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Original Article

A Clinical Trial of Comparing Dexmedetomidine and

Remifentanil on the Oximetry Parameters in the Patients with
End‑Stage Renal Disease Undergoing Arteriovenous Fistula
Formation
Mahmoud Reza Mohaghegh Dolatabadi1, Soudabeh Djalali Motlagh2, Mohamadreza Ghodraty2, Amineh Shafeinia3, Alireza Maleki4, Zeinab Norouzi5,
Shiva Khaleghparast6
1
Department of Anesthesiology, Hasheminejad Hospital, Iran University of Medical Sciences, 2Department of Anesthesiology, Firoozgar General Hospital,
Iran University of Medical Sciences, 3Department of Anesthesiology, Akbarabadi Hospital, Iran University of Medical Sciences, 4Department of Anesthesiology,
Rasoul Akram Hospital, Iran University of Medical Sciences, 5Department of Cardiac Rehabilitation, Rajaie Cardiovascular and Research Center,
6
Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran

Abstract
Background: Oximetry is a method for measuring the arterial hemoglobin saturation (SpO2) using pulse oximeter and is essential in any
type of anesthetic procedures. The growing population of geriatrics in the recent decades in combination with an increase in the prevalence
of chronic diseases including diabetes and hypertension are some of the leading causes for an increase in the prevalence of chronic kidney
disease and end-stage renal disease (ESRD). The definite treatment for ESRD is renal transplant but unfortunately, it may take a long time
to find a suitable kidney and continuing the patient’s life may depend on dialysis. Arteriovenous fistula (AVF) formation is one of the first
steps to prepare the patient for hemodialysis. ESRD itself is a reason for physical and psychosocial issues. Preparing a favorable condition
for AVF surgery is essential to decrease the burden of the underlying disease. An efficient respiratory supply is necessary in all parts of an
anesthetic procedures. Aims and Objectives: This study is a double-blind clinical trial to compare two anesthetic agents, dexmedetomidine
and remifentanil in patients with ESRD who underwent AVF formation. Materials and Methods: SpO2 was measured on different phases
including the time of initial incision, and after 10, 30, 60, 90, and 120 min of finishing the surgery. The data were analyzed using SPSS version
22, two-way repeated measures (ANOVA), and independent t-test. Results: This study showed that there was no any significant difference
in using any of these two agents with regard to SpO2 in the different times of measurements during the anesthetic procedure and after the
surgery in the recovery phase. Conclusion: This study showed that there is not any superiority in using DEX or REM in the patients undergo
AVF formation. More studies on the other groups of the patients with different surgeries.

Keywords: Arteriovenous fistula, dexmedetomidine, end‑stage renal disease, oximetry, remifentanil

Introduction blood oxygen constantly,[9] and after developing the first

version by the other researchers, it was used in the operating
Oximetry is used for evaluating the blood oxygen status and
room by Earl Wood in the late 1940s for the first time.[10] It was
pulse oximeter is a noninvasive tool for measuring the blood
used by Glenn Allen Millikan during world War II to evaluate
oxygen saturation.[1,2] The basic function of the pulse oximeter
is a spectrometry for quantification of arterial hemoglobin
Address for correspondence: Dr. Alireza Maleki,
saturation (SpO2).[3‑7] Pulse oximetry is one of the essential Department of Anesthesiology, Rasoul Akram Hospital,
parts for the patients’ care in anesthesia.[8] The first pulse Iran University of Medical Sciences, Tehran, Iran.
oximeter was created in 1935 by Matthes for evaluating the E‑mail: dr.alireza_maleki@irimed.org

Received: 19‑February‑2022 Revised: 06-June-2022

Accepted: 07‑June‑2022 Published: 11-October-2022 This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to
remix, tweak, and build upon the work non‑commercially, as long as appropriate credit
Access this article online
is given and the new creations are licensed under the identical terms.
Quick Response Code:
Website: For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com
http://www.rcvmonline.com/
How to cite this article: Dolatabadi MR, Motlagh SD, Ghodraty M,
Shafeinia A, Maleki A, Norouzi Z, et al. A clinical trial of comparing
DOI: dexmedetomidine and remifentanil on the oximetry parameters in the
10.4103/rcm.rcm_12_22 patients with end-stage renal disease undergoing arteriovenous fistula
formation. Res Cardiovasc Med 2022;11:66-70.

