Intrathecal dexmedetomidine for cesarean delivery: a scoping review

Off-label use of intrathecal dexmedetomidine (ITDex) is suggested in recent guidelines for pain management during cesarean delivery. The primary objective of this scoping review was to identify all publications reporting on ITDex for cesarean delivery, and secondarily to evaluate the evidence and characterize reported outcomes associated with its use.

Following PRISMA-Scr guidelines, we searched PubMed and Embase in October 2024 for articles reporting on ITDex for cesarean delivery and conducted a scoping review on randomized controlled trials (RCTs) and observational trials. A chart data with seven questions characterizing the studies and 13 evaluating clinical outcomes was developed.

Our search identified 48 publications in English between 2015 and October 2024: 43 RCTs, three observational trials, two case reports/series, resulting in 2,002 patients receiving ITDex (dose ranging 1-35 μg). Primary outome was stated in 31 (65 %) studies. There were seven dose-ranging studies, one study with fentanyl co-administration, none with morphine co-administration, three compared ITDex vs. clonidine (clonidine dose ranging 15-75 μg); 35 reported on shivering, 36 on block characteristics (onset and block duration), 38 evaluated postoperative analgesia, nine reported on pain during cesarean delivery.

Dexmedetomidine may be a valuable intrathecal adjuvant for cesarean delivery but the quality of study design and data reporting in the 48 publications was extremely poor. Though we identified 43 RCTs with at least one arm receiving ITDex, no study incorporated current multimodal opioid-sparing analgesia regimens (administration of intrathecal fentanyl and morphine with or without dexmedetomidine), therefore significant knowledge gaps remain.