy were identified as eligible for final inclusion. Intraoperative administration of dexmedetomidine is associated with decreased postoperative pain and opioid consumption, and it assures haemodynamic stability. Dexmedetomidine is an efficacious adjunct in craniotomy in adults, showing benefits in reduction of postoperative pain and analgesic consumption. Dexmedetomidine also offers haemodynamic stability. However, widespread methodological heterogeneity of the papers prohibits a valid meta-analysis.

A Case of Nasal Mucosa Cautery With Reintubation Under Pharyngeal Suction for Massive Epistaxis After Extubation

We describe a case of massive epistaxis that occurred after removal of a nasal endotracheal tube, prompting emergent reintubation. Mask ventilation could not be performed because the nasal cavity was packed with gauze and the airway was being evacuated with a suction catheter. Therefore, instead of inhalational anesthetics and muscle relaxants, boluses of midazolam and remifentanil were administered, and reintubation was promptly performed. Sedation was maintained with dexmedetomidine infusion and midazolam. Nasal cautery was performed near the left sphenopalatine foramen. The patient was extubated without agitation or additional hemorrhage. Immediate recognition of the potential for airway loss, sufficient control of active bleeding, and drug selection in accordance with the emergent circumstances enabled prompt resecuring of the airway without pulmonary aspiration of blood.

The Effect of Intravenous Dexamethasone and Dexmedetomidine on Analgesia Duration of Supraclavicular Brachial Plexus Block: A Randomized, Four-Arm, Triple-Blinded, Placebo-Controlled Trial

Intravenous dexamethasone and dexmedetomidine, in conjunction with peripheral nerve blockade, have each been reported to prolong the duration of analgesia. This study tested whether combined use further prolongs analgesia duration after supraclavicular brachial plexus block (BPB) in patients undergoing orthopedic upper extremity surgery. One hundred twenty patients were randomized 1:1:1:1 to Control (saline bolus and midazolam infusion [0.05 mg/kg loading, 20 µg/kg/h thereafter]); DMED (saline bolus and dexmedetomidine infusion [1 μg/kg loading, 0.4 μg/kg/h thereafter]); DEXA (dexamethasone [10 mg] bolus and midazolam infusion); and DMED-DEXA (dexmedetomidine infusion and dexamethasone bolus) groups. The primary outcome was the duration of postoperative analgesia, defined as the time from the end of the BPB to the first dose of analgesia via a patient-controlled device. Median (interquartile range) times to first dose of analgesia in the Control, DMED, DEXA, and DMED-DEXA groups were 8.1 (6.2–11.6), 9.0 (8.1–11.3), 10.7 (8.1–20.5), and 13.2 (11.5–19.1) hours, respectively (p < 0.001). Pairwise comparisons showed significant prolongation of analgesia in the DEXA included groups compared with the non-DEXA included groups (DEXA vs. control, p = 0.045; DEXA vs. DMED, p = 0.045; DMED-DEXA vs. control, p < 0.001; DMED-DEXA vs. DMED, p < 0.001). A mixed effect model showed that dexamethasone was the only significant factor for the prolongation of analgesia (p < 0.001). Intravenous dexamethasone prolonged the analgesia duration of supraclavicular BPB after orthopedic upper extremity surgery. The concurrent use of mild to moderate sedation dose of intravenous dexmedetomidine in addition to intravenous dexamethasone showed no additional benefit to the prolongation of analgesia.

Identifying the Minimal Effective Dose of Dexmedetomidine Infusion for Post-Operative Pain Control in Laparoscopic Cholecystectomy Patients

Objective: To compare the frequency of need of rescue analgesia and time of first rescue analgesia) of two different doses 0.2 μg/kg/h and 0.4 μg/kg/h of IV dexmedetomidine in patients undergoing laparoscopic cholecystectomy (LC). Material and Methods: A total number of 68 patients planned for LC under general anesthesia were included from January-2020 to January-2021. The patients were randomly divided into two groups; group D1 patients received dexmedetomidine 0.2 μg/kg/h i.v and group D2: received dexmedetomidine0.4 μg/kg/h i.v. After shifting the patient in recovery unit, the need of rescue analgesia and time of first rescue analgesia was noted for each patient. Results: Mean age of patients was 42.64±13.54 years. There were 47 (69.12%) females and 21 (30.88%) male patients. Rescue analgesia was needed by 16 patients (47.1 %) in group D1 and 07 patients (20.6 %) in group D2. The time of first rescue analgesia was 167.50±11.64 minutes in groups D1 and 263.44±19.03 minutes in group D2 (p-value of <0.001). Conclusion: Dexmedetomidine in an infusion dosage of 0.4 µg/kg/hour is helpful in providing adequate postoperative analgesia. Keywords: Rescue analgesia, dexmedetomidine, laparoscopic cholecystectomy.

Clonidine for the Treatment of Agitation After Dexmedetomidine Discontinuation in Pediatric Patients: A Retrospective Cohort Study

OBJECTIVE Dexmedetomidine has become a widely used drug in PICUs for sedation. We aim to determine the effects of clonidine on pediatric patients after dexmedetomidine use. METHODS This was a retrospective cohort study that evaluated all pediatric patients admitted to a tertiary PICU who received dexmedetomidine infusion for &gt;48 hours. Outcomes in patients exposed to clonidine (CLON) were compared with those of patients who were not exposed (NoCLON). RESULTS A total of 216 patients were included in this study (43 CLON and 173 NoCLON). The primary outcome, agitation, was less in the CLON cohort (9.3%) than in the NoCLON cohort (9.3% versus 29.5%, respectively; p &lt; 0.01). Hospital LOS was longer in the CLON group (59 versus 20 days, p &lt; 0.01), as was PICU LOS (37.4 versus 11.1 days, p &lt; 0.01). There was no significant difference in the occurrence of increased heart rate or blood pressure between the 2 cohorts. Patients exposed to concurrent midazolam and opioid infusions had higher incidence of agitation when they did not receive clonidine (CLON 8% versus NoCLON 37%, OR 0.15; 95% CI, 0.05–0.51; p &lt; 0.01). In contrast, there was no difference in the incidence of agitation for the CLON group versus the NoCLON group when dexmedetomidine was administered alone (25% versus 19%, OR 1.4; p = 0.99). CONCLUSIONS Our study confirms the importance and effectiveness of clonidine to treat agitation after dexmedetomidine discontinuation. A validated withdrawal scoring tool can help better define dexmedetomidine withdrawal in pediatric patients.