DISCUSSION

The hemodynamic alterations due to intense sympathetic stimulation accompanying

laparoscopic surgery, comprising of elevation in heat rate and rise in systolic, diastolic and
mean arterial pressure are well known. The potential for life-threatening complications
associated with such a response in also well documented. In the study, Slogoff and Keats noted
that there was strong relationship of both perioperative myocardial ischemia and postoperative
myocardial infarction with anaesthetic and surgical events known to produce intense
sympathetic stimulation, with or without hemodynamic abnormalities. Thus, it is logical to
look for methods to reduce sympathetic stimulation per se.

Various drugs and methods have been studied to prevent hemodynamic alterations due to stress
of surgery and anaesthesia. Dexmedetomidine, a highly selective α2 – agonist has been used by
many workers like Jalonen J et al, Bhattacharjee DP et al, Aantaa R et al, Kang WS et al,
Scheinin B et al, Jaakola ML et al, Levanen J et al, Guler G et al, Yildiz M et al, Tanskanen
PE et al, Bajwa SS Et al, Gupta K et al etc. for attenuation of hemodynamic responses in various
doses and along with various anaesthetic regimens for various types of surgeries Aho Met al
conducted a study in which dexmedetomidine was given, for the first time, to patients
undergoing a laparoscopic procedure, i.e. gynaecologic diagnostic laparoscopy, and the
hemodynamic and endocrine effects of three different doses of dexmedetomidine were
compared. All the workers have been quite successful in their efforts and have found
dexmedetomidine effective in attenuating the responses but their findings need to be further
substantiated and effectiveness of dexmedetomidine needs to be evaluated in laparoscopic
cholecystectomy.

Bhattacharjee DP et al studied the effects of dexmedetomidine on hemodynamics in patient

