Local anesthesia and sedation with dexmedetomidine (Precedex, Hospira) is more efficient and better tolerated than general anesthesia when conducting stapes surgery, according to a new study.
“We’re talking about a very delicate microsurgery within the ear,” noted Lynnie Correll, MD, PhD, of the Anesthesiology Department of the University of Rochester Medical Center, in Rochester, N.Y. Stapedotomy is a procedure in which a small fenestration is created in the footplate using either a laser or microdrill, after which a prosthesis is placed inside the hole. The procedure is the go-to surgical treatment for patients suffering from otosclerosis—a conductive hearing loss caused by disease of the bones in the otic capsule, often involving limited fixation of the stapes bone in the anterior cura.
A Retrospective Look
“The difficulty is that having surgery in your ear hurts, and people move around a lot,” Dr. Correll explained during a poster presentation at the New York State Society of Anesthesiologists 69th Annual PostGraduate Assembly. “But it would be really great if, in the middle of the surgery, the surgeon were able to ask, ‘Hey, can you hear?’ The goal is to potentially create a technique where the patient is awake enough to say, ‘I can hear now,’ but they’re not wiggling all over the place, because the size of the bone … is only 3 mm.”
Dr. Correll and her colleagues conducted a retrospective chart review of all 52 cases performed between September 2009 and January 2014 by a single surgeon at the University of Rochester, an academic medical center. They assessed differences between the use of general anesthesia and local anesthesia and sedation with dexmedetomidine. The team examined differences in duration of surgery, estimated blood loss, use of postoperative narcotics, nausea and vomiting, hemodynamic instability and the general ability of the patient to tolerate the procedure.
Before the study, Dr. Correll and her team posited that for this surgery, dexmedetomidine was as safe as standard general anesthesia.
“I always tell my patients that anesthesia is like taking a walk,” Dr. Correll explained. “You can go to the park, or you can climb Mount Kilimanjaro. Those are really different walks, but they’re both walks, and they both have risks.” In other words, both protocols were considered to have similar risk factors.
Of the 52 cases, only one case required conversion to general anesthesia when the original intention was to use dexmedetomidine. There was no difference between the two groups in hemodynamic instability or estimated blood loss, and patients generally required similar amounts of postoperative antiemetics and narcotics. Dr. Correll concluded that “in the vast majority of these surgeries,” use of dexmedetomidine is an appropriate approach.
Variation in Operating Time
An unexpected finding was a difference in operative time. The average duration of surgery was 56 minutes in the dexmedetomidine group and 70 minutes in the general anesthesia group.
“We’re not sure what accounts for the difference in time, because what is accounted for is strictly surgical time—the time between when the incision is made and the conclusion of the procedure.” Dr. Correll noted, “But the difference in time that it takes for a surgery that typically takes 45 minutes to an hour was 17 minutes. This is really huge.”
Because the cost of procedures is directly correlated with the amount of time spent in the operating room, the use of dexmedetomidine might offer a significant financial benefit when performing these surgeries. “Our next step is to analyze just what accounts for this difference in operative time,” Dr. Correll added.