Sedation Complications in Urology During Spinal Anesthesia With Dexmedetomidine or Midazolam Regarding OSA Risk
Sedation Complications in Urology During Spinal Anesthesia With Dexmedetomidine or Midazolam Regarding OSA Risk
Light to moderate sedation is recommended during surgery with spinal anesthesia . This study
 is exploring which sedation drug is better, midazolam or dexmedetomidine for transurethral
 resection of bladder and prostate in patients with or without high risk for obstructive sleep
 apnea (OSA). Patients were divided in two groups regarding OSA risk, and each group received
 midazolam or dexmedetomidine for sedation. Investigators observed intraoperative
 complications of airway and factors that are disturbing surgeon(movement due to participants
 coughing and restlessness) because one could puncture bladder or prostate and cause
 perforation.
All participants were premedicated with diazepam 5mg 12 hours and 1 hour before surgery.
 Thromboprophylaxis (enoxaparin 4000-6000 IU) depending on the body weight was given at least
 12 hours before surgery.

 Participants were divided by STOP-BANG(Snoring history, Tired during the day, Observed stop
 breathing while sleep, High blood pressure, BMI more than 35 kg/m2, Age more than 50 years,
 Neck circumference more than 40 cm and male Gender) questionnaire into one of two groups:
 high OSA and low&medium OSA. Each group was then allocated by permuted block randomisation
 into midazolam or dexmedetomidine group. The randomisation list was obtained from R program.
 The group allocations were contained in closed envelope that were opened before surgery after
 the completed enrollment procedure.

 Participants got IV cannula with switch for continuous intravenous infusion in operating
 theatre. Non invasive monitoring (electrodes for ECG, blood pressure cuff and pulse oximeter)
 was placed before induction of spinal anesthesia. Skin was disinfected and 40mg of 2%
 Lidocaine was given subcutaneously at lumbar vertebrae 3/4 level. 25 G spinal needle was used
 and after dura and arachnoidea were pierced 12.5-15 mg of 0.5% Levobupivacaine was applied.
 Participants were then positioned in uniform lithotomy position and 9cm pillow was inserted.
 After sensory block, defined as the absence of pain at T10 dermatome, was induced by
 needle-tip test by the anaesthesiologist, the surgery was initiated.

 Time after subarachnoid block was T0 and sedation with midazolam or dexmedetomidine was
 started via continuous intravenous infusion. Midazolam was started with 0.25 mg/kg of ideal
 body mass, and dexmedetomidine with 0.5 ug/kg through 10 minutes. Every 10 minutes sedation
 level was observed with Ramsay sedation scale (RSS). Drug was titrated to achieve RSS of 4 or
 5 (closed eyes and patient exhibited brisk or sluggish response to light glabellar tap or
 loud auditory stimulus). Independent blinded doctor was assessing RSS level, vital parameters
 and signs of airway obstruction every 10 minutes. Every 10 minutes systolic, diastolic and
 mean arterial pressure(MAP) were noticed along with heart rate, oxygen saturation by pulse
 oximetry(SpO2), RSS level and adverse intraoperative events: snoring as sign of airway
 obstruction, cough and restlessness as disturbing factors to surgeon. If peripheral oxygen
 fell below 90% supplemental oxygen was delivered by facemask with reservoir bag at flow of 10
 L/min. End tidal carbon dioxide(CO2)was measured for detection of possible apnea. If
 oxygenation was still inadequate chin lift and jaw thrust maneuver were performed and
 oropharyngeal airway was inserted if needed. If heart rate fell below 50 bpm atropine 0.1
 mg/kg was given and if systolic blood pressure fell below 100 mmHg(or MAP < 65 mmHg)
 ephedrine 5mg bolus was given. Total crystalloid infusion volume was noticed at the end of
 surgery. All measurements were performed every 10 minutes and 1 hour after surgery in urology
 intensive care. High risk OSA participants underwent cardiorespiratory polygraphy at Center
 for sleep medicine Split.
Inclusion Criteria:

 -  elective transurethral resection of bladder and prostate

 -  American Society of Anesthesiologists (ASA) physical status classification system: I,
 II, III

 Exclusion Criteria:

 -  regional anesthesia contraindications

 -  American Society of Anesthesiologists (ASA) physical status classification system: IV

 -  Atrioventricular cardiac block II and III degree

 -  Psychotic disorders

 -  Participants with tracheostomy

 -  Dementia

 -  Allergy on Dexmedetomidine or Midazolam