undergoing laparoscopic cholecystectomy. They gave dexmedetomidine infusion (0.2pAp/hr)
in one group and normal saline (02pg/kg/hr) in control group They concluded that
dexmedetomidine infusion in the perioperative period in laparoscopic cholecystectomy
provides better intraoperative and postoperative hemodynamic stability.
Pneumoperitoneum is produced by administration of carbon dioxide during laparoscopic
surgical procedures. Both pneumoperitoneum and carbon dioxide causes adverse
cardiovascular effects. Some of these effects are related to CO, and some are due to increased
intra-abdominal pressure secondary to creation of pneumoperitoneum.
Immediately after pneumoperitoneum, plasma level of norepinephrine, epinephrine and plasma
renin activity is increased. Increased catecholamine level activates the renin-angiotensin-
aldosterone-system (RAAS) leading to some characteristic hemodynamic alterations. All these
changes together contribute to elevated arterial pressure increased systemic and pulmonary
vascular resistance and reduced cardiac output.
In our study, we observed the effects of dexmedetomidine on hemodynamics during
perioperative period in patients undergoing laparoscopic surgeries and we did all the studies
on patients undergoing laparoscopic cholecystectomy. Dexmedetomidine is a highly selective
α2 adrenergic agonist with sedative anxiolytic, and analgesic, sympatholytic and
antihypertensive effects. Activation of receptors in the brain and spinal cord level inhibits
neuronal firing, thereby causing hypotension, bradycardia, sedation and analgesia. Generally
presynaptic activation of α2 adrenergic receptors inhibits the release of norepinephrine.
Postsynaptic activation of α2 adrenergic receptors in the central nervous system inhibits
sympathetic activity and therefore can decrease blood pressure and heart rate. It also produces
sedation and diminishes the intraoperative requirement of analgesics.
Laparoscopic cholecystectomy is performed in reverse Trendelenburg position. This particular
position causes diminished venous return which ultimately leads to further decrease in cardiac
output. Normal heart can cope with the increase in afterload caused by various mechanisms.
But patients with compromised cardiac function may not be able to tolerate the changes in
afterload produced by pneumoperitoneum and it may have deleterious effects on their
hemodynamics.
Ishizaki Y et al tried to evaluate the safe intra-abdominal pressure during laparoscopic surgery.
They observed a significant fall in cardiac output at 16 mm Hg of intra-abdominal pressure.
Hemodynamic alteration were not observed at 12 mm Hg of intra- abdominal pressure. Based
on all these observation recommendation is to monitor intra- abdominal pressure and to keep
it as low as possible. In our study, following pneumoperitoneum with carbon dioxide, minute
ventilation was adjusted so as to maintain normocapnia. Intra-abdominal pressure (LAP) was
monitored throughout the surgery and maintained below 14 mm Hg.
The present study was conducted in the Department of Anaesthesiology. Batra Hospital and
Medical Research Centre, New Delhi with due permission from committee of the Research
Review Board to study the effect of LV. dexmedetomidine infusion on intra operative
hemodynamics and requirement of fentanyl in laparoscopic surgeries. We did our study on
patients undergoing laparoscopic cholecystectomy.
Patients selected in present study belonged to age between 18- 60 years and weight between
40-70 kg. 60 patients were allocated in two groups, 30 patients in Group A (Study) and 30
patients in Group B (Control).
There was no statistically significant difference between both groups with regards to age (p-
value> 0.05). This helped us to judge the clinical significance of our study as the distribution,
metabolism, excretion and action of drug are undoubtedly varied in different age groups.
Therefore, clinically insignificant variation in age simply helped to alleviate these confounding
factors.
There was even distribution of weight in both groups. The mean weight was not significantly
different between both groups (p-value >0.05). Therefore, clinically insignificant variation in
weight simply helped to alleviate confounding factors for doses of drugs.
Other factors like sex distribution, ASA grade distribution, duration of surgery and volume of
intravascular fluids administered intraoperatively were also comparable in both groups (p-
value > 0.05).
The mean baseline hemodynamic parameters (Heart Rate, SBP, DBP, and MAP) were
comparable in both the groups. The difference was not statistically significant (p-value> 0.05).
1. Mean Heart Rate:
In Group A (Study) there was a statistically significant fall in the mean heart rate from baseline
after the dexmedetomidine pre-loading infusion(p-value < 005). This fall in heart rate can be
attributed to the sympatholytic effect of dexmedetomidine. Present study is comparable to
study done by Yildiz M et al, who reported that a single dose of dexmedetomidine 1mcg/kg
given preoperatively produced decrease in heart are. Significant fall in heart rate after
preloading with dexmedetomidine was also noted by Kang WS et al, Kabukchu HK et al,
Ghotki PS et al and Bajwa SS et al. The mean HR was significantly below baseline at all time-
points after induction till exsufflation ( p-value <0.05). It gradually increased after reversal and
returned to baseline just after extubation. Such an increase in mean heart rate after the
administration of injection neostigmine and glycopyrrolate for reversal and return to normal
values after extubation in dexmedetomidine group was also reported by Bajwa SS et al.
Hassan SB et al studied the effects of dexmedetomidine in morbidly obese patients undergoing
laparoscopic gastric bypass. They gave dexmedetomidine infusion (0. 4µg/kg/hr) in one group
and normal saline infusion (0. 4µg/kg/hr) in other group throughout the surgery and compared
the hemodynamics. They found that patients who received dexmedetomidine showed
significant decrease of intraoperative and postoperative mean blood pressure and heart rate.
The observations made in both these studies are similar to our study findings in providing
perioperative hemodynamic stability.
In Group B (Control), the mean heart rate decreased slightly after induction as compared to
just after preloading, but it increased significantly just after intubation (P-value <0.05) and
thereafter, remained above baseline at all-time points, with significant differences at all point
times till extubation (p-value < 0.05).
When the mean heart rates at different time points were compared in both groups, baseline
mean heart rate was comparable in both groups, heart rates in Group A(Study) were lower than
in Group B (Control) and significant differences were found at all time points of study
(p-value<0.05). These observations further highlight the beneficial effect, which addition of
dexmedetomidine had, on the heart rate of the patients. Although there was decrease in heart
rate in dexmedetomidine group, significant bradycardia was not noted in any of the cases.
Present study is comparable to study done by Bhattacharjee DP et al, who concluded that the
heart rate in dexmedetomidine group was significantly lower in all times compared to baseline
with significant difference in both groups.

