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ORIGINAL ARTICLE
Year : 2020  |  Volume : 14  |  Issue : 3  |  Page : 401-405  

Effect of two different doses of dexmedetomidine on the hemodynamics of “Hypertensive Patients” undergoing laparoscopic cholecystectomy


1 Department of Anesthesiology, KGMU, Lucknow, Uttar Pradesh, India
2 Department of Anesthesiology, IMS, BHU, Varanasi, Uttar Pradesh, India
3 Department of General Surgery, KGMU, Lucknow, Uttar Pradesh, India

Date of Submission04-Feb-2021
Date of Decision07-Feb-2021
Date of Acceptance17-Feb-2021
Date of Web Publication22-Mar-2021

Correspondence Address:
Dr. Ravi Prakash
Department of Anaesthesiology, KGMU, Chowk, Lucknow - 226 003, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aer.AER_14_21

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   Abstract 

Context: In laparoscopic cholecystectomy, pneumoperitoneum results in tachycardia, hypertension, and increased myocardial oxygen demand. These changes are more pronounced in hypertensive patients. The intravenous administration of dexmedetomidine attenuates sympathoadrenal response and provides better hemodynamic stability intraoperatively. Aims: To evaluate the hemodynamic stabilizing and sedation properties of two different doses of dexmedetomidine including 0.7 μg.kg−1.h−1 and 0.5 μg.kg−1.h−1 in hypertensive patients undergoing laparoscopic cholecystectomy. Settings and Design: This was a randomized, prospective, double-blind controlled trial. Subjects and Methods: A total of 60 controlled hypertensive patients of either sex, aged 30–60 years, and ASA class 2 without any other serious comorbid conditions who were undergoing laparoscopic cholecystectomy under general anesthesia were randomly assigned into three groups of 20 each. Group A and B received loading dose of dexmedetomidine 1 μg.kg−1 over 10 min and maintenance dose at 0.7 and 0.5 μg.kg−1.h−1, respectively. Group C received normal saline infusion only. Hemodynamic parameters (heart rate and systolic, diastolic, and mean arterial pressure) and sedation score were compared at different time intervals among groups. Statistical Analysis Used: The Chi-square test, ANOVA, and Tukey Post hoc Test. Results: Fluctuations in the hemodynamics of hypertensive patients are effectively attenuated by dexmedetomidine and there is no difference in the attenuation of these hemodynamic changes by maintenance dose of 0.5 or 0.7 μg.kg−1.h−1. However, maintenance dose of 0.5 μg.kg−1.h−1 causes lesser sedation. Conclusions: Dexmedetomidine administered as infusion in a maintenance dose of 0.5 μg.kg−1.h−1 serves as an ideal anesthetic adjuvant in hypertensive patients undergoing laparoscopic cholecystectomy.

Keywords: Anesthesia, dexmedetomidine, hypertension, laparoscopic cholecystectomy, sedation


How to cite this article:
Gautam S, Prakash V, Mishra N, Prakash R, Kumar S, Jafa S. Effect of two different doses of dexmedetomidine on the hemodynamics of “Hypertensive Patients” undergoing laparoscopic cholecystectomy. Anesth Essays Res 2020;14:401-5

How to cite this URL:
Gautam S, Prakash V, Mishra N, Prakash R, Kumar S, Jafa S. Effect of two different doses of dexmedetomidine on the hemodynamics of “Hypertensive Patients” undergoing laparoscopic cholecystectomy. Anesth Essays Res [serial online] 2020 [cited 2021 Apr 20];14:401-5. Available from: https://www.aeronline.org/text.asp?2020/14/3/401/311716