66 © 2022 Research in Cardiovascular Medicine | Published by Wolters Kluwer - Medknow

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Dolatabadi, et al.: Oximetry parameters of dexmedetomidine and remifentanil
the piolets’ O2 saturation (SaO2) during the flightes.[11] Then,
the scientists found that the clinical presentations of patients
with cyanosis are not reliable[12] due to severe anemia or skin
pigmentation.[13] Furthermore, the symptoms of hypoxia are
detected when the SaO2 is lower than 80%.[12] Pulse oximetry
is a useful measurement for the early diagnosis of cyanosis.[14]
In 1974, Aoyagi et al. made a type of pulse oximeter with the
combination of photoplethysmography and oximetry in a single
tool.[15] Since the early years of the 1980 decade, pulse oximetry
was widely used in the clinical fields.[16] According to the
recommendations of the American Society of Anesthesiologists,
pulse oximetry is a part of basic standard care in the operating
room. [17] Pulse oximetry is perhaps the most important
measurement tool to show valuable data including heart rate and
SaO2.[18] It is used to evaluate the peripheral oxygen supply and
is indicated in all of the patients, especially in the geriatrics.[19]
According to the aging of the population, the prevalence of
chronic diseases is increasing.[20] Chronic kidney disease (CKD)
is not only a consequence of aging but also is a complication
of other chronic diseases including hypertension and diabetes
mellitus.[21,22] Furthermore, with increasing in the elderly
population in the world, increasing the prevalence of CKD
is not surprising.[23] The definite treatment for end‑stage renal
disease (ESRD) is kidney transplant, but it is not available for a
huge population of patients for a long time, and continuing the
life in these patients is dependent to dialysis.[24,25] Arteriovenous
fistula (AVF) formation is the first step of hemodialysis in ESRD
patients and physical and psychological problems may happen
in most of these patients.[26‑28] A favorable anesthesia can reduce
the mentioned burden in the patients significantly and using
appropriate agents plays an important role to achieve to this
purpose. Dexmedetomidine (DEX) is a selective agonist of the
α‑2 adrenoceptor without the effect of respiratory depression.[29]
Remifentanil (REM) is an agonist of µ‑opioid receptor and is
known as an approximately safe agent for patients with CKD.[30]
Aim
In this study, the effect of the two anesthetic agents including
DEX and REM on the oximetry parameters is compared to each
other in the patients with ESRD who underwent AVF formation.
Methods
It is a double‑blind clinical trial. In this study based on the
σ2
n1 =n2 =( Z α + Z1− β ) 2 × (σ 12 + 2 ) formula, 40 patients
1−
2 k
with ESRD were enrolled. The inclusion criteria were being a
candidate for AVF formation, the age of 19–80 years old and
being in a stable hemodynamic on the admission. The exclusion
criteria were the positive history for the chronic diseases
including cardiovascular diseases, hepatic failure, history of
allergic reaction to any of the anesthetic agents, especially
opioids, the history of the recent respiratory infections or severe
bronchopulmonary diseases, pregnancy, or breastfeeding.
The patients participated freely in the study and with a complete
awareness about the study and also, the documented agreements
Research in Cardiovascular Medicine  ¦  July-September 2022  ¦  Volume 11  ¦  Issue 3
were collected from the participants. This study was under the
approval of the Iran University of Medical Sciences (IUMS)
with the code of IR. IUMS.FMD.REC.1399.115 and
was recorded in the clinical trial system with the ID of
IRCT20200502047269N1. First, demographic data including
age, gender, history of diabetes, hypertension, and addiction
were recorded. Then, vital signs of the patients were evaluated.
All of the patients were candidates for AVF formation and
they were stable hemodynamically to minimize the effects of
confounding factors on study results of the anesthesiological
study. Furthermore, the monitoring of vital signs was continued
during the anesthesiological procedures. Before starting the
surgery, routine monitoring was done including pulse rate,
electrocardiogram, noninvasive blood pressure monitoring, and
SPO2. Then, the patients were divided into two groups and the
blind sequencing of the patients was done using the website:
https://www.sealedenvelope.com/simple‑randomiser/v1/lists.
At the beginning of the procedure, 100 mg of subcutaneous
lidocaine was injected for all of the patients. For the first
group, DEX (intravenous bolus dose of 1 µg/kg in 10  min
and the maintenance dose of 0.5 µg/kg/h) and for the second
group REM (Intravenous bolus dose of 1 µg/kg in 10 min and
the maintenance dose of 0.2 µg/kg/min) were injected. The
SpO2 was measured when the initial incision was made and
then after 10 min, 30, 60, 90, and 120 min after finishing the
surgery in the recovery phase was also evaluated [Figure 1].
The data were analyzed using SPSS version 22, two‑way
repeated measures (ANOVA), and independent t‑test.
Results
Demographic data
In this study, 40 patients were participated. The mean age
in the DEX and the REM groups were 57.95 ± 10.86 and
59.5 ± 10.45 years old, respectively, and there was no any
significant difference between these two groups (P = 0.648). In
Figure 1: The flow diagram of the study. ESRD: End stage renal
disease, SpO2: Ar terial hemoglobin saturation, PR: Pulse rate,
NIBP: Noninvasive blood pressure monitoring, ECG: Electrocardiogram,
DEX: Dexmedetomidine, REM: Remifentanil, AVF: Arteriovenous fistula
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Dolatabadi, et al.: Oximetry parameters of dexmedetomidine and remifentanil

