Clonidine premedication for laparoscopic cholecystectomy: Reading between and beyond the lines…

Sir, The recent issue of the journal features an interesting original research article by Meena et al. where they conduct a randomized placebo-controlled clinical trial to study the effect of clonidine premedication on the perioperative hemodynamic and analgesic profile of the patients undergoing laparoscopic cholecystectomy (LC).[1] Sincerely acknowledging the authors’ efforts, it becomes imperative to concurrently draw the attention of the readership to certain unaddressed areas in this research, which mandate deliberation for a better understanding of the subject. Amidst the index double-blinded randomized study involving a 100 µg oral clonidine premedication dose in the investigative frame, it is highlighted that the sample size for the research endeavor was premised on the hemodynamic values emanating from an LC setting involving an oral dose of 150 µg clonidine, as outlined by Singh and Arora in the parent study.[1,2] Meanwhile the authors go on to attribute the lower sedation scores in their study to the reduced dose of clonidine, it was intriguing to witness a much higher duration of analgesia in their study (256.60 ± 34.97 min) when compared to the former study (185 ± 34.4 min).[1,2] Herein, it ought to be said that a more lucid definition of the duration of analgesia, would have assisted an improved comprehension, which in our discretion, conveys the time to the first rescue analgesic requirement[1] Even in the context of multimodal analgesia, one misses the account on the use of routine drugs such as paracetamol in the present study, which notably happens to be projected under GRADE A recommendation in the 2018 PROSPECT (Procedure-specific postoperative pain management) review update on the evidence-based pain management following LC.[1,3] Barazanchi et al. additionally recommend port-site local anesthetic infiltration as one of the components of analgesia for LC.[3] Humbly seeking clarification on the analgesic regimen employed in the control group, the ethical concerns that may arise out of not managing postoperative pain effectively across the study participants, purely for investigative purposes, can be extremely difficult to overlook[4] Given the simultaneous authors’ limitation of not having presented the intraoperative anesthetic requirement, especially in the backdrop of the lack of depth of anesthesia monitoring, it remains to be discerned as to how the hemodynamic fluctuations were actually managed by the blinded physician in the study by Meena et al.[1] Even in the general sense of the matter, the reduced anesthetic requirement is by itself a useful attribute of clonidine premedication[5] Lastly, the real-world value of any perioperative analgesia research continues to be limited in the absence of patient-centric outcomes or the outcomes aligned with the larger principles of enhanced recovery after surgery such as the patient satisfaction and quality of recovery or for that matter, the time to the postoperative resumption of feeding, restoration of the bowel function, and the length of hospital stay. Needless to say, perioperative analgesia can be peculiarly multifaceted, not only mandating a holistic research approach but an equally careful interpretation of the study results.[1,4] Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.