Effect of dexmedetomidine as an adjuvant to 0.25% bupivacaine for local infiltration of port site in laparoscopic cholecystectomy in terms of quality and duration of post-op analgesia

Abstract

Objective: Laparoscopic cholecystectomy (LC) technically has evolved as a day case procedure even to a extent that ASA III patients are also not a exclusion. Pain is one of the cause for unexpected overnight hospital stay. The recent PROSPECT (PROcedure SPECific Postoperative Pain Management) working Group has recommended port site infiltration along with NSAIDS and paracetamol as the preferred mode of analgesia for laparoscopic cholecystectomy. Hence, we studied about efficacy of dexmedetomidine as an adjuvant for local anesthetic portsite wound infiltration with bupivacaine in patients undergoing laparoscopic cholecystectomy. Methods: 120 patients of ASA I-II scheduled for LC were randomly allotted to two groups. Group A received port site wound infiltration with 24 mL of 0.25% bupivacaine and dexmedetomidine 2 µg kg -1 while Group B received wound infiltration with 24 mL of 0.25% bupivacaine divided equally for all the four laparoscopic port sites. A standard general anesthesia technique was used in all the patients. Pre-emptive analgesia with paracetamol 1 g IV given 30 minutes before skin incision. Tramadol 1 mg kg -1 and ketorolac 0.5 mg kg -1 IV infusion was administered as rescue analgesic. Postoperative pain score, duration of effective analgesia, need for rescue analgesic, time of ambulation and hospital discharge was recorded. Results: Dexmedetomidine group has better pain score, longer duration of effective analgesia, lower percentage of patients requiring rescue analgesic, and earlier ambulation and hospital discharge. Conclusion: We conclude that dexmedetomidine 2 μg kg -1 is an effective adjuvant to bupivacaine for port site wound infiltration in terms of quality and duration of postoperative analgesia following laparoscopic cholecystectomy. ÖZAmaç: Laparoskopik kolesistektomi (LK), teknik açıdan, ASA III hastaların bile dışlanmadığı günübirlik bir işlem haline gelmiştir. Ağrı, beklenmedik gece hastanede yatış nedenlerinden biridir. PROSPECT (PROcedure SPECific Postoperative Pain Management) çalışma grubu, NSAİİ'lar ve parasetamol ile port sahası infiltrasyonunu laparoskopik kolesistektomi için tercih edilen analjezi şekli olarak önermektedir. Buradan yola çıkarak, laparoskopik kolesistektomi yapılan hastalarda, port sahasına yara yeri infiltrasyonunda bupivakaine adjuvan olarak eklenen deksmedetomidinin etkinliğini çalıştık. Yöntem: LK planlanan 120 ASA I-II hasta rastgele iki gruba ayrıldı. Grup A'ya 24 mL %0.25 bupivakain ve 2 mcg kg -1 deksmedetomidin ile, Grup B'ye 24 mL % 0.25 bupivakain ile yara infiltrasyonu dört laparoskopik port bölgesi için eşit olarak bölünmüş dozda uygulandı. Tüm hastalarda standart bir genel anestezi tekniği kullanıldı. Cilt insizyonundan 30 dk önce parasetamol 1 g iv ile pre-emptif analjezi uygulandı. Tramadol 1 mg kg -1 ve ketorolak 0.5 mg kg -1 iv ile kurtarıcı analjezi sağlandı. Postoperatif ağrı skoru, etkili analjezi süresi, kurtarıcı analjezik ihtiyacı, ile mobilizasyon ve taburculuk zamanları kaydedildi. Bulgular: Deksmedetomidin grubunda, ağrı skoru daha iy...

Efficacy and safety of dexmedetomidine as an adjuvant to local wound infiltration anaesthesia: A meta‐analysis with trial sequential analysis of 23 randomised controlled trials

“…After reviewing the full texts of the articles, 24 trials were excluded. Finally, 23 RCTs were considered to be suitable for this meta‐analysis, 16‐38 encompassing a total of 1445 adult patients. The search process is shown in Figure 1.…”

“…The types of local anaesthetics include ropivacaine, 18,20,22‐26,28,30,33,36‐38 bupivacaine 16,17,19,21,29,31,32,34,35 and lidocaine 27 . The concentrations of ropivacaine were 0.2%, 20,22,23,30 0.3%, 26,33,36 0.375%, 25 0.5% 24,28,38 and 0.75% 18,37 ; the concentrations of bupivacaine were 0.25% 17,19,21,29,31,32,34,35 and 0.5% 16 ; and the concentration of lidocaine was 2.0% 27 . The doses of DEX were 0.5 μg/kg, 28,30 1.0 μg/kg, 16,17,20,22,24‐27,32,33,35,37,38 1.5 μg/kg, 18 2.0 μg/kg, 21,29,31,34 5.0 μg/kg 23,36 and 50 μg 19 .…”

“…Five trials 18,21,32,33,35 were rated as an unclear risk because of incomplete outcome data. Most of the studies (13 out of 23) 17,19,24,25,27,28,30‐33,36‐38 were assessed as having an unclear risk of other bias because of the lack of sufficient methodological reports. Overall, seven studies 16,20,22,23,26,29,34 had a low risk of bias, 13 studies 17‐19,21,24,27,28,30‐32,35,36,38 had an unclear risk of bias, and 3 studies 25,33,37 had a high risk of bias.…”

“…The total rescue analgesia rate was assessed by 16 studies 16‐21,24,25,29‐32,34‐37 . Patients in the DEX group required less rescue analgesia than patients receiving local anaesthetics alone (RR: 0.48; 95% CI: 0.36‐0.65; P < .00001; I 2 = 91%) (see Figure 3A).…”

“…All included studies reported various side effects, three 32,35,38 of which were excluded because of a lack of specific data. Thus, of the 23 studies, 20 16‐31,33,34,36,37 had complete data to allow for statistical analysis.…”