Research and Opinion in Anesthesia & Intensive Care

ORIGINAL ARTICLE
Year
: 2017  |  Volume : 4  |  Issue : 3  |  Page : 129--133

Shorter postanesthesia care unit stay with dexmedetomidine infusion during laparoscopic bariatric surgery: a randomized controlled trial


Mohamed El Sayed, Akmal Abdelsamad, Ayat Amer 
 Department of Anesthesia and Intensive Care, Faculty of Medicine, Zagazig University, Zagazig, Egypt

Correspondence Address:
Mohamed El Sayed
Department of Anesthesia and Intensive Care, Faculty of Medicine, Zagazig University, Zagazig
Egypt

Abstract

Introduction Lesser narcotics use during laparoscopic bariatric surgery is needed to decrease the impact on respiratory parameters and reduce analgesic requirements after surgery. Using dexmedetomidine has a role in perioperative pain control in obese patients’ recovery in postanesthetic care unit (PACU) and hospital stay. In this study, we hypothesized that dexmedetomidine would delay and decrease opioid requirements during surgery, promoting less time in the PACU and faster, safer recovery. Patients and methods After obtaining ethics committee approval, informed consent to participate in this study was obtained from 56 patients who were scheduled for planned laparoscopic bariatric surgery. Patients were randomly divided into two groups − group D (n=28) received dexmedetomidine 1 µg/kg loading for 10 min and 0.4 µg/kg/h maintenance until extubation, and group N (n=28) received normal saline (placebo) at the same volume and rate. PACU stay time, the total amount of intraoperative fentanyl used, recovery profile, pain score, and the total amount of pethidine used postoperatively were measured. Results The dexmedetomidine group showed significant decrease in intraoperative and postoperative hemodynamics, shorter recovery time, and shorter stay in PACU. Perioperative narcotic use, intraoperative fentanyl use, visual analog scale scores, PACU pethidine dose in the first hour, and total pethidine dose on the first day were significantly less in the dexmedetomidine group. Patient satisfaction at discharge regarding pain management was less in the control group. Conclusion Intraoperative dexmedetomidine infusion with its opioid-sparing effect enhanced recovery in this study population of morbidly obese patients undergoing laparoscopic bariatric surgery with minimal side-effects.



How to cite this article:
El Sayed M, Abdelsamad A, Amer A. Shorter postanesthesia care unit stay with dexmedetomidine infusion during laparoscopic bariatric surgery: a randomized controlled trial.Res Opin Anesth Intensive Care 2017;4:129-133


How to cite this URL:
El Sayed M, Abdelsamad A, Amer A. Shorter postanesthesia care unit stay with dexmedetomidine infusion during laparoscopic bariatric surgery: a randomized controlled trial. Res Opin Anesth Intensive Care [serial online] 2017 [cited 2017 Nov 18 ];4:129-133
Available from: http://www.roaic.eg.net/text.asp?2017/4/3/129/209663


Full Text

 Introduction



The global increase in obesity has led to an increase in the number of obese patients presenting to hospitals with various health conditions [1]. The WHO has estimated that around 1.5 billion people worldwide are obese, and many of them are candidates for bariatric surgeries [2]. Being effective procedures, bariatric surgeries are increasing becoming one of the most common surgical interventions of the gastrointestinal tract [3].

There are many challenges and difficulties that anesthesiologists have to deal with when treating obese and morbidly obese patients, because of their sensitive respiratory system to the depressant effects of opioid analgesics. They have a higher risk of respiratory depression and hemodynamic instability, which may thus increase morbidity and mortality. Other adverse effects of opioids noticed after bariatric surgery are nausea, vomiting, and ileus [4]. Apnea and heart block from opioid use in obese and morbidly obese patients have been reported after bariatric surgery in previous studies [5]. Because of the presence of such hazards, the American Society of Anesthesiologists recommends minimizing or avoiding perioperative narcotic administration to these patients [6].

Variability in patient response to opioids has its impact on anesthetists and surgeons to improve additional analgesic modalities to decrease opioid requirement. Other options can help in meeting discharge criteria earlier and minimizing adverse effects in obese patients [7].

Dexmedetomidine is a specific 2-adrenergic receptor agonist with sedative, analgesic, and sympatholytic effects that blunt many of the cardiovascular responses seen during the perioperative period. It is relatively unique in its ability to provide sedation without causing respiratory depression [8]. Dexmedetomidine has not been associated with respiratory depression, despite occasionally profound levels of sedation [9].

There are many controversies regarding anesthesia in morbidly obese patients. In our study, we hypothesized that dexmedetomidine infusion during laparoscopic sleeve gastrectomy will decrease postoperative respiratory depression and hypoxemia, decrease postanesthetic care unit (PACU) stay, help achieve good control of intraoperative hemodynamics, and decrease perioperative opioids usage.