the DEX group, 70% of the patients were male and 30% were The result of the two‑way repeated measure ANOVA showed
female. In addition, in the REM group, 55% of the patients that the difference in SpO2 in the two groups was not statistically
were male and 45% were female and the difference between significant (F = 0.032, df = 1, P = 0.859), and the effect of the
the two groups was not statistically significant (P = 0.327). The group was not prominent. Furthermore, the effect of time was not
history of hypertension in the DEX and RME groups was 80% statistically significant (F = 0.968, df = 5, P = 0.414) and SpO2
and 85%, respectively (P = 1.00). Furthermore, 60% of the was not so different in the several times of evaluation. Finally,
patients in the DEX group were diabetic, and it was 45% in the according to the results of the mentioned analysis, the difference
REM group. Furthermore, the difference was not statistically in the group and time was not prominent and SpO2 changes
significant (P = 0.342). In addition, the rate of addiction was during the study were approximately equal in the two groups.
close to each other in both groups and it was 10% and 15% in
The side effects of the anesthetic agents
the DEX and REM groups, respectively (P = 0.633). Body mass
Cochran’s q‑test analysis showed that the incidence of
index in the DEX and REM groups were 26.7 ± 3.42 kg/m2
bradycardia and tachycardia on the beginning of the surgery
and 25.15  ±  2.61  kg/m2, respectively, with no statistically after the incision, was 17.5% (7 cases), and 10 min after the
significant difference (P = 0.115) [Table 1]. beginning of the surgery was 30% (12 cases). In addition, they
The comparison of SpO2 in the dexmedetomidine and were seen in 7.5% (three patients), and 5% (two patients) after
remifentanil groups 30 and 60 min, respectively. The same results were repeated
For evaluation of SpO2, the measurement was done using pulse after 90 and 120 min, respectively.
oximeter several times during and after the surgery. SpO2 on
the beginning of the surgery and just after the surgical incision, Discussion
was 97.95 ± 1.50 in the DEX and 98.10 ± 1.48 in the REM Preparing favorable ventilation and continues oximetry in any
group (P = 0.589). SpO2 assessment was continued during type of anesthetic procedure is essential and plays an important
the surgery in different times including 10  min after starting role not only for saving the safety of the patient but also for
the surgery and 30, 60, 90, and 120 min after the surgery in preventing the long‑term complications of the anesthesia. In
the recovery phase. 10 min after the beginning of the surgery, this study, the efficacy and the safety of two agents including
SpO2 was 97.85 ± 1.23 in the DEX group and 97.85 ± 0.88 in DEX and REM were studied in the patients who underwent
the REM group (P = 0.884). Thirty minutes after the surgery in
the recovery phase, SpO2 in the DEX and the REM groups were
97.95 ± 1.15 and 97.60 ± 1.14, respectively (P = 0.340). 60 min Table 1: Demographic data
after the surgery SpO2 in the DEX and the REM groups were Indicator Frequency (%) P
98.15 ± 1.09 and 98.05 ± 0.89, respectively (P = 0.876). After DEX group REM group
90 min, SpO2 in the DEX and the REM groups were 98.15 ± 1.14 Mean age* 57.95±10.86 59.5±10.45 0.648
and 98.05 ± 1.23, respectively (P = 0.693). Finally, 120 min after BMI* 26.7±3.42 25.15±2.61 0.115
the surgery Spo2 was 98.10 ± 1.17 in the DEX and 98.25 ± 1.12 in Sex (male) 14 (70) 11 (55) 0.327
the REM groups (P = 0.680). Overall, no statistically significant Hypertension 16 (80) 17 (85) 1.00
difference was found with regard to SpO2 while using DEX or DM 12 (60) 9 (45) 0.342
REM in the different times of assessment [Table 2 and Figure 2]. Addiction 2 (10) 3 (15) 0.633
*The numbers indicate SD±mean. DEX: Dexmedetomidine,
REM: Remifentanil, BMI: Body mass index, DM: Diabetes mellitus,
SD: Standard deviation

