Propofol Target-Controlled Infusion Versus Dexmedetomidine for Sedation During Chronic Subdural Hematoma Surgery Under Local Anesthesia
Propofol Versus Dexmedetomidine for Sedation During Chronic Subdural Hematoma Surgery: A Prospective Randomized Controlled Trial
Chronic subdural hematoma is a collection of old blood on the surface of the brain that mainly affects older adults. It is often treated by draining the blood through a small hole in the skull (burr hole), under local anesthesia combined with intravenous sedation while the patient keeps breathing spontaneously. Propofol and dexmedetomidine are the two sedatives most commonly used for this purpose.
This randomized pilot study will compare how well each drug maintains a moderate and stable level of sedation during surgery. Sixty adults will be randomly assigned to receive either propofol by target-controlled infusion or dexmedetomidine. The main outcome is the percentage of surgical time spent at the target sedation level, defined as a Richmond Agitation-Sedation Scale (RASS) score between -2 and -3.
The study will also compare the time needed to reach the target sedation, breathing and cardiovascular side effects, sedation failures, recovery time, and surgeon and anesthesiologist satisfaction. The results will be used to estimate the sample size of a future confirmatory trial.
Tutkimuksen yleiskatsaus
Tila
Interventio / Hoito
Yksityiskohtainen kuvaus
Design: single-center, prospective, randomized (1:1), controlled, parallel-group pilot trial.
Randomization: computer-generated list in fixed blocks of 4, prepared by a person not involved in the study. Allocations are concealed in sequentially numbered, opaque, sealed envelopes opened in strict order in the operating room immediately before sedation starts.
Masking: the patient, the surgeon, and the postoperative outcome assessor are blinded to group allocation; the syringe and infusion line are covered with an opaque sleeve. The anesthesiologist, who administers the sedative and scores the intraoperative RASS, is not blinded.
Standardized sequence (identical in both arms): T0 start of sedative and sufentanil 5 µg IV; T0 + 10 min lidocaine 2% with epinephrine infiltration by the surgeon (maximum 5 mg/kg); T1 skin incision; T2 burr hole drilling; T3 end of skin closure and discontinuation of the sedative in both arms; T4 modified Aldrete score ≥ 9.
Sedation monitoring: RASS scored before sedation and every 5 minutes using a standardized procedure. Target sedation: RASS -2 to -3. If RASS ≥ +1, a cause (pain, hypoxia, bladder distension, position) is sought and treated before increasing the sedative.
Sedation failure: dose ceiling reached for at least 10 min with RASS > -2 on two consecutive assessments; persistent agitation (RASS ≥ +2 on two consecutive assessments); rescue with a non-protocol sedative; conversion to general anesthesia or intubation; persistent desaturation (SpO2 < 92% for ≥ 30 s despite oxygen and airway maneuvers); or major hemodynamic instability requiring discontinuation of the sedative or continuous vasopressors.
Statistical analysis: modified intention-to-treat population (all randomized patients who received at least one dose of the study drug), with a supportive per-protocol analysis. After a sedation failure, all remaining time until T3 is counted as outside the target. Comparisons are exploratory and reported with 95% confidence intervals. Hemodynamic changes are analyzed using summary measures per patient.
Sample size: no data exist on the primary outcome in this setting; 30 patients per group were chosen according to published recommendations for pilot trials (Julious 2005; Whitehead 2016). Feasibility criteria: recruitment of ≥ 8 patients per month, ≥ 70% of eligible patients randomized, titration algorithm followed in ≥ 80% of patients, and complete primary outcome data in ≥ 90%.
