Dexmedetomidine as a non-opiate adjunct to multimodal perioperative pain control in pediatric patients undergoing craniofacial reconstructive surgery: a retrospective study

Purpose: Craniofacial (CF) reconstruction surgery involves a surgical approach to the CF region to repair cranial vault and facial deformities. The surgery is extensive, often requiring wide scalp dissections and multiple osteotomies and is associated with significant postoperative pain and analgesic requirements. Dexmedetomidine is a highly selective alpha-2 receptor agonist that mediates central nervous system sympathetic activity and pain modulation, thus producing both analgesia and sedation. Intraoperative use of dexmedetomidine could be particularly helpful in these surgeries as a means of reducing postoperative opioid administration and opioid-induced side effects. We hypothesized that intraoperative administration of dexmedetomidine in children undergoing CF reconstructive surgery would have a greater reduction in postoperative opioid requirements, pain, sedation scores, and opioid-induced side effects compared to patients who did not receive dexmedetomidine. Methods: All patients with craniosynostosis who underwent either CVR or BFOA at Children’s National Health System between July 1, 2013 and June 30, 2017 (48 months duration) were retrospectively evaluated. Thirty-nine patients received dexmedetomidine intraoperatively while 41 patients did not receive dexmedetomidine. Demographic data was analyzed and a multitude of continuous and categorical perioperative variables were assessed. Primary outcome measure was mean postoperative morphine equivalent requirements. Secondary outcome measures included presence of opioid related side effects, pain scores, mechanical ventilator days, and ICU and hospital length of stay. Normality of all continuous outcomes was determined and means were compared using a student’s t-test. Categorical outcomes were compared using a Fisher’s exact test. A p-value of \u3c0.05 was considered statistically significant. Results: There were significant demographic differences in terms of age and weight between the two groups in which those receiving dexmedetomidine were younger and weighed less than those that did not receive dexmedetomidine. Intraoperative dexmedetomidine use was not associated with significantly lower postoperative opioid requirements or pain scores. However, patients who received higher doses of intraoperative dexmedetomidine did have significantly lower rescue medication administration for nausea and vomiting postoperatively. Conclusion: Contrary to the hypothesis, dexmedetomidine was not associated with reduced postoperative opioid requirements or pain scores in children undergoing CF reconstructive surgery. Interestingly, our findings suggest that dexmedetomidine may be protective in terms of postoperative opioid-induced nausea. A prospective, randomized controlled trial is needed to better analyze the relationship between intraoperative dexmedetomidine use and postoperative opioid requirements, opioid-related side effects, and pain scores in children undergoing such surgery