2. Mean Systolic Blood Pressure:

The mean systolic blood pressure in Group A (Study) decreased after the pre-loading infusion,
and the change was found to be statistically significant (p-value<0.05). Ghodki PS et al, in their
study found this fall in mean SBP after loading infusion of dexmedetomidine to be statistically
significant (p-value <0.05). After induction, SBP decreased further; this may be attributed to
the additive hypotensive effect of propofol over the sympatholytic effect of dexmedetomidine.
The mean SBP remained below baseline at all time-points from skin incision, insufflation, 15
and 30 minutes after insufflation and at exsufflation, only nearing baseline just after extubation.
None of the patients developed severe hypotension unresponsive to fluids. After extubation,
SBP increased to cross baseline, but the difference was not found to be statistically significant
(p-value >0.05).
In Group B (Control), there was a significant fall in the mean Systolic BP below baseline after
induction (p-value < 0.05), but it increased after intubation and remained above baseline at all-
time points, with significant differences at all stress points, i.e. just after insufflation. 15 and
30 min after insufflation, just after reversal and just after extubation (p-value< 0.05). Maximum
rise in mean systolic BP was seen at just after insufflation.
Comparison between the two groups revealed that the mean systolic blood pressure was
comparable at baseline (p - value > 0.05). Just after induction, SBP in Group A (Study) was
lower than in Group B (Control), which may be attributed to the hypotensive effect of
dexmedetomidine added to the hypotensive effect of agents required for induction in Group A
After intubation, SBP values in Group A were lower than in Group B at all time-points,
differences being significant just after insufflation, 15 and 30 min, after insufflation, after
exaltation and just after reversal (p-value <0.05).
Tulanogullari B et al studied the effect of dexmedetomidine on both early and late recovery
after laparoscopic bariatric surgery. Eighty consenting ASA II-III morbidly obese patients
were randomly assigned to 1 of 4 treatment groups: (1) control group received a saline infusion
during surgery, (2) Dex 0.2 group received infusion of 0. 2µg/kg/hr (3) Dex 0.4 group received
an infusion of 4µg/kg/hr and (4) Dex 0.8 group received an infusion of 4µg/kg/hr IV. The
intraoperative hemodynamic values were similar in the four groups, arterial blood pressure
values were significantly reduced in the Dex 0.2.04, and 0.8 groups compared with the control
group on admission to the post anaesthesia care unit (PACU).
Yildiz M et al used dexmedetomidine 1µg/kg as a single preinduction dose in one group and
the other group received normal saline at same dose, scheduled for elective minor surgeries to
see its effect on perioperative hemodynamics, Both groups received fentanyl 1µg/kg during
induction They found that dexmedetomidine group had decreased blood pressure and heart rate
as well as the recovery time.
3. Mean Diastolic Blood Pressure:
The mean diastolic blood pressure in Group A (Study) decreased after the pre-loading infusion,
but the change was not found to be statistically significant (p-value > 0.05). Ghodki PS et al,
in their study found similar decrease in mean DBP with loading infusion of dexmedetomidine
which was statistically non-significant. After induction, DBP decreased further, this may be
attributed to additive hypotensive effect of propofol over sympatholytic effect of
dexmedetomidine. This fall in DBP after induction was statistically significant (p-value <0.05).
The mean DBP gradually increased and crossed baseline just after insufflation, to become
significant - value < 0.05). There was a fall below baseline just after exsufflation, but DBP
again increased and crossed baseline after extubation.
In Group B (Control), there was a significant fall in the mean DBP below baseline after
induction (p-value < 0.05), but it increased significantly above baseline after intubation
(p-value < 0.05) and thereafter, remained above baseline at all time points, with significant
differences at incision, just after insufflation, 15 and 30 min. after insufflation, after
exsufflation, just after reversal and just after extubation (p-value < 0.05).
Comparison between the two groups revealed that the mean diastolic blood pressure was
comparable at baseline (p-value > 0.05). Just after induction, DBP in Group A (Test) was lower
than in Group B(Control), which may be attributed to the additive effect of dexmedetomidine
hypotensive effects with induction agents but none of the patients developed hypotension. After
intubation, similar to Systolic BP. Diastolic BP values in Group A (Study) were lower than in
Group A (Study) at all time-points, differences being similar skin incision, just after
insufflation, 15 and 30 min of insufflation, exsufflation and at reversal (p-value < 0.05)