Opintotyyppi
Ilmoittautuminen (Arvioitu)
Vaihe
- Vaihe 4
Yhteystiedot ja paikat
Opiskeluyhteys
- Nimi: Rabeb Hammami, Assistant Professor
- Puhelinnumero: +216 56442412
- Sähköposti: hammamirabeb2@gmail.com
Osallistumiskriteerit
Kelpoisuusvaatimukset
Opintokelpoiset iät
Hyväksyy terveitä vapaaehtoisia
Sukupuolet, jotka voivat opiskella
Kuvaus
Inclusion Criteria:
- Age 18 years or older
- Confirmed diagnosis of unilateral chronic subdural hematoma scheduled for burr-hole surgery under local anesthesia with sedation
- Glasgow Coma Scale score ≥ 13
- Baseline Richmond Agitation-Sedation Scale score of 0 or -1 before any sedation
- ASA physical status I to III
- Written informed consent signed by the patient
Exclusion Criteria:
- Refusal to participate
- Allergy or contraindication to propofol or dexmedetomidine
- Major cognitive impairment preventing understanding of instructions
- Receptive aphasia preventing RASS assessment
- Baseline heart rate < 50 beats per minute
- Second- or third-degree atrioventricular block without a pacemaker
- ASA III with decompensated respiratory disease (COPD on long-term oxygen therapy, severe asthma)
- Body mass index > 35 kg/m²
- Inability to understand the language without an available interpreter
- Participation in another clinical trial
Opintosuunnitelma
Miten tutkimus on suunniteltu?
Suunnittelun yksityiskohdat
- Ensisijainen käyttötarkoitus: Tukevaa hoitoa
- Jako: Satunnaistettu
- Inventiomalli: Rinnakkaistehtävä
- Naamiointi: Kaksinkertainen
Aseet ja interventiot
Osallistujaryhmä / Arm |
Interventio / Hoito |
|---|---|
|
Kokeellinen: dexmedetomidine
Dexmedetomidine sedation titrated to a RASS of -2 to -3, combined with lidocaine 2% with epinephrine infiltration and a single dose of sufentanil 5 µg IV, for burr-hole surgery under local anesthesia with spontaneous breathing. |
Loading dose of 1 µg/kg over 10 minutes, then 0.6 µg/kg/h. Increased by 0.2 µg/kg/h every 10 minutes if RASS > -2; decreased by 0.2 µg/kg/h if RASS = -4; temporarily stopped if RASS = -5, apnea or airway obstruction, and restarted at a rate reduced by 0.2 µg/kg/h once RASS ≥ -3. Range 0.2 to 1.0 µg/kg/h. Stopped at the end of skin closure.
Muut nimet:
|
|
Active Comparator: propofol
Propofol sedation by target-controlled infusion titrated to a RASS of -2 to -3, combined with lidocaine 2% with epinephrine infiltration and a single dose of sufentanil 5 µg IV, for burr-hole surgery under local anesthesia with spontaneous breathing. |
Target-controlled infusion (Schnider model, effect-site mode) started at an effect-site concentration of 1.0 µg/mL. Increased by 0.3 µg/mL every 5 minutes if RASS > -2; decreased by 0.3 µg/mL if RASS = -4 and by 0.5 µg/mL if RASS = -5, apnea, or airway obstruction. Maximum 3.0 µg/mL. No manual boluses. Stopped at the end of skin closure.
Muut nimet:
|
Mitä tutkimuksessa mitataan?
