Intra-articular dexmedetomidine in knee arthroscopy: A systematic review and meta-analysis

Ke Peng, Wei-Rong Chen, Xiao-Wen Meng, Juan Zhang, Fu-Hai Ji, Ke Peng, Wei-Rong Chen, Xiao-Wen Meng, Juan Zhang, Fu-Hai Ji

Abstract

The aim of this meta-analysis is to evaluate the analgesic effects of intra-articular dexmedetomidine (DEX) in arthroscopic knee surgery. A comprehensive literature search was conducted to identify randomized controlled trials (RCTs) comparing intra-articular DEX versus control for postoperative analgesia in knee arthroscopy. Trial sequential analysis (TSA) was applied to determine the reliability of the evidence. Twelve RCTs including 594 patients met the eligibility criteria. DEX treatment significantly improved postoperative pain outcomes, with weighted mean differences (95% confidence interval) between the DEX and control groups of -1.57 (-1.94 to -1.20, P < 0.00001) for pain scores at rest at postoperative 1 h, -8.54 mg (-11.96 to -5.13, P < 0.00001) for morphine-equivalents at postoperative 0-24 h, and 257.57 min (209.86 to 305.28, P < 0.00001) for time to first request for postoperative analgesia. TSA indicated there is sufficient evidence for these outcomes. Intra-articular DEX did not affect the incidence of postoperative nausea and vomiting, hypotension, bradycardia, or somnolence. This meta-analysis demonstrated that intra-articular administration of DEX improved pain outcomes in the early postoperative period after knee arthroscopy. Due to the limited number of trials and patients included in this meta-analysis, more evidence is required to confirm these findings.

Conflict of interest statement

The authors declare no competing interests.

Figures

Figure 1
Figure 1
PRISMA flow diagram.
Figure 2
Figure 2
Risk of bias assessment. (a) Risk of bias graph; (b) risk of bias summary.
Figure 3
Figure 3
Intra-articular DEX versus control in knee arthroscopy: pain intensity at rest at 1 h postoperatively. (a) Forest plot; (b) Trial sequential analysis; (c) Sensitivity analysis; (d) Begg’s funnel plot. DEX, dexmedetomidine; WMD, weighted mean difference; RIS, required information size.
Figure 4
Figure 4
Intra-articular DEX versus control in knee arthroscopy: morphine-equivalents 0–24 h postoperatively. (a) Forest plot; (b) Trial sequential analysis; (c) Sensitivity analysis; (d) Begg’s funnel plot. DEX, dexmedetomidine; WMD, weighted mean difference; RIS, required information size.
Figure 5
Figure 5
Intra-articular DEX versus control in knee arthroscopy: time to first analgesic request. (a) Forest plot; (b) Trial sequential analysis; (c) Sensitivity analysis; (d) Begg’s funnel plot. DEX, dexmedetomidine; WMD, weighted mean difference; RIS, required information size.
Figure 6
Figure 6
Intra-articular DEX versus control in knee arthroscopy: adverse effects. (a) Postoperative nausea and vomiting; (b) Hypotension; (c) Bradycardia; (d) Somnolence. DEX, dexmedetomidine; WMD, weighted mean difference.