4. Average of Mean Arterial Pressure:

In Group B (Control), there was a significant fall in the average of MAP below baseline after
induction (p-value < 0.05), but it increased significance above baseline after intubation
(p-value <0.05) and thereafter, remained above baseline at all-time points with significant
differences in the insufflation, 15 and 30 min after insufflation, after extubation, just after
reversal and just after extubation.(P-value < 0.05). Similar trend was observed by Bhattacharjee
DP et al in their study.
The average of MAP in Group ‘A’ (Study) deceased after the pre-loading infusion, but the
change was not found to be statistically significant (p-value>0.05). Kabukcu HK et al in their
study also found similar decrease in mean of MAP after loading infusion of Dexmedetomidine
which was statistically non-significant. Bhattacharjee DP et al, Bajwa SS et al, Gupta K et al
and Sen S et al found this decrease in MAP to be significant (p-value < 0.05) in their respective
studies. On the contrary, Kang WS et al reported a transient increase MAP following
dexmedetomidine preloading infusion They attributed it to the dominant hemodynamic effect
of dexmedetomidine through postsynaptic α2B - mediated vasoconstriction at higher dosages
compared with the vasodilatory effect of remifentanil at the dosages used in their study. They
also suggested that the reduced propofol dosage owing to adjuvant dexmedetomidine might
have contributed to less of a propofol - induced vasodilatory effect in group dexmedetomidine.
In present study, after induction, MAP decreased further, which may be attributed to additive
hypotensive effect of induction agents over sympatholytic effect of dexmedetomidine. This fall
in MAP after induction was statistically significant (p-value <0.05), Bhattacharjee DP et al,
Kang WS et al, Kabukcu HK et al, Bajwa SS et al, Gupta K et al and Sen S et al also found this
decrease in MAP after induction to be significant in their respective studies. The average of
MAP gradually increased and crossed baseline just after insufflation. After exsufflation, it
decreased below baseline, only to increase again after reversal and cross Baseline just after
extubation. Similar rise-fall rise trend for MAP was observed by Bhattacharjee DP et al and
Gupta K et al in their respective studies, except that MAP remained below baseline at all-time
points. Increase in MAP after reversal was also reported in a study by Bajwa SS et al, Kabukcu
HK et al, in their study, found MAP after intubation to be significantly below baseline. But, no
significant difference from baseline was seen at any time point in present study, except just
after induction or just before intubation. Joris JL et al studied the hemodynamic changes during
laparoscopic cholecystectomy. They observed that peritoneal insufflation resulted in a
significant increase (±35%) of mean arterial pressure, a significant reduction (±20%) of cardiac
index, and a significant increase of systemic (±65%) and pulmonary (±90%) vascular
resistances. Similarly there was increase in HR. SBP, DBP and MAP in our study after
pneumoperitoneum in both the groups, but the rise was lower in dexmedetomidine group as
compared to placebo group.
Cunningham AJ et al and Dorsay GA et al assessed the ejection fraction (EF) of left ventricle
by trans-esophageal echocardiography during pneumoperitoneum. No significant change in
ejection fraction was reported up to 15 mm Hg of intra-abdominal pressure. Considering all
these facts intra-abdominal pressure was kept below 14 mm Hg. In our study, in spite of
maintaining end tidal carbon dioxide(CO2) level between 35-40 mmHg and intra-abdominal
pressure below 14 mm Hg significant rise was observed in heart rate, systolic, diastolic and
mean arterial blood pressure in the control group compared to the dexmedetomidine group
Comparison between the two groups revealed that the average of MAP was comparable at
baseline (p - value > 0.05). Just after induction, MAP in Group B (Control) was lower than in
Group ‘A’ (Study), which may be attributed to the hypotensive effect of extra propofol required
for induction in Group B. After intubation, similar to SBP and DBP. MAP values in Group A
(Study) were lower than in Group B(Control) at all time-points, differences being significant
just after intubation, just after insufflation, 30 min, after insufflation, after exsufflation and just
after reversal (p-value < 0.05). In their study Bhattacharjee DP et al also reported similar
findings. MAP values in group D (DEX) were significantly lower (p-value < 0.05) after
intubation and pneumoperitoneum and remained lower throughout the pneumoperitoneum and
in the postoperative. However, in contrast to present study, they found the MAP values in group
D (DEX) were significantly lower (p-value < 0.05) after induction than in group S (Saline).
This may have been due to additive sympatholytic effect of dexmedetomidine over hypotensive
effect of propofol in Group D, as they used the same dose of propofol for induction in both
groups i.e. 2 mg/kg. Also, they found that after preloading infusion of dexmedetomidine or
09% saline, MAP values were significantly lower in group D than in group S (p-value <0.05)
while the present study suggested no significant difference.
5. Average of mean of saturation of oxygen (Spo2)
There was no fall in oxygen saturation parameter noticed in both the groups in intraoperative
period and at shifting of the patient to post op care unit in our study finding. (p-value > 0.05)