 Aim



Our aim was to determine the efficacy of dexmedetomidine infusion in laparoscopic bariatric surgery − our primary outcome was time of stay in the PACU, and the secondary outcome was narcotic use in the perioperative period.

 Patients and methods



This prospective, randomized, double-blind clinical trial was conducted at Zagazig University Hospital, between October 2015 and October 2016, after obtaining approval from our hospital ethics committee in September 2015. Written informed consent was obtained from all patients scheduled for elective laparoscopic gastric sleeve surgery.

This study was carried on 56 patients (18–50 years), of both sexes, with a BMI greater than 40 kg/m2 and less than 60 kg/m2, who were scheduled for elective laparoscopic gastric sleeve surgery. Exclusion criteria included patient refusal, age less than 18 years or more than 50 years, difficult in intubation, presence of neuromuscular diseases, known drug hypersensitivity, kidney failure, and liver failure.

Randomization was carried out by the coin-flip method: head for one group and tail for the other, until one group was completed, and after that all randomly selected individuals were automatically allocated to the other group (randomization with balance).

All patients were subjected to preoperative general and local examination in addition to routine investigations (e.g. complete blood count, prothrombin time, partial thromboplastin time, international normalized ratio, liver function tests, kidney function tests, as well as ECG if needed).

Deep venous thrombosis prophylaxis with low molecular weight heparin was started 12 h before the operation. All patients received premedication with 5 mg midzolam intravenously; basic monitoring was carried out by ECG [heart rate (HR)], blood pressure (BP) cuff to record mean arterial pressure (MAP), and capniogrphy and SpO2 values. The weight-adjusted doses of all study medications were based on the patient’s actual body weight, starting anesthesia with 5 mg midzolam, fentanyl (0.5 µg/kg), propofol (1–2 mg/kg), and rocuronium (0.6 mg/kg) for intubation. Mechanical ventilation; volume controlled ventilation with tidal volume of 6–8 ml/kg with positive end expiratory pressure of 5 cmH2O. The respiratory rate was adjusted to achieve normocarbia by end-tidal CO2 monitor. For maintenance anesthesia, isoflurane 1 MAC was used, and muscle relaxation was induced in increments based on peripheral nerve stimulation in both groups. In group D, a loading volume of 1 μg/kg/5–10 min dexmedetomidine was administered intravenously (Precedex 100 µg/ml; Hospira Inc., USA), and then infused at a rate of 0.4 µg/kg/h as indicated in the package insert. In group C, instead of dexmedetomidine, normal saline was administered at the same loading volume (ml) and same infusion rate (ml/hr) with an identical syringe. Next, fentanyl (0.5 µg/kg) boluses were administered if BP or HR showed 20% increase from the baseline reading to control hemodynamics.

The effect of muscle relaxants was reversed using neostigmine/atropine, and patients were extubated according to the operating room recovery profile with respect to time to eye opening, time to follow simple commands, and tracheal extubation. Patients were then transferred to the PACU.

In the PACU, discharge criteria were normal respiratory rate, no hypopnea or apnea, base line oxygen saturation as preoperative values with or without oxygen supplementation, fair motor activity and no surgical bleeding. Pain control was achieved with pethidine 50 mg intravenously. Nausea and vomiting were treated with metoclopramide 10 mg intravenously.

Two anesthesiologists were present during surgery: one was in charge of anesthesia (induction, tracheal intubation, recovery, and extubation), whereas the other was in charge of recording all variables. The laparoscopic gastric sleeve operation was performed by a single, experienced bariatric surgeon. In both groups, the primary objective was to evaluate PACU stay (min). Secondary outcomes were to measure total amount of fentanyl needed to MAP and HR intraoperatively, recovery profile, total amount of postoperative opioids used, pain postoperatively using the visual analog scale (VAS) (0 no pain–10 maximum pain), and length of hospital stay.

Adverse effects such as bradycardia, hypotension, arrhythmia, nausea, vomiting, or respiratory depression were recorded, and patients’ oxygen saturation and breathing in the PACU were monitored for at least 2 h. Patient satisfaction was based on their pain management (on a 10-point scale with 1 meaning completely dissatisfied and 10 meaning completely satisfied).

