Preoperative dexmedetomidine and intraoperative bradycardia in laparoscopic cholecystectomy: a meta-analysis with trial sequential analysis

Abstract

Background: While laparoscopic surgical procedures have various advantages over traditional open techniques, artificial pneumoperitoneum is associated with severe bradycardia and cardiac arrest. Dexmedetomidine, an imidazole derivative that selectively binds to α2-receptors and has sedative and analgesic properties, can cause hypotension and bradycardia. Our primary aim was to assess the association between dexmedetomidine use and intraoperative bradycardia during laparoscopic cholecystectomy.

Methods: We performed a systematic review with a meta-analysis and trial sequential analysis using the following PICOS: adult patients undergoing endotracheal intubation for laparoscopic cholecystectomy (P); intravenous dexmedetomidine before tracheal intubation (I); no intervention or placebo administration (C); intraoperative bradycardia (primary outcome), intraoperative hypotension, hemodynamics at intubation (systolic blood pressure, mean arterial pressure, heart rate), dose needed for induction of anesthesia, total anesthesia requirements (both hypnotics and opioids) throughout the procedure, and percentage of patients requiring postoperative analgesics and experiencing postoperative nausea and vomiting and/or shivering (O); randomized controlled trials (S).

Results: Fifteen studies were included in the meta-analysis (980 patients). Compared to patients that did not receive dexmedetomidine, those who did had a higher risk of developing intraoperative bradycardia (RR: 2.81, 95% CI [1.34, 5.91]) and hypotension (1.66 [0.92,2.98]); however, they required a lower dose of intraoperative anesthetics and had a lower incidence of postoperative nausea and vomiting. In the trial sequential analysis for bradycardia, the cumulative z-score crossed the monitoring boundary for harm at the tenth trial.

Conclusions: Patients undergoing laparoscopic cholecystectomy who receive dexmedetomidine during tracheal intubation are more likely to develop intraoperative bradycardia and hypotension.

Keywords: Bradycardia; Cholecystecomy; Dexmedetomidine; Laparoscopy; Meta-analysis; Review.

Fig. 1.

PRISMA flowchart of the study.

Fig. 2.

Risk of bias assessment. Overview of risk of bias assessment using RoB2 Tool.

Fig. 3.

Intraoperative bradycardia forest plot. Forest plot of intraoperative bradycardia.

Fig. 4.

Intraoperative bradycardia trial sequential analysis (TSA). Trial sequential analysis TSA of intraoperative bradycardia. The blue line represents cumulative evidence. The red horizontal lines represent monitoring boundaries for benefit (upper line), monitoring boundaries for harm (lower line), and futility boundaries (middle lines). The red vertical line corresponds to the required sample size.