6. Duration of surgery, extubation, emergence from anaesthesia

Emergence from anaesthetic effects and extubation are equally crucial as is laryngoscopy,
intubation and surgical period. Dexmedetomidine enables a smooth transition from the time of
administration of reversal to the post-extubation phase by suppressing the CNS sympathetic
activity, leading to high quality of extubation with minimum hemodynamic changes, as we
observed in majority of our patients in dexmedetomidine group.

Duration of Surgery:
The mean duration of surgery in Group A (dexmedetomidine group) was 46.67 ± 4.35 minutes
and that in group B (Control) was 47.43±396 minutes (p-value 0.478).

Extubation:
In our study, in Group A (dexmedetomidine group) during extubation, the mean
HR (81.47 ± 4.01/min), SBP(125.13 ± 2.18mmHg), DBP(82.13 ± 4.02mmHg) and
MAP(96.47 ± 5.40 mmHg) were noted and compared with group B (control group) which
were: the mean HR (86.83 ± 8.40/min), SBP (126.07 ± 8.56 mmHg), DRP(83.43 ± 6.73 mmHg)
and MAP(97.64 ± 6.86 mmHg). When compared to the baseline parameters in group B
(control group) HR, SBP, DBP and MAP were significantly higher at the time of extubation
(p value <0.05) as compared to baseline, whereas in Group A (study), SBP, DBP and MAP
were comparable to the baseline parameters Above data suggests that hemodynamics were
much more stable in dexmedetomidine group than control group during extubation
Turan Get al in 2008 examined the effects of dexmedetomidine given at the end of the
procedure to prevent hyper dynamic responses during extubation and to allow a comfortable
and high-quality recovery. They concluded that dexmedetomidine 05 mcg kg administered 5
min. before the end of surgery stabilizes hemodynamics, allows easy extubation, provides a
more comfortable recovery and early neurological examination following intracranial
operations.
Emergence from Anaesthesia:
We also observed the hemodynamics during emergence from anaesthesia i.e. time for
extubation and time to respond to oral commands and found that it was similar in both the
groups. The mean duration of surgery in group A(Study) was 46.67 ± 4.35 minutes and in
Group B (Control) was 47.43 ± 3.96 minutes (p-value 0.478). The mean duration of extubation
time in group A (dexmedetomidine group) was 6.77 ± 0.73/minutes and in control group it was
7.00 ± 0.58minutes (p-value 0.184). The mean duration of response to oral commands in Group
A(dexmedetomidinegroup) was 8.59 ± 0.70 /minutes and in group B (control group) it was
8.78 ± 0.72/minutes (p value=0.304). There was no statistically significant difference found in
the duration of surgery, extubation time and response to oral commands when compared in
both the groups (p>0.05) dexmedetomidine does not seems to have significant respiratory
depression property.
Bhattacharjee DP compared infusion of dexmedetomidine 0.2g/kg/hr and normal saline
0.2g/kg/hr in patients undergoing laparoscopic cholecystectomy and found that there was no
difference in extubation time and response to oral commands in both the groups and the
hemodynamics were much more stable as compared to placebo group during extubation in
dexmedetomidine group. These findings are similar to our study results.
Guler G et al all studied the effect of Single-dose dexmedetomidine attenuates airway and
circulatory reflexes during extubation. Five minutes before the end of surgery, patients were
given dexmedetomidine 0.5µg/kg (Group D) or saline placebo (Group P) intravenous over 60
sec. The blinded anaesthetist awoke all the patients, and the number of coughs per patient was
continuously monitored for 15 min after extubation, coughing was evaluated on a 4-point scale.
Heart rate (HR) and systolic and diastolic blood pressure (SAP, DAP) were measured before,
during and after tracheal extubation. The time from tracheal extubation and emergence from
anaesthesia were recorded, there were no differences between the groups in the incidence of
breath holding or desaturation. HR, SAP and DAP increased at extubation in both groups
(P<0.05), but the increase was less significant with dexmedetomidine. The time from tracheal
extubation and emergence from anaesthesia were similar in both groups.
Adverse complications:
We observed in our study that none of the patients had any episode of bradycardia and
hypotension in Group A (dexmedetomidine) and Group B (control). Studies using
dexmedetomidine have commonly reported cardiovascular side effects such as bradycardia,
sinus arrest and hypotension mainly because of sympatholytic effect. But none of the patient
in our study had an episode of bradycardia or hypotension which could be because we used
lower loading dose of 0.6µg/kg followed by 0.3 µg/kg/hr maintenance dose. In several study
reports, dexmedetomidine infusion rates ranging from 0.1 to 10 µg/kg/hr have been used. The
studies with higher infusion rates had more incidences of adverse effects like hypotension and
bradycardia. Also no significant respiratory depression, apnea, muscle rigidity or decrease in
SpO2 was seen in any of our patients.
In our study, none of the patients in dexmedetomidine group had nausea or vomiting in the
post-operative period, whereas 4 patients (135) in group B(control) had nausea and vomiting
(p-value 0.038).
Massad IM et al, reported that combining dexmedetomidine to other anaesthetic agents,
resulted in more balanced anaesthesia and a significant drop in the incidence of postoperative
nausea and vomiting after laparoscopic gynaecological surgeries.
Tulungullari B et al also found that those patients receiving dexmedetomidine had lesser
incidence of postoperative nausea and vomiting.
Turgut N et al used dexmedetomidine infusion in lumbar laminectomy patients Group D
received Dexmedetomidine 0.6µg/kg as bolus before induction and 0.2µg/kg/hr by infusion.
They found that before and after extubation, MAP values in Group F (fentanyl) were
significantly higher than those in Group D (dexmedetomidine). There was no statistical
difference in heart rate between the groups. Extubation time and post anaesthesia care unit
discharge time were similar in both groups. The fentanyl group patients required supplemental
analgesia earlier than the dexmedetomidine group. Postoperative nausea and vomiting were
significantly higher in Group F.
The findings of our study are in agreement with the findings of various above mentioned
investigators in that dexmedetomidine infusion intraoperatively is an effective agent to reduce
the hemodynamic fluctuations associated with laparoscopic surgery. It also reduces the
incidence of postoperative nausea vomiting.