   Introduction Top


Laparoscopic cholecystectomy has revolutionized the treatment for gallstone disease and is considered a gold standard modality in the present era.[1] Advantages of laparoscopy include less postoperative pain, small incisions, shorter hospitalization, and faster functional recovery. Despite multiple benefits, any laparoscopic surgery always poses a challenge to its successful anesthetic management, mainly due to significant alteration of hemodynamic, resulting from the combined effects of pneumoperitoneum, patient position, anesthesia, and hypercapnia from the absorbed carbon dioxide (CO2) that is used to produce pneumoperitoneum.[2] CO2 is readily absorbed from peritoneal cavity into circulation resulting in hypercapnia. Both factors, hypercapnia and pneumoperitoneum, stimulate sympathetic nervous system which causes release of catecholamines and vasopressin and activation on renin–angiotensin system. All these changes collectively lead to decrease in cardiac output and elevated systemic and pulmonary vascular resistance, which, in turn, results in tachycardia, hypertension, and increased myocardial oxygen demand.

These hemodynamic changes are even more pronounced in hypertensive patients than normotensive patients during general anesthesia and require more anesthetic interventions to get hemodynamic stability. Hemodynamic stability if not managed successfully, particularly in hypertensive patients, can lead to poor outcomes during intraoperative and postoperative period.[3] Markedly increase in arterial pressure can be a risk factor for adverse cardiac events in patients with preexisting essential hypertension and ischemic heart disease. In various studies, many methods such as propofol infusions, high doses of opioids analgesics, benzodiazepines, beta-blockers, and calcium channel blockers have been used to overcome this hemodynamic stress response.

We have used dexmedetomidine in our study. It is selective α2 receptor agonist with hypnotic, sedative, anxiolytic, sympatholytic, and analgesic properties without producing significant respiratory depression. Therefore, we have compared two different doses of dexmedetomidine to evaluate hemodynamic stability and sedation properties in controlled hypertensive patients posted for elective laparoscopic cholecystectomy.


   Subjects and Methods Top


After approval from the institutional ethics committee, this randomized double-blind study was carried out at the department of anesthesiology in collaboration with the department of general surgery of a tertiary care hospital. After written informed consent, controlled hypertensive patients undergoing elective laparoscopic cholecystectomy under general anesthesia with an age range between 30 and 60 years of either sex, ASA status II, and weight 60 ± 20 kg (body mass index between 20 and 30) were included in the study, whereas patients with a history of allergy to dexmedetomidine or any of the drugs to be administered, clinically significant cardiovascular, neurologic, renal, hepatic, or gastrointestinal diseases, ASA status III or IV, hypertensive patients on beta-blocker, and pregnant or lactating women were excluded from the study. Preanesthetic evaluation was done and patients were advised a day before surgery to maintain fasting for 8 h, aspiration prophylaxis, and anxiolytics.

Sixty patients were randomly divided into three groups of 20 each in Group A, B, and C. Group A and B received loading dose of dexmedetomidine 1 μg.kg−1 over 10 min and maintenance dose at 0.7 μg.kg−1.h−1 and 0.5 μg.kg−1.h−1, respectively. Group C received normal saline infusion only. Volume of loading dose was 100 ml in all three groups and infusion volume was 50 ml.h−1.

On the day of surgery, patients were premedicated and baseline hemodynamic were recorded; infusion of the study medication (dexmedetomidine/NS) was started at weight-adjusted doses according to the patient's actual body weight. The calculated loading dose of dexmedetomidine was given over 10 min in Group A and B, whereas in Group C, NS infusion was continued for 10 min before induction and hemodynamic variables were recorded after completion. After completion of loading dose, infusion was set to maintenance dose of 0.7 μg.kg−1.h−1 in Group A and 0.5 μg.kg−1.h−1 in Group B, whereas in Group C, normal saline infusion was continued.

Preoxygenation with 100% oxygen was done and induction was started with injection fentanyl at 1.5 μg.kg−1, propofol 2.0 mg. kg−1, and intubation after vecuronium dose of 0.1 mg. kg−1. The patient was maintained on 50% O2 + N2O, vecuronium, dexmedetomidine infusion (in maintenance dose in Group A and B) and sevoflurane (in Group C).

Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), SpO2, and EtCO2 were recorded at induction, laryngoscopy, intubation, 1 min after intubation, 5 min after intubation, intraoperative, and after extubation. After CO2 desufflation, dexmedetomidine/NS infusion was stopped, the patient was reversed, and successful extubation was done (sedation score noted).


   Results Top


Sixty patients were divided into three groups as Group A, Group B, and Group C of 20 each. Patients were comparable in terms of age, sex, and duration of surgery. No significant difference was found in age, sex, and duration of surgery [Table 1].
Table 1: Demographic profile and mean duration of surgery

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The mean HR in Group A at baseline was 87.89 ± 10.88 per minute, which after minor fluctuations goes to the minimum value 66.00 ± 6.28 per minute at 40 min and after that it increases with minor fluctuations and finally got 81.00 ± 5.77 per minute at 120 min. The mean HR in Group B at baseline was 88.10 ± 6.97 per minute, which after minor fluctuations goes to the minimum value 69.85 ± 5.38 per minute at 20 min and after that it increases with minor fluctuations and finally got average 81.33 ± 5.03 per minute at 120 min. The mean HR in Group C at baseline was 80.89 ± 12.01 per minute, which was increased gradually with minor fluctuations and goes to the maximum value 107.64 ± 8.44 per minute at 100 min and later on finally got average 106.33 ± 9.61 per minute at 120 min. Significant differences in HR were observed among the groups at preinduction (P = 0.027) and then from intubation to 110 min (P < 0.001). Between Group A and B, significant differences were observed at induction, 30 min –70 min [Figure 1].
Figure 1: Intergroup comparison of heart rates at various time points

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The mean SBP in Group A at baseline was 146.00 ± 8.41 mmHg, which after minor fluctuations goes to the minimum value 112.00 ± 6.63 mmHg at 90 min and after that it increases with minor fluctuations and finally got 124.00 ± 0.00 mmHg at 110 min. The mean SBP in Group B at baseline was 143.47 ± 7.94 mmHg, which after minor fluctuations goes to the minimum value 114.63 ± 7.92 mmHg at 20 min and after that it increases with minor fluctuations and finally got average 124.00 ± 9.38 mmHg at 90 min. The mean SBP in Group C at baseline was 130.40 ± 11.67 mmHg, which was increased gradually with minor fluctuations and goes to the maximum value 152.80 ± 10.61 mmHg at 20 min and later on finally got average 148.40 ± 9.21 mmHg at 120 min. Significant differences in SBP were observed among the groups from induction to 100 min (P < 0.01). Between Group A and B, significant differences were observed at intubation, 1 and 90 min [Figure 2].
Figure 2: Intergroup comparison of systolic blood pressure at various time points

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The mean DBP in Group A at baseline was 91.10 ± 4.96 mmHg, which after minor fluctuations goes to the minimum value 70.00 ± 7.31 mmHg at 30 min and after that it increases with minor fluctuations and finally got 81.33 ± 2.31 mmHg at 120 min. The mean DBP in Group B at baseline was 87.89 ± 5.83 mmHg, which after minor fluctuations goes to the minimum value 71.11 ± 6.89 mmHg at 30 min and after that it increases with minor fluctuations and finally got average 84.67 ± 1.15 mmHg at 120 min. The mean DBP in Group C at baseline was 80.90 ± 5.60 mmHg, which was increased gradually after lowest point at induction with minor fluctuations and goes to the maximum value 97.33 ± 5.77 mmHg at 120 min. Significant differences in DBP were observed among the groups from induction to 100 min (P < 0.05). Between Group A and B, significant differences were observed at 90 and 100 min [Figure 3].
Figure 3: Intergroup comparison of diastolic blood pressure at various time points between Group A and B

