Page 23 - CASA Bulletin of Anesthesiology 2022; 9(5)
P. 23

Vol. 9, No 5, 2022


               Patient Outcomes

                   Isolating the immunomodulatory effects of DEX on post-operative patient outcomes, rather
               than attributing the outcomes observed to DEX’s other effects such as sympatholysis, analgesia,
               or anxiolysis remains a challenge in existing studies. In cardiac surgeries, while intraoperative
               DEX was shown to improve mortality and incidence of cardiac/cerebrovascular events, and
               delirium, investigators did not observe a statistically significant benefit in reducing sepsis or
               other post-operative complications. 20–22  The authors reasoned that sepsis was a secondary
               outcome and the studies may have been inadequately powered to detected a difference.

                   In non-cardiac surgeries, perioperative DEX use was also associated with fewer adverse
               cardiac events despite increased intraoperative hypotension and bradycardia.  In a non-
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               perioperative randomized control study of sepsis, DEX administration was not associated with
               improvement in mortality or ventilator-free days.
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               Cancer
                   Animal and in vitro studies have demonstrated an association between DEX and tumor
               progression, possibly through stimulation of alpha-2 receptors on tumor cells. 17, 25–28  In clinical
               studies, the impact of intraoperative DEX use on recurrence-free survival and overall survival are
               mixed. Two recent studies, one among adults undergoing lung adenocarcinoma resection and the
               another among pediatric patients undergoing cytoreductive surgery for peritoneal carcinomatosis,
               found no significant association between intraoperative DEX exposure and recurrence-specific
               survival or overall survival. 29,30  In another propensity-matched trial, intraoperative DEX was not
               associated with recurrence but was associated with overall decrease in survival of patients after
               non-small cell lung cancer surgery.  These results are somewhat surprising as DEX was
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               previously thought to be potentially superior to opioids in cancer patients due to its lack of
               immunosuppressive effects that were observed in opioids and volatile anesthetics and subsequent
               tumor progression.  Existing studies suggest that dexmedetomidine may not be an optimal
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               multimodal analgesic agent for cancer patients, even if the underlying mechanism is due to
               different signaling pathways rather than immune suppression.

               Conclusion

                   Dexmedetomidine has an important role in multimodal analgesia due to anti-inflammatory
               effects and immunomodulatory benefits. Patient and procedure factors, such as inflammatory or
               oncologic history or dexmedetomidine dosing, must be considered in determining the inclusion
               of dexmedetomidine in the analgesic plan. Further trials are needed to understand the
               perioperative effects of dexmedetomidine in diverse clinical situations.











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