Table 2: The variability of oxygen saturation in two

groups of the study
Indicator DEX group REM group P
Beginning of the surgery 97.95±1.50 98.10±1.48 0.589
(after surgical incision)
During the surgery (10 min 97.85±1.23 97.85±0.88 0.884
after the surgical incision)
30 min after finishing the 97.95±1.15 97.60±1.14 0.340
surgery (recovery)
60 min after finishing the 98.15±1.09 98.05±0.89 0.876
surgery (recovery)
90 min after finishing the 98.15±1.14 98.05±1.23 0.693
surgery (recovery)
Figure 2: The diagram for comparing the mean and standard deviation 120 min after finishing the 98.10±1.17 98.25±1.12 0.680
of Spo2 on the beginning of the surgery, during and after the surgery in surgery (recovery)
the frequent times of evaluation in the two groups DEX: Dexmedetomidine, REM: Remifentanil

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Dolatabadi, et al.: Oximetry parameters of dexmedetomidine and remifentanil
AVF formation. The result of our study showed that there is not
any significant difference in using DEX or REM in the patients
undergo AVF formation. Furthermore, other side effects of
these two agents, for example, tachycardia and bradycardia
were inappreciable.
Our study showed that there was not any significant difference
in SpO2 between using REM or DEX. In the previous studies,
the effect of these two agents on the oximetry parameters,
side effects, and hemodynamic status of the patients was
evaluated. The study of Xu T. was done among the patients
who underwent awake intubation and compared two agents
including DEX and REM. The results showed that the levels
of SpO2 were not different by using any of these two agents.[31]
However, the study of St‑Pierre et al. showed different results.
They concluded that the frequency of decreasing in SpO2 was
significantly higher in the REM group.[32]
Most of the previous studies showed that DEX was superior to
REM in stabilization of hemodynamic parameters. The study
of Lee et al. was done among the elderlies with vertebroplasty
and kyphoplasty for comparing DEX with REM. Their study
revealed that the levels of SpO2 was higher in the patients of
DEX group. Also, respiratory depression was lower in this
group, but the analgesia was lower in comparison with REM
group.[33] The study of Janatmakan et al. showed that using
infusion of DEX could prepare favorable hemodynamical
situation in the patients undergoing spinal surgery. [34]
Furthermore, other studies showed that DEX is superior to
REM in preventing respiratory depression.[32,35,36]
In the meta‑analysis done by Tang et al., the efficacy and the
safety of DEX and REM in the aware patients who underwent
endoscopic fiberoptic intubation were compared to each other.
Both agents were acceptable and tolerated very well by the
patients, but DEX was more effective in decreasing the incidence
of hypoxia and memory recall of endoscopy.[37] On the other
hand, the study of Beloeil et al. in the noncardiac intermediate
or major surgeries showed that DEX was not superior to
REM. Furthermore, the serious side effects of DEX including
hypoxemia and bradycardia were dominant.[38] In the study
done by Gazi et al., the patients who underwent hysteroscopy
were studied. Their study showed that the postsurgical pain
was lower in the DEX group and the hemodynamic parameters
were more stable, but 30 min after the surgery, the mentioned
parameters were more favorable in the REM group.[39] Another
study was done in the patients who underwent hysteroscopy by
Park et al. and two combined agents were compared with each
other including DEX‑REM and propofol‑REM. Their study
revealed that in the first group with the combination of DEX,
the prevalence of respiratory depression was lower and the
hemodynamic complications were not higher.[40]
According to the mentioned previous studies DEX can be
superior to REM for preventing respiratory depression. Our
study showed that there was not any significant difference in
using DEX or REM in the anesthesiological procedures. It
seems that in the critically ill or complicated patients DEX is a
Research in Cardiovascular Medicine  ¦  July-September 2022  ¦  Volume 11  ¦  Issue 3
better choice. The patients with ESRD are the critical patients
and they may be complicated with other underlying diseases,
so DEX is preferable in this group of patients.
Conclusion
The results of our study showed that in the patients who
underwent AVF formation, there was not any significant
difference in the SpO2 measurement in different times of
evaluation. Furthermore, the side effects of these two drugs on
the heart rate and the incidence of bradycardia and tachycardia
were low. It seems that although there is not any superiority in
using DEX over REM in patients who undergo AVF formation,
DEX is preferable. More studies on the higher number of
groups of patients undergoing different surgeries, especially in
the patients with underlying diseases and also, evaluating the
other side effects of these agents are recommended.
Ethical clearance
This study was under the approval of the Iran University of
Medical Sciences (IUMS) with the code of IR. IUMS.FMD.
REC.1399.115 and was recorded in the clinical trial system
with the ID of IRCT20200502047269N1. Date: 2021.24.1.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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