Ensisijaiset tulostoimenpiteet
Tulosmittaus |
Toimenpiteen kuvaus |
Aikaikkuna |
|---|---|---|
|
Percentage of time within target sedation
Aikaikkuna: Intraoperative, from skin incision to end of skin closure (approximately 1 hour)
|
Percentage of the time between skin incision and end of skin closure spent with a Richmond Agitation-Sedation Scale (RASS) score between -2 and -3 (scale range -5 [unarousable] to +4 [combative]). RASS is scored every 5 minutes; each score is assumed valid until the next one. After a sedation failure, all remaining time is counted as outside the target. |
Intraoperative, from skin incision to end of skin closure (approximately 1 hour)
|
Toissijaiset tulostoimenpiteet
Tulosmittaus |
Toimenpiteen kuvaus |
Aikaikkuna |
|---|---|---|
|
Time to target sedation
Aikaikkuna: From start of sedation until target sedation is first reached (up to 1 hour)
|
Time from the start of the sedative to the first RASS score between -2 and -3, in minutes. |
From start of sedation until target sedation is first reached (up to 1 hour)
|
|
Surgeon and anesthesiologist satisfaction
Aikaikkuna: Immediately after the end of skin closure
|
Satisfaction rated by the surgeon and by the anesthesiologist on a 5-point Likert scale (from very satisfied to very dissatisfied). |
Immediately after the end of skin closure
|
|
Recovery time
Aikaikkuna: From end of surgery until recovery, assessed up to 2 hours
|
Time from discontinuation of the sedative to a modified Aldrete score ≥ 9 (or return to baseline neurological status in patients with hemiparesis), in minutes. |
From end of surgery until recovery, assessed up to 2 hours
|
|
Incidence of respiratory adverse events
Aikaikkuna: From start of sedation until discharge from the post-anesthesia care unit (up to 4 hours)
|
Number of patients with apnea (> 20 s), hypoventilation (respiratory rate < 8/min or loss of the capnography waveform), desaturation (SpO2 < 92% for ≥ 30 s), upper airway obstruction or need for ventilatory assistance. |
From start of sedation until discharge from the post-anesthesia care unit (up to 4 hours)
|
|
Incidence of hemodynamic adverse events
Aikaikkuna: From start of sedation until end of surgery (approximately 1 hour)
|
Number of patients with bradycardia (heart rate < 50 bpm), hypotension (mean arterial pressure < 65 mmHg or decrease > 25% from baseline) or hypertension (systolic pressure > 160 mmHg or increase > 20% from baseline), and need for corrective treatment. |
From start of sedation until end of surgery (approximately 1 hour)
|
|
Sedation failure rate
Aikaikkuna: Intraoperative (approximately 1 hour)
|
Proportion of patients with efficacy failure (dose ceiling with RASS > -2, persistent agitation, non-protocol rescue sedative) or procedural failure (conversion to general anesthesia, persistent desaturation, major hemodynamic instability). |
Intraoperative (approximately 1 hour)
|
Yhteistyökumppanit ja tutkijat
Opintojen ennätyspäivät
Opi tärkeimmät päivämäärät
Opiskelun aloitus (Arvioitu)
Ensisijainen valmistuminen (Arvioitu)
Opintojen valmistuminen (Arvioitu)
Opintoihin ilmoittautumispäivät
Ensimmäinen lähetetty
Ensimmäinen toimitettu, joka täytti QC-kriteerit
Ensimmäinen Lähetetty (Todellinen)
Tutkimustietojen päivitykset
Viimeisin päivitys julkaistu (Todellinen)
Viimeisin lähetetty päivitys, joka täytti QC-kriteerit
Viimeksi vahvistettu
Lisää tietoa
Tähän tutkimukseen liittyvät termit
Avainsanat
Muita asiaankuuluvia MeSH-ehtoja
- Aivoverenkiertohäiriöt
- Aivojen sairaudet
- Keskushermoston sairaudet
- Hermoston sairaudet
- Verisuonisairaudet
- Sydän-ja verisuonitaudit
- Haavat ja vammat
- Patologiset prosessit
- Krooninen sairaus
- Sairauden ominaisuudet
- Verenvuoto
- Kranioaivo-trauma
- Trauma, hermosto
- Intrakraniaaliset verenvuotot
- Intrakraniaalinen verenvuoto, traumaattinen
- Patologiset tilat, merkit ja oireet
- Hematooma, subduraalinen
- Hematooma
- Hematooma, subduraalinen, krooninen
- Orgaaniset kemikaalit
- Heterosykliset yhdisteet, 1-rengas
- Heterosykliset yhdisteet
- Atsolit
- Hiilivety
- Hiilivedyt, sykliset
- Hiilivedyt, aromaattiset
- Imidatsolit
- Fenolit
- Bentseenijohdannaiset
- Deksmedetomidiini
- Propofol
Muut tutkimustunnusnumerot
- INNMBHN-16/2026
- approval number 16/2026 (Muu tunniste: Ethics Committee of Institut National Mongi Ben Hmida de Neurologie, approval number 16/2026)
Yksittäisten osallistujien tietojen suunnitelma (IPD)
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IPD-suunnitelman kuvaus
Individual participant data will not be shared publicly; anonymized data may be made available upon reasonable request to the principal investigator.
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