Comparison of Dexmedetomidine, Remifentanil, and Esmolol for the Control of Hypertension During Tracheal Extubation and Emergence From Anesthesia After a Craniotomy

Abstract

Hypertension has been reported during emergence from anesthesia to be >90% in neurosurgical patients. We examined the effects of dexmedetomidine, remifentanil, and esmolol infusion on recovery profiles and cardiovascular responses of patients during the emergency period after a craniotomy. ASA I to III physical status patients, who were undergoing intracranial surgery for either vascular or spaceoccupying lesions, were eligible if aged between 17 and 65 years. Anesthesia was induced using propofol and dexmedetomidine and maintained using sevoflurane and dexmedetomidine infusion. Patients were randomly allocated in 3 groups. Dexmedetomidine infusion was continued until the initiation of skin closure in group D. Dexmedetomidine infusion was discontinued in other groups after placing the bone graft. Thereafter, remifentanil infusion (0.25 mg/kg/min) or esmolol infusion (0.25 mg/kg/min) were started in the other groups (group R or E) until the initiation of skin closure. Extubation time, recovery time, incidence of coughing during extubation, and hemodynamic variables during the emergence phase were recorded. During the emergence phase, the systolic and mean arterial blood pressures and heart rates were similar compared with baseline values in all study groups. The median extubation time was similar in the dexmedetomidine (4.9 min), remifentanil (3.9 min), and esmolol groups (2.7 min). The incidence of cough was similar in the dexmedetomidine group compared with the remifentanil or esmolol groups. Time to eye opening, time to orientation, and response to verbal command were longer in the dexmedetomidine group compared with the remifentanil group. We concluded that remifentanil, dexmedetomidine, and esmolol infusion can be used to control blood pressure during emergence from anesthesia after a craniotomy.

Comparison of dexmedetomidine and remifentanil on reducing coughing during emergence from anesthesia with tracheal intubation: A meta-analysis

“…A total of 2,481 citations were retrieved according to the search strategy (PubMed = 277, Embase = 1716, and Cochrane Library = 488). After removing duplicate and ineligible studies, we finally included eight studies (Chen et al, 2016;Güneş et al, 2013;Kim et al, 2021;Kim et al, 2016;Park et al, 2016;Polat et al, 2015;Qing et al, 2015;Wang et al, 2015) (502 participants) for this meta-analysis (Figure 1; Table 1).…”

“…Güneş et al's study and Chen et al's study respectively use fentanyl and tramadol for analgesia during operation, and there are no differences between dexmedetomidine group and remifentanil group for each study. (Chen et al, 2016;Güneş et al, 2013) However, since increasing the dose of medications may cause more adverse effects, we analyzed both the efficacy and side effects of dexmedetomidine and remifentanil in inhibiting emergence cough. Fourth, the included studies contain tracheal extubation in awake and deeply anesthetized patients, which may cause different airway stimulation.…”

“…Six studies (Chen et al, 2016;Kim et al, 2016;Kim et al, 2021;Park et al, 2016;Qing et al, 2015;Wang et al, 2015) comparing dexmedetomidine with remifentanil were included in the pooled analysis to assess the incidence of moderate to severe coughing; one study (Polat et al, 2015) reported grade of coughing using median (range) and one study (Güneş et al, 2013) only reported the incidence of coughing. There was no difference in the occurrence of moderate to severe coughing between two drugs during emergence from anesthesia (p = 0.39), with moderate heterogeneity (I 2 = 52%; Figure 3).…”

“…Six studies (Güneş et al, 2013;Fan et al, 2015;Polat et al, 2015;Wang et al, 2015;Kim et al, 2016; comparing dexmedetomidine with remifentanil reported recovery time, and the pooled analysis showed that the average recovery time of remifentanil was shorter than dexmedetomidine (p = 0.008), with high heterogeneity (I 2 = 95%; Figure 4). In the sensitivity analysis, Values are mean ± SD, median (range) or number.…”

“…When excluding the study of Wang et al, (Wang et al, 2015) the statistical heterogeneity changed from high to moderate (I 2 = 35%). Six studies (Chen et al, 2016;Güneş et al, 2013;Kim et al, 2016;Park et al, 2016;Polat et al, 2015;Wang et al, 2015) comparing dexmedetomidine with remifentanil reported the extubation time, and the pooled analysis showed that remifentanil did not shorten the extubation time compared with dexmedetomidine (p = 0.13), with high heterogeneity (I 2 = 63%; Figure 2). However, the advantage of remifentanil still existed after removing the study of Park et al (Park et al, 2016) (p = 0.001) and the statistical heterogeneity became insignificant (I 2 = 0).…”