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The mean MBP in Group A at baseline was 109.53 ± 0.06 mmHg, which after minor fluctuations goes to the minimum value 82.95 ± 7.48 mmHg at 30 min and after that it increases with minor fluctuations and finally got 95.00 ± 0.00 mmHg at 130 min. The mean MBP in Group B at baseline was 106.40 ± 5.37 mmHg, which after minor fluctuation goes to the minimum value 85.50 ± 5.77 mmHg at 25 min and after that it increases with minor fluctuations and finally got average 100.00 ± 0.00 mmHg at 130 min. The mean MBP in Group C at baseline was 105.38 ± 6.97 mmHg, which after minor fluctuations and goes to the value 112.50 ± 7.78 mmHg at 120 min. Significant differences in MBP were observed among the groups from induction to 110 min (P < 0.05). Between Group A and B, significant differences were observed at 90 min [Figure 4].
Figure 4: Intergroup comparison of mean arterial pressure at various time points

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Campbell sedation score

The mean sedation score in Group A at extubation was 3.30 ± 0.47, which was reduced to 2.25 ± 0.44 at 1 h and further reduced to 1.80 ± 0.41 at 2 h.

The mean sedation score in Group B at extubation was 3.10 ± 0.31, which was reduced to 2.00 ± 0.32 at 1 h and further reduced to 1.40 ± 0.50 at 2 h. The mean sedation score in Group C at extubation was 2.25 ± 0.44, which was reduced to 1.40 ± 0.50 at 1 h and further reduced to 1.00 ± 0.00 at 2 h. Highly significant differences in the sedation score were observed among the groups at extubation (P < 0.001), 1 h (P < 0.001), and 2 h (P < 0.001).

Between group A and B, significant differences were observed at 1 and 2 h [Figure 5].
Figure 5: Intergroup comparison of Campbell sedation score at various time points

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   Discussion Top


Laparoscopic surgeries under general anesthesia are associated with unique hemodynamic changes in the form of decreased venous return and increased systemic vascular resistance leading to systemic hypertension. This increases the need for deepening the plane of anesthesia and requires the use of vasodilators to counteract the rising blood pressures. IAPs higher than 10 mmHg due to peritoneal insufflation with CO2 induce significant alterations in hemodynamic, characterized by decrease in venous return, increase in arterial pressure, and elevation of systemic and pulmonary vascular resistance and HR.[4],[5] These hemodynamic changes are even more pronounced and challenging in hypertensive patients than normotensive patients during general anesthesia and require more anesthetic interventions to get hemodynamic stability.[6]

Dexmedetomidine is a highly selective α2 adrenoceptor agonist, which possesses analgesic, hypnotic, sedative, amnesic, anxiolytic, and sympatholytic properties without producing significant respiratory depression. Its sympatholytic effect decreases MAP and HR by reducing norepinephrine release. In addition, dexmedetomidine has the ability to reduce both the anesthetic and opioid analgesic requirements during the perioperative period. Various studies were carried out before and demonstrated that dexmedetomidine effectively attenuates hemodynamic response to critical incidences such as direct laryngoscopy, endotracheal intubation, creation of pneumoperitoneum, and extubation in patients undergoing laparoscopic surgeries.

A study was done by Bakhamees et al. and Bhattacharjee et al. to analyze the effects of dexmedetomidine on morbidly obese patients undergoing laparoscopic bariatric surgery and laparoscopic cholecystectomy, respectively. Better control of intraoperative and postoperative hemodynamic was seen in both studies.[7],[8] These findings are consistent with our study.

Our finding is also consistent with Shamim et al. who compared the effect of two doses of dexmedetomidine (loading dose of 1 μg.kg−1 over 10 min followed by maintenance dose of 0.5 μg.kg−1.h−1 and 0.7 μg.kg−1.h−1 on stress response in laparoscopic pyeloplasty).[9]

Ghodki et al. studied the effects of dexmedetomidine as an adjuvant in laparoscopic surgery using entropy monitoring. They also found a reduction in systolic BP in the dexmedetomidine group.[10]

We found that dexmedetomidine causes significant decrease in blood pressure and it significantly attenuates changes in blood pressure on direct laryngoscopy, endotracheal intubation, pneumoperitoneum creation, extubation, and other stressful events. We also found that there was no significant difference in the attenuation of changes in blood pressure by maintenance dose of 0.5 or 0.7 μg.kg−1.h−1. This is supported by the study of Manne et al., which states that dexmedetomidine effectively attenuates changes in blood pressure due to stressful events related to anesthesia and laparoscopy and also found that after a loading dose of 1 μg.kg−1, a maintenance dose of 0.4 μg. kg−1.h−1 is more effective in the attenuation of hemodynamic stress response as compared to maintenance dose of 0.2 μg. kg−1.h−1.[11]

Masoori Tahir et al. studied clinical efficacy of dexmedetomidine in two different doses (0.3 and 0.6 μg.kg−1.h−1) to attenuate the hemodynamic changes during laparoscopic cholecystectomy and found that dexmedetomidine infusion was effective for attenuating the hemodynamic changes due to laryngoscopy and laparoscopy, but were better with maintenance infusion of dexmedetomidine at the dose of 0.6 μg.kg−1.h−1.[12] However, in our study, we compared maintenance dose of 0.5 and 0.7 μg.kg−1.h−1 in hypertensive patients and both were equally effective. Vora et al. compared the effect of dexmedetomidine (at a dose of 1 μg.kg−1 over 10 min followed by 0.5 μg.kg−1.h−1) and normal saline on hemodynamic changes during laparoscopic surgeries and found that dexmedetomidine provided a stable hemodynamic profile in the perioperative period and effectively blunted pressor response to intubation and extubation. The above findings are consistent with our study.[13]

A study was done by of Hall et al. to determine the safety and efficacy of dexmedetomidine by evaluating sedation, analgesia, cognition, and cardiorespiratory function and the authors found that dexmedetomidine causes sedation in a dose-dependent manner.[14] The above findings are also consistent with our study. However, we have done our study in controlled hypertensive patients to analyze stress response under general anesthesia in laparoscopic cholecystectomy. Hence, this can be summarized that significant fluctuations occur in hemodynamic of hypertensive patients during direct laryngoscopy, tracheal intubation, pneumoperitoneum creation, extubation, and other stressful events during laparoscopic cholecystectomy under general anesthesia. These hemodynamic changes are effectively attenuated by dexmedetomidine and there is no difference in the attenuation of these hemodynamic changes by maintenance dose of 0.5 or 0.7 μg.kg−1.h−1. However, maintenance dose of 0.5 μg.kg−1.h−1 causes lesser sedation and can be safely used as an anesthetic adjuvant in hypertensive patients undergoing laparoscopic surgeries.


   Conclusions Top


Dexmedetomidine in a maintenance dose of 0.5 μg.kg−1.h−1 provides equal hemodynamic stability and causes lesser sedation, when compared to maintenance dose of 0.7 μg.kg−1.h−1, with no serious side effects or adverse reactions. Hence, it is concluded that dexmedetomidine administered as infusion in a maintenance dose of 0.5 μg.kg−1.h−1 serves as an ideal anesthetic adjuvant in hypertensive patients undergoing laparoscopic cholecystectomy.

Limitations of the study

In our study, we included the patients undergoing laparoscopic cholecystectomy only with maximum surgery duration of 2 h. Further studies may be carried out to analyze the effectiveness of dexmedetomidine infusion in other laparoscopic surgeries of longer duration also.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Antoniou SA, Antoniou GA, Koch OO, Pointner R, Granderath FA. Meta-analysis of laparoscopic vs open cholecystectomy in elderly patients. World J Gastroenterol 2014;20:17626-34.  Back to cited text no. 1
    