References

    1. Kim S, Bosque J, Meehan JP, Jamali A, Marder R. Increase in outpatient knee arthroscopy in the United States: a comparison of National Surveys of Ambulatory Surgery, 1996 and 2006. The Journal of bone and joint surgery. American volume. 2011;93:994–1000. doi: 10.2106/JBJS.I.01618.
    1. Gerlach AT, Murphy CV, Dasta JF. An updated focused review of dexmedetomidine in adults. The Annals of pharmacotherapy. 2009;43:2064–2074. doi: 10.1345/aph.1M310.
    1. Dahl MR, Dasta JF, Zuelzer W, McSweeney TD. Lidocaine local anesthesia for arthroscopic knee surgery. Anesth Analg. 1990;71:670–674. doi: 10.1213/00000539-199012000-00016.
    1. Stein C, et al. Analgesic effect of intraarticular morphine after arthroscopic knee surgery. N Engl J Med. 1991;325:1123–1126. doi: 10.1056/NEJM199110173251602.
    1. Bondok RS, Abd El-Hady AM. Intra-articular magnesium is effective for postoperative analgesia in arthroscopic knee surgery. Br J Anaesth. 2006;97:389–392. doi: 10.1093/bja/ael176.
    1. Gentili M, Juhel A, Bonnet F. Peripheral analgesic effect of intra-articular clonidine. Pain. 1996;64:593–596. doi: 10.1016/0304-3959(95)00188-3.
    1. Al-Metwalli RR, et al. Effect of intra-articular dexmedetomidine on postoperative analgesia after arthroscopic knee surgery. Br J Anaesth. 2008;101:395–399. doi: 10.1093/bja/aen184.
    1. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339:b2535. doi: 10.1136/bmj.b2535.
    1. Higgins, J. & Green, S. Cochrane handbook for systematic reviews of interventions. The Cochrane Collaboration Version 5.1.0, Available from: (2011).
    1. Turan A, et al. Preoperative angiotensin-converting enzyme inhibitor use is not associated with increased postoperative pain and opioid use. Clin J Pain. 2013;29:1050–1056. doi: 10.1097/AJP.0b013e318287a258.
    1. Von Korff M, et al. De facto long-term opioid therapy for noncancer pain. Clin J Pain. 2008;24:521–527. doi: 10.1097/AJP.0b013e318169d03b.
    1. Guyatt GH, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336:924–926. doi: 10.1136/.
    1. Begg CB, Mazumdar M. Operating characteristics of a rank correlation test for publication bias. Biometrics. 1994;50:1088–1101. doi: 10.2307/2533446.
    1. Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997;315:629–634. doi: 10.1136/bmj.315.7109.629.
    1. Ning GZ, et al. Rivaroxaban for thromboprophylaxis after total hip or knee arthroplasty: a meta-analysis with trial sequential analysis of randomized controlled trials. Sci Rep. 2016;6:23726. doi: 10.1038/srep23726.
    1. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327:557–560. doi: 10.1136/bmj.327.7414.557.
    1. Xu X, et al. Tomato consumption and prostate cancer risk: a systematic review and meta-analysis. Sci Rep. 2016;6:37091. doi: 10.1038/srep37091.
    1. Brok J, Thorlund K, Wetterslev J, Gluud C. Apparently conclusive meta-analyses may be inconclusive–Trial sequential analysis adjustment of random error risk due to repetitive testing of accumulating data in apparently conclusive neonatal meta-analyses. Int J Epidemiol. 2009;38:287–298. doi: 10.1093/ije/dyn188.
    1. Wetterslev J, Thorlund K, Brok J, Gluud C. Trial sequential analysis may establish when firm evidence is reached in cumulative meta-analysis. J Clin Epidemiol. 2008;61:64–75. doi: 10.1016/j.jclinepi.2007.03.013.
    1. Kjaergard LL, Villumsen J, Gluud C. Reported methodologic quality and discrepancies between large and small randomized trials in meta-analyses. Ann Intern Med. 2001;135:982–989. doi: 10.7326/0003-4819-135-11-200112040-00010.
    1. Alipour M, et al. Effect of dexmedetomidine on postoperative pain in knee arthroscopic surgery; a randomized controlled clinical trial. The archives of bone and joint surgery. 2014;2:52–56.
    1. Cao, W. B. & Liu, Z. F. Clinical observation of intraarticular dexmedtomidine on postoperative analgesia after arthroscopic knee surgery. Jilin Medicine. 37, 312–314 [article in Chinese] (2016).
