Dexmedetomidine in Enhanced Recovery After Surgery (ERAS) Protocols for Postoperative Pain

Abstract

Purpose of Review Effective acute pain management has evolved considerably in recent years and is a primary area of focus in attempts to defend against the opioid epidemic. Persistent postsurgical pain (PPP) has an incidence of up to 30-50% and has negative outcome of quality of life and negative burden on individuals, family, and society. The 2016 American Society of Anesthesiologists (ASA) guidelines states that enhanced recovery after surgery (ERAS) forms an integral part of Perioperative Surgical Home (PSH) and is now recommended to use a multimodal opioid-sparing approach for management of postoperative pain. As such, dexmedetomidine is now being used as part of ERAS protocols along with regional nerve blocks and other medications, to create a satisfactory postoperative outcome with reduced opioid consumption in the Post anesthesia care unit (PACU). Recent Findings Dexmedetomidine, a selective alpha 2 agonist, possesses analgesic effects and has a different mechanism of action when compared with opioids. When dexmedetomidine is initiated at the end of a procedure, it has a better hemodynamic stability and pain response than ropivacaine. Dexmedetomidine can be used as an adjuvant in epidurals with local anesthetic sparing effects. Its use during nerve blocks results in reduced postoperative pain. Also, local infiltration of IV dexmedetomidine is associated with earlier discharge from PACU. Summary Perioperative use of dexmedetomidine has significantly improved postoperative outcomes when used as part of ERAS protocols. An in-depth review of the use of dexmedetomidine in ERAS protocols is presented for clinical anesthesiologists.

Effect of single-dose dexmedetomidine on the incidence of emergence delirium after sevoflurane-based anesthesia in children undergoing strabismus surgery

“…Similar findings were reported when dexmedetomidine infusion was used before operations on children undergoing hernia repair [30]. Currently, usage of dexmedetomidine in the perioperative period has shown to significant ly improve outcomes in the postoperative period especially when used in the enhanced recovery after surgery protocols were accompanied with less time of discharge from PACU and better patient's satisfaction [31].…”

Adjunctive dexmedetomidine infusion in open living donor hepatectomy: A way to enhance postoperative analgesia and recovery

“…Our results agreed with previous reviews that reported that DEX played an essential role as an opioid alternative in multimodal analgesia that formed part of ERAS care. 2,3,5 Ge et al 12,13 showed the benefits of intraoperative DEX infusion in terms of lower VAS scores, reduced morphine consumption, and decreased numbers of pain-induced IV-PCA pump presses during the first 24 hours after abdominal colectomy and hysterectomy. Xu et al 14 also reported similar outcomes on postoperative pain in patients treated with DEX during abdominal hysterectomy.…”

“…Thus, in this present study, we administered DEX as continuous infusion, without a loading dose. According to the product information, the recommended rate of maintenance infusion of DEX for sedation is 0.2‐0.7 mcg/kg/h 5 . Adjunctive DEX infusion at a relatively slow rate of 0.4 mcg/kg/h has previously been used to maintain GA in patients undergoing abdominal surgery and was found to relieve acute postoperative pain effectively 12,13,19,24 .…”

Comparison of Epidural Dexmedetomidine Versus Ropivacaine Infusion Effectiveness in Preventing Erection Following Reconstructive Urethral Surgery: A Randomized Clinical Trial

“…The α2 agonist agents can reduce norepinephrine secretion by stimulating peripheral α 2 presynaptic receptors. In addition, the most important mechanism of dexmedetomidine in penile erection prevention may be due to its α 2 -adrenoceptor agonistic property by acting on vascular smooth muscle enhancing vasoconstriction in peripheral arteries to prevent erections (8,9,(17)(18)(19).…”