2.
Ramos LP, Araújo RB, Castro MD, Ramos MR, Cunha-E-Silva JA, Iglesias AC. Hemodynamic evaluation of elderly patients during laparoscopic cholecystectomy. Rev Col Bras Cir 2018;45:e1659.  Back to cited text no. 2
    
3.
Manohar Harison Madia M, Kumar Singh A, Manohar Wrangler Richi S, Badan Singh R. A comparison of perioperative hemodynamic stability with amlodipine and telmisartan during laparoscopic cholecystectomy in known hypertensive patients. AJMR 2019;8:AN04-7.  Back to cited text no. 3
    
4.
Schauer PR, Luna J, Ghiatas AA, Glen ME, Warren JM, Sirinek KR. Pulmonary function after laparoscopic cholecystectomy. Surgery 1993;114:389-97.  Back to cited text no. 4
    
5.
Latimer RG, Dickman M, Day WC, Gunn ML, Schmidt CD. Ventilatory patterns and pulmonary complications after upper abdominal surgery determined by preoperative and postoperative computerized spirometry and blood gas analysis. Am J Surg 1971;122:622-32.  Back to cited text no. 5
    
6.
Kvolik S, Brozović G, Rakipović-Stojanović A, Drenjančević-Haršanji I, Kristek J, Šakić K, et al. More hemodynamic changes in hypertensive versus non-hypertensive patients undergoing breast cancer surgery in general anesthesia: A prospective clinical study. Med Glas Ljekarske Komore Zeničko Dobojskog Kantona 2009;6:97.  Back to cited text no. 6
    
7.
Bakhamees HS, El-Halafawy YM, El-Kerdawy HM, Gouda NM, Altemyatt S. Effects of dexmedetomidine in morbidly obese patients undergoing laparoscopic gastric bypass. Middle East J Anaesthesiol 2007;19:537-51.  Back to cited text no. 7
    
8.
Bhattacharjee DP, Nayek SK, Dawn S, Bandopadhyay G, Gupta K. Effects of dexmedetomidine on haemodynamics in patients undergoing laparoscopic cholecystectomy – A comparative study. J Anaesthesiol Clin Pharmacol 2010;26:45.  Back to cited text no. 8
    
9.
Shamim R, Srivastava S, Rastogi A, Kishore K, Srivastava A. Effect of two different doses of dexmedetomidine on stress response in laparoscopic pyeloplasty: A randomized prospective controlled study. Anesth Essays Res 2017;11:1030-4.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Ghodki PS, Thombre SK, Sardesai SP, Harnagle KD. Dexmedetomidine as an anesthetic adjuvant in laparoscopic surgery: An observational study using entropy monitoring. J Anaesthesiol Clin Pharmacol 2012;28:334-8.  Back to cited text no. 10
[PUBMED]  [Full text]  
11.
Manne GR, Upadhyay MR, Swadia V. Effects of low dose dexmedetomidine infusion on haemodynamic stress response, sedation and post-operative analgesia requirement in patients undergoing laparoscopic cholecystectomy. Indian J Anaesth 2014;58:726-31.  Back to cited text no. 11
[PUBMED]  [Full text]  
12.
Masoori TA, Gupta K, Agarwal S, Bansal M, Zuberi A, Samad A. Clinical efficacy of dexmedetomidine in two different doses to attenuate the hemodynamic changes during laparoscopic cholecystectomy. Int J Res Med Sci 2018;6:959.  Back to cited text no. 12
    
13.
Vora KS, Baranda U, Shah VR, Modi M, Parikh GP, Butala BP. The effects of dexmedetomidine on attenuation of hemodynamic changes and there effects as adjuvant in anesthesia during laparoscopic surgeries. Saudi J Anaesth 2015;9:386-92.  Back to cited text no. 13
    
14.
Hall JE, Uhrich TD, Barney JA, Arain SR, Ebert TJ. Sedative, amnestic, and analgesic properties of small-dose dexmedetomidine infusions. Anesth Analg 2000;90:699-705.  Back to cited text no. 14
    


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