Statistical analysis

According to Tufanogullari et al., the mean duration of PACU stay in the control arm was 104±33 versus 82±24 min in the dexmedetomidine 0.4 arm, with β-error=0.8 and α-error=0.05. The appropriate sample size was 28 patients per study group. There was no possibility of dropouts as all data were collected during hospital stay. Continuous variables are expressed as mean±SD, and categorical variables are expressed as numbers (percentages). Continuous variables were checked for normality using the Shapiro–Wilk test. Independent Student’s t-test was used to compare two groups of normally distributed data. Percentages of categorical variables were compared using the χ2-test. All tests were two-sided. A P-value less than 0.05 was considered statistically significant. All data were analyzed using statistical package for the social sciences for windows version 18.0 (SPSS Inc., Chicago, Illinois, USA) and MedCalc for windows version 13 (MedCalc Software bvba, Ostend, Belgium).

 Results



[Table 1] shows no statistically significant differences in the demographic data and time of surgery of the studied groups.{Table 1}

[Figure 1] and [Figure 2] show significant decreases in intraoperative and postoperative HR readings in the dexmedetomidine group compared with the control group.{Figure 1}{Figure 2}

[Table 2] shows the recovery profile: time to eye opening, time to follow simple commands, and safe extubation time were significantly shorter in the dexmedetomidine group compared with the control group. These durations were measured from end of surgery to discontinuation of anesthesia and infusions.{Table 2}

[Table 3] shows that the PACU variables measured postoperatively − HR, MAP, and VAS pain score − were significantly less in the dexmedetomidine group than in the control group. Duration of stay in the PACU was lesser in the dexmedetomidine group with P less than 0.05, and hospital stay in both groups was comparable. Nausea in the control group was observed only in seven patients − one case resolved spontaneously without treatment and the other six required treatment, and therefore the total number of patients needing treatment was nine. In the dexmedetomidine group, three patients suffered from nausea − only one patient required treatment with antiemetic therapy and the other two patients needed no treatment.{Table 3}

[Table 4] shows that perioperative narcotic use, intraoperative fentanyl consumption, PACU pethidine dose in the first hour, and total pethidine dose on the first day were significantly less in the dexmedetomidine group compared with the control group. Patient satisfaction at discharge regarding pain management was less in the control group with P less than 0.05.{Table 4}

 Discussion



Dexmedetomidine is a new analgesic adjuvant for the obese population, as its serum concentration is not affected by body weight or BMI in obese and morbidly obese patients because it binds to plasma proteins after infusion [10]. The results of our study show that infusion of dexmedetomidine intraoperatively during laparoscopic bariatric procedures had better control of intraoperative and postoperative HR, MAP, and decreased the total amount of intraoperative fentanyl required for maintenance of anesthesia. These findings are in agreement with Arain et al. [11], who reported the ability of dexmedetomidine to decrease anesthesia requirements, better control HR and BP, and provide analgesia without respiratory depression. Administration of opioids has been associated with obstruction of the upper airway. In addition, use of opioids has been associated with abnormal breathing patterns including central sleep apnea, obstructive sleep apnea, ataxic breathing, and hypoxemia [12]. Feld et al. [13], reported that continuous infusion of dexmedetomidine with its anxiolytic, analgesic, and sedative effects make it an ideal anesthetic adjunct to general anesthesia for obese and morbidly obese patients. Tufanogullari et al. [14] and Drese et al. [15] found that dexmedetomidine reduces perioperative and postoperative opioid requirements and length of recovery room stay when administered as an adjunct during laparoscopic bariatric procedures. We also conclude that intraoperative infusion of dexmedetomidine decreases postoperative nausea, vomiting, and VAS pain scores along with having opioid-sparing effects in the PACU and on postoperative day 1. Recovery was faster and PACU stay time was less in this group, minimizing early respiratory complications. This finding was proved by Ozkose et al. [16], who reported that administering dexmedetomidine reduces the doses of anesthetics required, resulting in more rapid recovery from anesthesia and a reduced need for pain medication in the PACU, thereby reducing the length of stay. We support the idea of opioid replacement by dexmedetomidine as Ramsay and Luterman [17], suggested its infusion is a useful alternative to opioid analgesics as it has no respiratory-depressant effects. Our results are proven by other studies that have used dexmedetomidine in other groups of patients undergoing various procedures. For example, Gurbet et al. [18], used it intraoperatively, thus decreasing morphine requirements postoperatively, in 50 women undergoing total abdominal hysterectomy. Aho et al. [19] showed that after laparoscopic tubal ligation dexmedetomidine relieved pain and reduced opioid requirements. Moreover, in the form multimodal analgesia in facilitating the recovery process, dexmedetomidine may prove to be a cost-effective adjuvant [20].

 Conclusion



Intraoperative dexmedetomidine infusion with its opioid-sparing effect enhanced the recovery of this study population of morbidly obese patients undergoing laparoscopic bariatric surgery with minimal side-effects.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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