7. Requirement of opioids (fentanyl citrate)

In our study fentanyl citrate top-ups of 0.5µg/kg were given intraoperatively whenever required
to keep mean blood pressure within 20% of baseline value. In group B (dexmedetomidine
group) -6.7% patients (only 2 ) required single dose of fentanyl top up and 93.3% of the patient
did not required any top up doses. In Group A (control group) - 25 patients (83.3%) required
single top u, 5 patients (16.75%) required 2 top ups
Thus those patients who received dexmedetomidine infusion had lesser requirement of fentanyl
and the hemodynamic parameters were much more stable than control group.
Varshali MK et al used dexmedetomidine infusion intraoperatively. They also used fentanyl in
the increments of inj. fentanyl 0.5µg/kg to keep MAP within 20% of baseline value; they said
that those patients receiving dexmedetomidine intraoperatively had 33% less fentanyl
requirement and 32% less isoflurane requirement as compared to placebo group.
Bajwa SS et al in their study showed that dexmedetomidine is an excellent drug as it not only
decrease the magnitude of hemodynamic response to intubation, surgery and extubation but
also decreased the dose of opioids und isoflurane in achieving adequate analgesia and
anaesthesia respectively. The requirement of fentanyl and isoflurane during the surgical period
was significantly decreased in patients who received dexmedetomidine pre-operatively
(p<0.001)
Feld et al showed that dexmedetomidine could be used in place of fentanyl for intraoperative
control of blood pressure and heart rate during open gastric bypass surgery.
 LIMITATIONS

1. There were certain limitations as our study was done in surgeries of short duration
(around one hour) and on small number of patients (30 in each group). More studies are
required to establish the effect of dexmedetomidine on surgeries of longer duration and
on large number of patients.
2. Moreover the study was done on ASA I and II patients, but the usefulness will of
immense help in high risk cardiac patients.
3. Further studies are required to modify dosage of dexmedetomidine in order to have
wider margin of safety in terms of hemodynamic perturbations without affecting its
analgesic or sedative potentials.
 RECOMMENDATIONS

