Authors: Uduak U. Williams, M.D.; Elizabeth Rebello, M.D., FASA
ASA Monitor 02 2018, Vol.82, 14-15.
The number of outpatient surgical procedures in the United States has more than doubled from 12 to 26 million over the past few decades.1 The anesthetic plan should be tailored to allow rapid recovery; however, the combination of sedatives with analgesics such as opioids can lead to respiratory depression, which could prolong recovery from ambulatory surgery. In addition, we are increasingly aware that some portion of opioid-naïve patients may become chronic opioid users following surgery.2 –4 With the ongoing public health crisis of opioid addiction, more focus and attention has been placed on decreasing perioperative opioid consumption. Fortunately, adjuvants such as dexmedetomidine may be incorporated into the anesthetic plan in order to decrease perioperative opioid requirements and usage.
Dexmedetomidine is a centrally acting selective alpha-2 receptor agonist with sedative, analgesic and neuroprotective properties. It is very valuable in the ambulatory setting given its properties of sedation with limited respiratory depression. Sedation is believed to be due to the activation of presynaptic and postsynaptic alpha-2 receptors in the locus coeruleus. The drug was initially approved for sedation in the ICU for up to 24 hours duration; however, its clinical uses have expanded over the past few years. For example, in 2003 the U.S. Food and Drug Administration (FDA) added an indication for dexmedetomidine for surgical and procedural sedation.
The sedation and reduced opioid consumption associated with dexmedetomidine is not without cost: there may be a longer recovery time in the postanesthesia care unit. For example, Wang et al. performed a randomized controlled trial comparing dexmedetomidine and propofol for conscious sedation during inguinal hernia repair in the ambulatory setting. Their results showed a significantly reduced intraoperative fentanyl requirement in the group receiving dexmedetomidine, a reduced pain score and a slightly longer recovery time post-procedure.5 Long et al. also found a decrement in narcotic administration postoperatively in patients undergoing thyroidectomy in the ambulatory setting.6 In addition, Salman et al. showed reduced analgesic requirements with the use of dexmedetomidine infusion in ambulatory laparoscopic surgery patients.7 Dexmedetomidine may be of added benefit in sleep apnea-prone patients with morbid obesity as it reduces narcotic consumption and preserves respiratory drive.8
“Multiple studies demonstrate the opioid-sparing effect of dexmedetomidine. It should be considered as a potential adjuvant to the multimodal treatment plan in the outpatient setting.”
The meta-analysis by Schnabel et al. of 28 randomized controlled trials (RCTs) including 1,420 adult ambulatory surgery patients demonstrated that dexmedetomidine administration led to lower postoperative pain, reduced opioid consumption and a lower risk for opioid-related adverse events.9 A systematic review of the pediatric population by Zhu et al. had similar findings.10 Another meta-analysis involved 11 RCTs with pediatric patients undergoing appendectomies, otolaryngology procedures, adenotonsillectomies and other outpatient procedures.11 This study noted decreased emergence agitation compared to placebo and decreased postoperative nausea and vomiting (PONV). However, achieving statistical significance in reducing PONV has not been shown in the majority of studies.
The primary adverse event with perioperative use of dexmedetomidine is bradycardia. In addition, the half-life of dexmedetomidine is approximately two hours, which may delay discharge in the recovery room. Studies have been equivocal.
With the current national opioid crisis, finding adjuvants to reduce the need for opioids in the ambulatory setting is in the best interests of our patients. Multiple studies demonstrate the opioid-sparing effect of dexmedetomidine. It should be considered as a potential adjuvant to the multimodal treatment plan in the outpatient setting. Further studies to explore the clinical benefit and long-term effects of dexmedetomidine are needed.
References:
Koyyalamudi V, Sen S, Patil S, et al. Adjuvant agents in regional anesthesia in the ambulatory setting. Curr Pain Headache Rep. 2017;21(1):6.
Clarke H, Soneji N, Ko DT, Yun L, Wijeysundera DN . Rates and risk factors for prolonged opioid use after major surgery: population based cohort study. BMJ. 2014;348:g1251.
Alam A, Gomes T, Zheng H, Mamdani MM, Juurlink DN, Bell CM . Long-term analgesic use after low-risk surgery: a retrospective cohort study. Arch Intern Med. 2012;172(5):425–430.
Goesling J, Moser SE, Zaidi B, et al. Trends and predictors of opioid use after total knee and total hip arthroplasty. Pain. 2016;157(6): 1259–1265.
Wang HM, Shi XY, Qin XR, Zhou JL, Xia YF . Comparison of dexmedetomidine and propofol for conscious sedation in inguinal hernia repair: a prospective, randomized, controlled trial. J Int Med Res. 2017;45(2):533–539.
Long K, Ruiz J, Kee S, et al. Effect of adjunctive dexmedetomidine on postoperative intravenous opioid administration in patients undergoing thyroidectomy in an ambulatory setting. J Clin Anesth. 2016;35:361–364. Salman AE, Aypar U . Dexmedetomidine as a substitute for remifentanil in ambulatory gynecologic laparoscopic surgery. Saudi Med J. 2009;30(1):77–81.
Abu-Halaweh S, Obeidat F, Absalom AR, et al. Dexmedetomidine versus morphine infusion following laparoscopic bariatric surgery: effect on supplemental narcotic requirement during the first 24 h. Surg Endosc. 2016;30(8):3368–3374.
Schnabel A, Meyer-Friessem CH, Reichl SU, Zahn PK, Pogatzki-Zahn EM . Is intraoperative dexmedetomidine a new option for postoperative pain treatment? A meta-analysis of randomized controlled trials. Pain. 2013;154(7):1140–1149.
Zhu A, Benzon HA, Anderson TA . Evidence for the efficacy of systemic opioid-sparing analgesics in pediatric surgical populations: a systematic review. Anesth Analg. 2017;125(5):1569–1587.
Schnabel A, Reichl SU, Poepping DM, Kranke P, Pogatzki-Zahn EM, Zahn PK . Efficacy and safety of intraoperative dexmedetomidine for acute postoperative pain in children: a meta-analysis of randomized controlled trials. Paediatr Anaesth. 2013;23(2):170–179.