The Safety and Efficacy of Dexmedetomidine vs. Sufentanil in Monitored Anesthesia Care during Burr-Hole Surgery for Chronic Subdural Hematoma: A Retrospective Clinical Trial

Abstract

Background: Chronic subdural hematoma (CSDH) is a very common clinical emergency encountered in neurosurgery. While both general anesthesia (GA) and monitored anesthesia care (MAC) can be used during CSDH surgery, MAC is the preferred choice among surgeons. Further, while dexmedetomidine (DEX) is reportedly a safe and effective agent for many diagnostic and therapeutic procedures, there have been no trials to evaluate the safety and efficacy of DEX vs. sufentanil in CSDH surgery. Objective: To evaluate the safety and efficacy of DEX vs. sufentanil in MAC during burr-hole surgery for CSDH. Methods: In all, 215 fifteen patients underwent burr-hole surgery for CSDH with MAC and were divided into three groups: Group D1 (n = 67, DEX infusion at 0.5 μg·kg-1 for 10 min), Group D2 (n = 75, DEX infusion at 1 μg·kg-1 for 10 min), and Group S (n = 73, sufentanil infusion 0.3 μg·kg-1 for 10 min). Ramsay sedation scale (RSS) of all three groups was maintained at 3. Anesthesia onset time, total number of intraoperative patient movements, hemodynamics, total cumulative dose of DEX, time to first dose and amount of rescue midazolam or fentanyl, percentage of patients converted to alternative sedative or anesthetic therapy, postoperative recovery time, adverse events, and patient and surgeon satisfaction scores were recorded. Results: The anesthesia onset time was significantly less in group D2 (17.36 ± 4.23 vs. 13.42 ± 2.12 vs. 15.98 ± 4.58 min, respectively, for D1, D2, S; P < 0.001). More patients in groups D1 and S required rescue midazolam to achieve RSS = 3 (74.63 vs. 42.67 vs. 71.23%, respectively, for D1, D2, S; P < 0.001). However, the total dose of rescue midazolam was significantly higher in group D1 (2.8 ± 0.3 vs. 1.9 ± 0.3 vs. 2.0 ± 0.4 mg, respectively, for D1, D2, S; P < 0.001). The time to first dose of rescue midazolam was significantly longer in group D2 (17.32 ± 4.47 vs. 23.56 ± 5.36 vs. 16.55 ± 4.91 min, respectively, for D1, D2, S; P < 0.001). Significantly fewer patients in groups S and D2 required rescue fentanyl to relieve pain (62.69 vs. 21.33 vs. 27.40%, respectively, for D1, D2, S; P < 0.001). Additionally, total dose of rescue fentanyl in group D1 group was significantly higher (212.5 ± 43.6 vs. 107.2 ± 35.9 vs. 98.6 ± 32.2 μg, respectively, for D1, D2, S; P < 0.001). Total number of patient movements during the burr-hole surgery was higher in groups D1 and S (47.76 vs. 20.00 vs. 47.95%, respectively, for D1, D2, S; P < 0.001). Four patients in D1 and five in S converted to propofol. The time to recovery for discharge from the PACU was significantly shorter in group D2 (16.24 ± 4.15 vs. 12.48 ± 3.29 vs. 15.91 ± 3.66 min, respectively, for D1, D2, S; P < 0.001). Results from the patient and surgeon satisfaction scores showed significant differences favoring group D2 (P < 0.05). More patients in groups D1 and S showed higher levels of the overall incidence of tachycardia and hypertension, and required higher doses of urapidil and esmolol (P < 0.05). Six patients experienced respiratory depression in group S. Conclusion: Compared with sufentanil, DEX infusion at 1 μg·kg-1 was associated with fewer intraoperative patient movements, fewer rescue interventions, faster postoperative recovery, and better patient and surgeon satisfaction scores and could be safely and effectively used for MAC during burr-hole surgery for CSDH.

Keywords: burr-hole surgery; chronic subdural hematoma; dexmedetomidine; monitored anesthesia care; sufentanil.

Figures

Figure 1

Patient enrolment flow diagram.

Figure 2

Hemodynamics monitoring across the three groups. (A) Comparison of heart rates (HR) (beats/min) among the three groups at different time points. (B) Comparison of mean arterial pressure (MAP) (mmHg) in the three groups at different time points. Baseline vital signs were not statistically difference among the three groups (P > 0.05). Compared with S group, both HR and MAP in the D1 and D2 groups were significantly decreased at T2 (after bolus administration of drug), T3 (before local anesthetic), T4 (before skin incision), T7 (arrival at the PACU), T8 (5 min after arrival at the PACU), and T9 (10 min after arrival at the PACU) (P < 0.05). The lowest levels of HR and MAP among the three groups both occurred at T2. *P < 0.05 vs. group D2.

Figure 3

(A) Percentage of patients who required rescue midazolam, and mean midazolam dosage used during the study. (B) Percentage of patients who did not require rescue fentanyl, and mean fentanyl dosage used in patients requiring rescue fentanyl during the study. *P < 0.05 vs. group D2, ∧P < 0.05 vs. group S.