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• W2767347810 abstract "We enjoyed reading the study by Dutta et al1Dutta V. Kumar B. Jayant A. et al.Effect of continuous paravertebral dexmedetomidine administration on intraoperative anesthetic drug requirement and post-thoracotomy pain syndrome after thoracotomy: A randomized controlled trial.J Cardiothorac Vasc Anesth. 2017; 31: 159-165Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar on paravertebral dexmedetomidine, particularly with the increasing interest in the use of this drug during thoracic surgery. This randomized trial failed to demonstrate its primary objective of 50% reduction in isoflurane concentration, which suggests that it also may have been underpowered for important pain outcomes. We question whether a smaller reduction in isoflurane concentration should have been used for the power calculation. The study by Saadaway et al2Saadawy I. Boker A. Elshahawy M.A. et al.Effect of dexmedetomidine on the characteristics of bupivacaine in a caudal block in pediatrics.Acta Anaesthesiol Scand. 2009; 53: 251-256Crossref PubMed Scopus (126) Google Scholar the authors alluded to in the text was performed in children, whereas a study in adults by Harsoor et al3Harsoor S.S. Rani D.D. Lathashree S. et al.Effect of intraoperative dexmedetomidine infusion on Sevoflurane requirement and blood glucose levels during entropy-guided general anesthesia.J Anaesthesiol Clin Pharmacol. 2014; 30: 25-30Crossref PubMed Scopus (25) Google Scholar only showed a 28% reduction using an intravenous infusion. This would be consistent with the results by Zeng et al,4Zeng X. Jiang J. Yang L. et al.Epidural dexmedetomidine reduces the requirement of propofol during total intravenous anaesthesia and improves analgesia after surgery in patients undergoing open thoracic surgery.Sci Rep. 2017; 7: 3992Crossref PubMed Scopus (8) Google Scholar who showed a 22% reduction in anesthetic dose (albeit of propofol) in adults between placebo and either intravenous or epidural dexmedetomidine. However, it may have been more appropriate to power against pain outcomes given the main findings of the work, again with the likely effect of increasing study numbers. The assessment of pain under anesthesiologists has always proved elusive to us as anesthetists, and in the absence of direct assessment we must rely on surrogates such as heart rate and blood pressure, while accepting that they are influenced by other intraoperative factors. The authors have accounted for awareness by using the bispectral index to guide titration of isoflurane concentration and pain using a >20% rise in both mean arterial pressure and heart rate to guide fentanyl administration. Dexmedetomidine, however, has sedative and analgesic effects while causing a decrease in hemodynamic markers. Therefore, it is difficult to know whether the lower mean arterial pressure and heart rate in the dexemedetomidine group truly represents a reduced sensation of pain or is merely a direct effect of the drug itself. Although the authors are to be commended on their method of blinding the syringe preparation, the significant hemodynamic side-effect profile of dexmedetomidine inadvertently may have unmasked the patient allocation to both anesthetic and nursing staff. We wonder if the use of a blinding questionnaire would have detected this. We also question who is best placed to insert the paravertebral catheter. Although the technique may be associated with fewer side effects than the gold standard thoracic epidural and the remaining risks can be minimized by the use of ultrasound guidance, pleural placement still can take place, as reported in 12% of patients in this study. In our unit, we have now moved to surgical placement under direct vision, which may be both more effective and time efficient.5Elsayed H. Insertion of paravertebral block catheters intraoperatively to reduce incidence of block failure.Interact Cardiovasc Thorac Surg. 2012; 14: 648-649Crossref PubMed Scopus (7) Google Scholar" @default.
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• W2767347810 date "2018-02-01" @default.
• W2767347810 modified "2023-10-18" @default.
• W2767347810 title "The Power of Perioperative Dexmedetomidine" @default.
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• W2767347810 doi "https://doi.org/10.1053/j.jvca.2017.11.010" @default.
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