The Effects of Dexmedetomidine and Remifentanil on Hemodynamic Stability and Analgesic Requirement After Craniotomy: A Randomized Controlled Trial.
BACKGROUND
Anesthesia for craniotomies should blunt responses to noxious stimuli, whereas subsequently leaving patients sufficiently alert for early neurological evaluation. The aim was to compare postoperative blood pressure control, pain, and opioid requirement after anesthesia with dexmedetomidine versus remifentanil. We therefore tested 2 primary hypotheses: (1) intraoperative administration of dexmedetomidine provides better control of postoperative blood pressure than remifentanil; and (2) patients given dexmedetomidine have less postoperative pain and use less opioid.


METHODS
Adults having elective brain tumor excisions under balanced general anesthesia with endotracheal intubation were randomized to an infusion of remifentanil (0.08 to 0.15 μg/kg/min, n=71) or dexmedetomidine (0.2 to 0.7 μg/kg/h, n=68). Patients also received propofol, rocuronium, fentanyl, and sevoflurane. The mean arterial pressure (MAP) and pain were recorded at 15, 30, 45, 60, and 90 postoperative minutes. Outcomes were assessed with joint hypothesis testing, evaluating noninferiority and superiority.


RESULTS
Compared with remifentanil, the use of dexmedetomidine was associated with reduced postoperative MAP (88±12 vs. 98±11 mm Hg), with estimated mean difference (97.5% confidence interval) of -10 (-13, -4) mm Hg, P<0.001, and mean visual analog pain score (2.9±2.6 vs. 5.1±2.4 points), with estimated mean difference of -5 (-10, -3) points, P<0.001, and required less median opioid consumption (5 [0, 10] vs. 10 [7, 15] mg morphine equivalents), with estimated median difference of -5 (-10, -3) mg, P<0.001. Dexmedetomidine was both noninferior and superior to remifentanil in maintaining postoperative hemodynamics and providing improved pain control.


CONCLUSIONS
Intraoperative dexmedetomidine better controlled postoperative MAP and provided superior analgesia in patients undergoing craniotomy.
Departments of †Outcomes Research *General Anesthesiology ‡Quantitative Health Sciences, Cleveland Clinic §Department of Internal Medicine, Medicine Institute, Cleveland Clinic, Fairview Hospital, Cleveland, OH.
Shobana
S
Rajan
Matthew T
MT
Hutcherson
Daniel I
DI
Sessler
Andrea
A
Kurz
Dongsheng
D
Yang
Michael
M
Ghobrial
Jinbo
J
Liu
Rafi
R
Avitsian
D000698:Analgesia / Q000706:statistics & numerical data*; D003399:Craniotomy; D020927:Dexmedetomidine / Q000494:pharmacology*; D005260:Female; D006439:Hemodynamics / Q000187:drug effects*; D006801:Humans; D006993:Hypnotics and Sedatives / Q000494:pharmacology; D008297:Male; D008875:Middle Aged; D010880:Piperidines / Q000494:pharmacology*; D011183:Postoperative Complications / Q000517:prevention & control*; D000077208:Remifentanil
D006993:Hypnotics and Sedatives; D010880:Piperidines; D020927:Dexmedetomidine; D000077208:Remifentanil