A Paradigm Shift: The Implementation of Utilizing Dexmedetomidine and Propofol for Laryngeal Mask Airway Insertion

ABSTRACT Background: Laryngeal mask airway (LMA) is a common airway device used intraoperatively for anesthetic airway management. The insertion of LMA requires anesthesia and adequate suppression of airway reflexes. The factors that affect the insertion and positioning of LMA are jaw relaxation, mouth opening, episodes of coughing or movement during insertion, and the depth of anesthesia. If all these parameters are satisfactory, then there will be a minimal hemodynamic stress response, which is required for LMA insertion. In search of an optimum drug, recent studies have suggested that dexmedetomidine is superior to fentanyl as an anesthetic adjuvant in decreasing the requirement of propofol and maintaining stable hemodynamics intraoperatively. Objectives: This literature review aimed to evaluate the current randomized controlled trials (RCTs) on the impact of dexmedetomidine as an adjunct to propofol during LMA insertion. Methodology: A literature search was conducted to identify studies on patients receiving propofol and fentanyl or propofol and dexmedetomidine while undergoing laryngeal mask airway (LMA) insertion. Evidence selection requires the selection of credible databases and sources. Many databases are available with a wide range of articles in different fields of healthcare provisions. The search was conducted in October 2020; thus, the search was current and up to date. The selected databases resulted in a different number of articles related to the search terminologies. PubMed yielded 98 articles, Medline resulted in 112 articles, and CINAHL revealed 143, and Scopus resulted in 56 results. A total of 409 articles were retrieved from the selected databases. Duplicated articles were removed, leaving 204 articles for further evaluation. Thirteen randomized control trials (RCTs) were evaluated in this systematic review. Data sources: Data sources included MedLine, CINAHL, EMBASE, Pubmed, and Google Scholar. Sources were chosen to answer the Population, Intervention, Comparison, and Outcome (PICO) question: (P) In adult surgical patients who present for laryngeal mask insertion (I), does Dexmedetomidine- Propofol IV (C) compared to Fentanyl- Propofol IV (O) decrease hemodynamic instability, ensure spontaneous respirations, and reduce the propofol dosage requirement for induction? Study selection: The inclusion criteria for the articles included: Studies published after 2019, RCTs published in English, dexmedetomidine as the treatment, and opioid consumption as the primary outcome. Exclusion criteria included: meta-analyses and systematic analyses, failure to focus on LMA insertion, and dexmedetomidine not used as treatment. Results: The evidence search, and screening resulted in 15 RCTs. Eleven studies demonstrated dexmedetomidine is a superior adjuvant in preserving respirations and a stable hemodynamic profile. Four studies demonstrated dexmedetomidine could reduce propofol dose requirements by as much as 38%. Conclusion: Evidence shows that dexmedetomidine as a co- induction agent with propofol not only gives excellent overall insertion conditions and hemodynamic stability but also reduces the requirement of induction as well as incremental doses of propofol. Keywords: Dexmedetomidine, LMA, fentanyl, surgical units, surgery, postoperative, perioperative