 Dexmedetomidine in loading dose of 0.6µg/kg followed by infusion of 0.3µg/kg/hr as

an anaesthetic adjuvant is recommended in laparoscopic surgeries to provide
perioperative hemodynamic stability and to facilitate smooth emergence from
anaesthesia.
 Dexmedetomidine offers an added advantage of opioid sparing properties, thus it offers
the advantage of avoiding unwanted side effects of opioids.
 Dexmedetomidine also affords added advantage of reduction in post-operative
complications such as nausea-vomiting.
 However further study is recommended to evaluate its effect on hemodynamic
parameters in high risk group patients with compromised cardio-respiratory function
undergoing laparoscopic surgical procedures.
 Larger studies with a bigger study size and different loading and maintenance dosage
of dexmedetomidine without rendering its useful properties of analgesia, anxiolysis,
sedation and without any respiratory side effects is recommended.
 SUMMARY

Aim of the study was to evaluate the efficacy of dexmedetomidine in the dose of 0.6µg/kg as
a single bolus followed by 03µg/kg infusion dose in maintaining hemodynamic response to
laryngoscopy, tracheal intubation and carboperitoneum creation in adult patients undergoing
laparoscopic surgeries and opioid requirement. After approval by the Hospital Ethics
Committee, the present study was conducted on sixty adult ASA Grade I or II patients of either
sex in the age group 18 to 60 years admitted to Batra Hospital & Medical Research Centre,
New Delhi, who underwent elective laparoscopic surgeries under general anaesthesia.
There was no statistically significant difference in the demographic data between both groups.
Both groups were comparable in terms of age, weight, sex, ASA grade distribution, duration
of surgery and volume of intra-venous fluids administered intra operatively.
 The mean baseline variables (HR. SBP. DBP, MAP, SpO2) were comparable in both
groups.
 When the mean Heart Rate's at different time points were compared in both groups,
significant differences were found at all time-points.
 When the mean Systolic Blood Pressure’s at different time points were compared in
both groups, significant differences were found at all time-points till just after reversal.
 When the mean Diastolic Blood Pressures at different points were compared in both
groups, Diastolic BP values in Group A (Study) were lower than in Group B at all time-
points, differences being significant at all time-points from skin incision till extubation.
 When the averages of Mean Arterial Pressure at different time points were compared
in both groups, significant differences were found at all time points just after intubation
till just after reversal.
 The mean duration of surgery in Group A and Group B were comparable and the
difference was not statistically significant (46.67 ± 4.35 minutes vs 47.43 ± 3.96
minutes)

 The mean extubation time (time from end of all infusions to intubation) in Group A
(dexmedetomidine) and group B(control) were comparable and the difference was not
statistically significant (6.77 ± 0.73 minutes vs 7.00 ± 0.58). Similarly, response to oral
commands in both the groups was comparable (8.59 ± 0.7 minutes vs 8,78 ± 0.72).
 In Group A(dexmedetomidine) requirement of fentanyl citrate (opioid agent used) was
significantly less as compared to that of Group B(control) (6.7% patients required single
top up fentanyl in group A and 83.3% patients required single top up, 16.7% patients
required 2 top-ups in group B (control) the difference being statistically significant.
 Four patients (13%) in the control group had nausea and vomiting in the post-operative
period, difference being statistically significant and none of the patients had episode of
bradycardia, hypotension or hypertension.
 CONCLUSIONS

 We conclude from our study the dexmedetomidine intravenous infusion in the dose
range of loading 0.6µg/kg followed by maintenance of 0.3µg/kg/hr reduces the rise in
heart rate, systolic blood pressure, diastolic blood pressure and mean arterial pressure
associated with the creation and maintenance of pneumoperitoneum during the
laparoscopy surgical procedures.
 Thus, it provides perioperative hemodynamic stability in ASA I and II grade patients
during laparoscopic surgeries because of their sedative, hypnotic anxiolytic and
sympatholytic properties.
 Hence, dexmedetomidine infusion of 0.6 µg/kg followed by 0.3 µg/kg/hr as an
anaesthetic adjuvant can be used in laparoscopic surgeries to provide perioperative
hemodynamic stability and to facilitate smooth emergence from anaesthesia. It also
affords added advantage of opioid sparing properties and in preventing post op nausea
and vomiting. However further study is required to evaluate its effect on hemodynamic
parameters in high risk group patients with compromised cardio-respiratory function
undergoing laparoscopic surgical procedures.