American Society of Regional Anesthesia and Pain Medicine August 2018 - 33
Review of Dexmedetomidine (Precedex) for Acute Pain and Analgesia
M
anagement of acute postoperative pain is an important
health care issue.1 Multimodal analgesia is a strategy
employing more than one type of analgesic agent or
technique, resulting in additive or synergistic analgesia while
reducing adverse effects encountered with the sole use of
one analgesic.1,2 The American Society of Anesthesiologists
recommends multimodal analgesia for acute postoperative pain
management.3 As many as 80% of surgical patients experience
postoperative pain, with ramifications such as poor patient
satisfaction, the development of persistent postsurgical pain,
and extended time in the postanesthesia recovery unit.4,5 Recent
literature suggests that administration of dexmedetomidine may
play a promising role as a part of multimodal analgesia in the
perioperative period.1,2,4-6
Dexmedetomidine was first approved by the Food and Drug
Administration in 1999 for short-term use as an analgesic
and sedative medication in the intensive care unit.6 Compared
with clonidine, the prototypical alpha (α)-2 adrenoreceptor,
dexmedetomidine is eight times more specific for α-2
adrenoreceptors with an α2:α1 selectivity ratio of 1,600:1.7 As
a highly selective α-2 adrenoreceptor agonist, this medication
functions as a sedative, anxiolytic, and analgesic without any
respiratory depressive effects. It has a short terminal half-life
of 2 hours, compared with 8 hours for clonidine, and its most
notable side effects are bradycardia and hypotension, although
hypertension is observed only with higher doses.6-8 Administration
routes include intravenous, intramuscular, perineural, intranasal,
buccal, epidural, and intrathecal.
Several studies have investigated
the potential benefits of
dexmedetomidine delivered
perioperatively. Review of
recent literature finds that most
discuss intravenous, perineural,
and neuraxial administration
and its impact on perioperative
outcomes. This article focuses
on studies and meta-analyses
investigating perioperative
dexmedetomidine administration
and its effect on analgesia
(summarized in Tables 1 and 2).
Esperanza Ingersoll-Weng, MD
Clinical Assistant Professor
Department of Anesthesia
Amanda Greene, MD
Anesthesia Resident, CA-3
Department of Anesthesia
University of Iowa Carver College of Medicine
Iowa City, Iowa
decreased, with lower reported pain scores at rest and with activity
compared with the control group. The authors suggested that
dexmedetomidine has an opioid-sparing effect, and its use may
promote postoperative analgesia.9
A number of authors have researched the use of intraoperative
dexmedetomidine specifically for patients undergoing abdominal
surgeries.10-12 Ge et al11,12 reported on the primary outcome of
postoperative opioid use in the first 24 hours and found reduced
consumption, which correlates with results from Tufanogullari et
al.10 However, Tufanogullari
et al10 did not find decreased
opioid requirements on
postoperative days 1, 2, or
7. Both studies concluded
that dexmedetomidine was
beneficial in their patient
populations, with Tufanogullari
et al10 further recommending
a 0.2 μg/kg/h infusion rate to
minimize the risk of adverse
cardiovascular side effects.
"Of note, many of the studies have
also shown that perioperative
dexmedetomidine use has a
trend toward decreased adverse
side effects such as PONV when
compared with other commonly
prescribed analgesic medications."
Acute postoperative pain is common among patients undergoing
radical mastectomy, which increases the risk of chronic
hyperalgesia.9 Fan et al9 randomized 45 patients undergoing
radical mastectomy to receive intraoperative lactated Ringers or
dexmedetomidine. The time to patients' first morphine request
was greater in the dexmedetomidine group. Postoperative patientcontrolled anesthesia (PCA) use in the first 24 hours was also
Following general anesthesia
for neurosurgical cases, a
rapid neurological assessment
of patients is frequently desired. Remifentanil is often a popular
choice in such cases because it provides rapid and reliable
emergence from general anesthesia.13 Rajan et al13 and Hwang
et al14 compared remifentanil and dexmedetomidine infusions in
patients undergoing craniotomy or posterior lumbar interbody
fusion, respectively. The authors concluded that dexmedetomidine
was a reasonable alternative to remifentanil because their results
American Society of Regional Anesthesia and Pain Medicine
2018
33
Table of Contents for the Digital Edition of American Society of Regional Anesthesia and Pain Medicine August 2018
American Society of Regional Anesthesia and Pain Medicine August 2018 - 1
American Society of Regional Anesthesia and Pain Medicine August 2018 - 2
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