    1. Cui, J. Z., Zhang, X. B., Zhang, Y. H. & Zhao, Z. B. Efficacy of intra-articular dexmedetomidine for postoperative analgesia in arthroscopic knee surgery. Chinese Journal of Modern Medicine. 24, 94–97 [article in Chinese] (2014).
    1. Elbadawy AM, Salama AK, Mohammad MM. Comparative study of intra-articular dexmedetomidine versus ketamine as adjuvant analgesics after knee arthroscopy. Egyptian J Anaesth. 2015;31:309–314. doi: 10.1016/j.egja.2015.05.003.
    1. Lei, L. et al. Efficacy of intra-articuIar dexmedetomidine for postoperative analgesia in patients with arthroscopic knee surgery. Pain Clin J. 10, 121–124 [article in Chinese] (2014).
    1. Panigrahi R, et al. Intra-articular adjuvant analgesics following knee arthroscopy: comparison between single and double dose dexmedetomidine and ropivacaine a multicenter prospective double-blind trial. Orthop Surg. 2015;7:250–255. doi: 10.1111/os.12182.
    1. Panigrahi R, et al. High dose dexamethasone offers better postoperative analgesia than dexmedetomidine when added to intra articular ropivacaine following knee arthroscopic surgery. Anaesth, Pain & Intensive Care. 2016;20:273–277.
    1. Paul S, Bhattacharjee DP, Ghosh S, Dawn S, Chatterjee N. Efficacy of intra-articular dexmedetomidine for postoperative analgesia in arthroscopic knee surgery. Ceylon Med J. 2010;55:111–115. doi: 10.4038/cmj.v55i4.2627.
    1. Wang, C. G. et al. The efficacy of dexmedetomidine for multimodal analgesia on postoperative analgesia after arthroscopic knee surgery. Int J Anesth Resus. 35, 977–980 [article in Chinese] (2014).
    1. Yao, M. et al. The effects of intra-articular infusion dexmedetomidine on postoperative analgesia in patients with arthroscopic knee surgery. J Clin Anesthesiol. 28, 896–898 [article in Chinese] (2012).
    1. Zhang, Y., Yin, J. L., Wang, X. L., Bao, H. G. & Chen, L. H. Efficacy of Intra-articular dexmedetomidine in combination with ropivacaine for postoperative analgesia in arthroscopic knee surgery. Pharmaceutical and Clinical Research. 23, 294–296 [article in Chinese] (2015).
    1. Kirksey MA, Haskins SC, Cheng J, Liu SS. Local Anesthetic Peripheral Nerve Block Adjuvants for Prolongation of Analgesia: A Systematic Qualitative Review. PLoS One. 2015;10:e0137312. doi: 10.1371/journal.pone.0137312.
    1. Abdallah FW, Brull R. Facilitatory effects of perineural dexmedetomidine on neuraxial and peripheral nerve block: a systematic review and meta-analysis. Br J Anaesth. 2013;110:915–925. doi: 10.1093/bja/aet066.
    1. Ebert TJ, Hall JE, Barney JA, Uhrich TD, Colinco MD. The effects of increasing plasma concentrations of dexmedetomidine in humans. Anesthesiology. 2000;93:382–394. doi: 10.1097/00000542-200008000-00016.
    1. Funai Y, et al. Systemic dexmedetomidine augments inhibitory synaptic transmission in the superficial dorsal horn through activation of descending noradrenergic control: an in vivo patch-clamp analysis of analgesic mechanisms. Pain. 2014;155:617–628. doi: 10.1016/j.pain.2013.12.018.
    1. Oda A, et al. Effects of alpha2-adrenoceptor agonists on tetrodotoxin-resistant Na+ channels in rat dorsal root ganglion neurons. Eur J Anaesthesiol. 2007;24:934–941. doi: 10.1017/S0265021507000543.
    1. Chen BS, Peng H, Wu SN. Dexmedetomidine, an alpha2-adrenergic agonist, inhibits neuronal delayed-rectifier potassium current and sodium current. Br J Anaesth. 2009;103:244–254. doi: 10.1093/bja/aep107.
    1. Vorobeichik L, Brull R, Abdallah FW. Evidence basis for using perineural dexmedetomidine to enhance the quality of brachial plexus nerve blocks: a systematic review and meta-analysis of randomized controlled trials. Br J Anaesth. 2017;118:167–181. doi: 10.1093/bja/aew411.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe