Dexmedetomidine as an Adjuvant to Scalp Block in Patients undergoing Elective Craniotomy: A Prospective Randomized Controlled Trial

Scalp block has been proposed to be part of multimodal approach to prevent hemodynamic responses to noxious stimulation during craniotomy and to prevent postoperative pain. Craniotomy pain may be severe and there is a lack of consensus and evidence in different types of analgesia for cranial neurosurgery. Regional analgesia techniques have been practiced in neurosurgical patients as they minimize anesthetic requirements and provide pain relief, allowing neurological assessment with a lower incidence of systemic complications [1]

Noxious stimuli during craniotomy like skull-pin fixation may increase blood pressure even during deep general anesthesia and cause an increase of intracranial pressure and/or bleeding in injured parenchyma [2]. Even opioids are the first-line analgesic therapy, their adverse effects, such as sedation and respiratory depression, may interfere with neurologic assessment and increase intracranial pressure during intracranial surgery. As result non-opioid analgesics may be useful as part of a multimodal regimen for post-craniotomy pain. Paracetamol and non-steroidal anti-inflammatory drugs are beneficial in early post-operative period, but paracetamol alone is inefficient and nonsteroidal anti-inflammatory drugs can increase bleeding risk [3]

Postoperative pain can be managed by scalp block with long-acting local anesthetics, such as ropivacaine, the duration though of sensory block is not enough to avoid the postoperative use of analgesics. The use of adjuvants, such as clonidine and steroids, with local anesthetics for early onset and for prolonging the duration of blocks, has been introduced in clinical practice many years ago and still remains of high interest [4]. Dexmedetomidine, a highly selective alpha-2 adrenergic receptor agonist that has an alpha-2 to alpha-1 selectivity ratio seven times greater than that of clonidine [5], has recently been studied for its analgesic effects and has the potential to become an alternative to clonidine. Dexmedetomidine acts additionally to local anesthetics, prolonging their duration of action. Limited literature is available on the efficacy of dexmedetomidine with local anesthetics for analgesia in neurosurgical patients.

This study was designed to evaluate the effect of scalp block with or without dexmedetomidine combined with general anesthesia on hemodynamic stability during main noxious stimuli, intraoperative consumption of fentanyl and remifentanil and on postoperative pain in patients undergoing elective craniotomy.

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