Effect of adjunctive dexmedetomidine on postoperative intravenous opioid administration in patients undergoing thyroidectomy in an ambulatory setting

Abstract

Study Objective

Two of the most feared complications for patients undergoing thyroid surgery are pain and postoperative nausea and vomiting. Thyroidectomy is considered high risk for postoperative nausea and vomiting, and recent studies have looked at adjuncts to treat pain, limit narcotic use, “fast-track” the surgical process, and enhance recovery without compromising the patient's safety. One such perioperative medication of interest is dexmedetomidine (Dex), a centrally acting α-2 agonist that has been associated with reducing pain and postoperative opioid consumption. Our aim was to examine the effectiveness of Dex as an adjunctive intraoperative medication to reduce postoperative narcotic requirements in patients undergoing outpatient thyroid surgery.

Design, Setting, Patients and Intervention

After obtaining approval from the Institutional Review Board at The University of Texas MD Anderson Cancer Center, we searched the electronic medical record for the period October 2013 to March 2015 to identify patients who had undergone thyroid surgery in the ambulatory setting under general anesthesia.

Measurements and Main Results

A total of 71 patients underwent thyroidectomy or thyroid lobectomy in the outpatient setting. Of the patients receiving adjunctive Dex, a lower proportion (50%, n = 9) received postoperative intravenous opioids when compared with control patients (79%, n = 42) (P = .017). One patient (5%) in the Dex group required rescue postoperative antiemetics as compared to 11 (21%) patients in the control group (P = .273).

Conclusions

Our data suggest that intraoperative use of Dex reduced narcotic administration in the postoperative period among study population patients undergoing thyroidectomy.

Introduction

Two of the most feared anesthetic complications for patients undergoing thyroid surgery are pain and postoperative nausea and vomiting. Patients undergoing general anesthesia for thyroidectomy who are not given prophylactic antiemetics for postoperative nausea and vomiting (PONV) have an incidence as high as 64%; however, this can be ameliorated by the use of prophylactic antiemetics [1], [2]. This is concerning because PONV after thyroid surgery may increase the risk of bleeding, which can lead to potential neck hematoma and subsequent airway obstruction [3]. Although relatively well tolerated, thyroid surgery does result in postoperative pain, which is frequently treated with opioids. However, opioid medications are associated with respiratory depression, PONV, and immune suppression [4]. As with many other surgical procedures, the emphasis on enhanced recovery programs and “fast-track” protocols has led to an increase in outpatient thyroidectomy procedures over the last 25 years. After thyroid surgery, patients are traditionally observed for airway compromise, hemorrhage, and hypocalcemia [5], [6]. Postoperative pain or nausea and vomiting may increase the patient's length of stay in the hospital. Likewise, postoperative pain and nausea/vomiting result in a delay in returning patients to their baseline functional status [3], [7].

Recent studies have looked at adjuncts to treat pain, limit narcotic use, “fast-track” the surgical process, and enhance recovery without compromising the patient's safety [7], [8]. The vital role of the anesthesiologist in facilitating an enhanced surgical recovery with the use of such careful perioperative medication is indisputable [9].

One such perioperative medication of interest is dexmedetomidine (Dex), a centrally acting α-2 agonist that has been associated with reducing pain and postoperative opioid consumption. Likewise, it provides adequate sedation with minimal risk of respiratory depression [10], [11]. Dex has been described to reduce postoperative rescue pain medication when mixed with a local anesthetic and administered via a regional anesthesia technique [12]. To our knowledge, no published report has previously described the use of intravenous Dex for decreasing postoperative narcotic administration in patients undergoing thyroidectomy, and it does not appear that the use of Dex infusion as an adjunct intraoperative medication has been studied exclusively in a thyroidectomy population. We sought to evaluate the effectiveness of Dex infusion as an adjunctive intraoperative medication to reduce postoperative narcotic requirements in patients undergoing outpatient thyroid surgery.