|Year : 2016 | Volume
| Issue : 2 | Page : 165-169
Use of dexmedetomidine for fast-track anesthesia in noncomplex pediatric cardiac surgery
Eman Mohamed Kamel, Heba Fouad Abdelaziz, Iman Kamal Abo Seif
Department of Anesthesia, Intensive Care, and Pain Management, Ain Shams University, Cairo, Egypt
|Date of Submission||12-Jun-2015|
|Date of Acceptance||22-Oct-2015|
|Date of Web Publication||11-May-2016|
Iman Kamal Abo Seif
Department of Anesthesia, Intensive Care, and Pain Management, Ain Shams University, Cairo
Source of Support: None, Conflict of Interest: None
Fast-track anesthesia technique is now an important aspect for reducing or eliminating the adverse effects of prolonged postoperative ventilation together with reducing ICU and hospital length of stay. This study was conducted to evaluate the effect of using dexmedetomidine as an adjuvant drug for fast-track technique in pediatric cardiac surgery.
Patients and methods
Sixty patients of both sexes with ages ranging from 1 to 12 years indicated for correction of noncomplex congenital heart diseases with cardiopulmonary bypass (CPB) were included in this study. After standard inhalational induction using sevoflurane for all patients, they were randomly classified into two groups of 30 each. In the dexmedetomidine group (group D), the patients received an initial bolus dose of dexmedetomidine (0.4 mg/kg) over 10 min, followed by continuous infusion of 0.5 mg/kg/h until the end of CPB. In the propofol group (group P) the patients received an initial bolus dose of propofol (2 mg/kg) over 30 s, followed by infusion at rate of 0.5 mg/kg/min until the end of CPB.
There were significant differences between the two groups (P < 0.05). As regards hemodynamics, heart rate was higher in the propofol group, whereas mean arterial pressure was higher in the dexmedetomidine group. Moreover, total dose of fentanyl, time of extubation in ICU, postoperative pain score, and need for postoperative analgesia were significantly higher in the propofol group.
Dexmedetomidine helps in fast-track anesthesia in pediatric cardiac surgery and has many desirable effects that encourage its use in the perioperative period.
Keywords: dexmedetomidine, fast track, pediatric cardiac surgery
|How to cite this article:|
Kamel EM, Abdelaziz HF, Abo Seif IK. Use of dexmedetomidine for fast-track anesthesia in noncomplex pediatric cardiac surgery. Ain-Shams J Anaesthesiol 2016;9:165-9
|How to cite this URL:|
Kamel EM, Abdelaziz HF, Abo Seif IK. Use of dexmedetomidine for fast-track anesthesia in noncomplex pediatric cardiac surgery. Ain-Shams J Anaesthesiol [serial online] 2016 [cited 2021 May 9];9:165-9. Available from: http://www.asja.eg.net/text.asp?2016/9/2/165/182222
| Introduction|| |
Over five decades ago, routine overnight ventilation was one of the essential components of postoperative care after pediatric cardiac surgery . An advancement in the modern era is the use of fast-track technique in cardiac surgery, which refers to the concept of early extubation, mobilization, short ICU stay, and early hospital discharge . This effort is taken to reduce perioperative morbidity and costs, leading to improved patient and parent satisfaction . The term 'early extubation' is used when endotracheal tube is removed either in the operating room (OR) after procedure or within 6 h after surgery in the ICU . Reintubation following early extubation in patients undergoing noncomplex CHD correction is very low, with rates less than 2-3%.
Noncomplex pediatric cardiac surgery refers to simple repairs of atrial septal defects, ventricular septal defects, or patent ductus arteriosus .
Many anesthetic techniques can be used for fast tracking in pediatric cardiac cases, such as the use of high doses of short-acting opioids, and rapid and short-acting inhalational anesthetics. The use of a neuroaxial technique can also be beneficial as single dose intrathecal, or thoracic epidural catheter insertion, but still remains a controversy in terms of safety and outcomes. Moreover, the use of nonopioid analgesics during the postoperative period has been advocated, such as the use of acetaminophen and/or ketolac .
In 1999, the FDA approved the short-acting a2 -agonist dexmedetomidine for use in sedation. Besides its sedative properties, dexmedetomidine provides effective pain relief and blunt stress responses, decreasing mean arterial pressure (MAP) and heart rate (HR) . The use of dexmedetomidine intraoperatively in pediatric cardiac surgery allows early extubation and rapid recovery .
| Aim of the work|| |
The aim of this study was to evaluate the effect of using dexmedetomidine intraoperatively as an adjuvant drug for fast-track technique in noncomplex pediatric cardiac surgery.
| Patients and methods|| |
After approval of the local ethical committee of Anesthesia and Intensive Care Department, Faculty of Medicine, Ain Shams University, written informed consent was taken from the parents. This study was conducted in the cardiac ORs and cardiac intensive care of Ain Shams University Hospitals over a period of 8 months from September 2014 to April 2015 on 60 patients of both sexes with ages ranging from 1 to 12 years undergoing elective correction of noncomplex congenital heart diseases with CPB. Exclusion criteria included complex surgical procedures, having asthma, re-do open heart surgery, infective endocarditis, pulmonary hypertension, heart failure and other systemic diseases such as renal or hepatic diseases, and any previous adverse reaction to any of the medications used in this study.
All patients received intramuscular premedication in the form of midazolam (0.5 mg/kg) 30-40 min before induction of anesthesia. In the OR, monitoring was started for all patients in the form of five-lead ECG, pulse oximetry, capnography, and noninvasive blood pressure.
Anesthesia was induced for all patients by means of inhalation of sevoflurane in 100% oxygen. After loss of consciousness a peripheral intravenous cannula was inserted, and then fentanyl (5-10 µg/kg) was given. Rocuronium as a neuromuscular blockade was given at a dose of 0.9 mg/kg to facilitate endotracheal intubation. After intubation, an arterial cannula was inserted for invasive blood pressure monitoring and repeated arterial blood gases analysis was performed. In addition, a nasopharyngeal probe for measuring temperature and a urinary catheter for monitoring urine output were inserted.
Patients were mechanically ventilated with 50% O 2 in air to keep end tidal CO 2 between 30 and 35 mmHg; a central venous line was also inserted. Anesthesia was maintained with low doses sevoflorane less than 1 MAC with titration. Increment doses of fentanyl were given if needed at a dose of 1-2 µg/kg and rocuronium (Esmorane) infusion at a rate of 0.3 mg/kg/h to maintain muscle relaxation, with no need for additional neuromuscular-blocking agent after CPB.
Patients were randomly classified into one of the two equal groups of 30 each. In group D, the dexmedetomidine group, the patients received an initial bolus dose of dexmedetomidine (0.4 mg/kg) over 10 min immediately after endotracheal tube insertion, followed by continuous infusion at a rate of 0.5 mg/kg/h until the end of CPB.
In group P, the propofol group (n = 30), the patients received an initial bolus dose of propofol (2 mg/kg) over 30 s just after endotracheal tube insertion, followed by infusion at a rate of 0.5 mg/kg/min until the end of CPB.
The mean perfusion pressure was maintained at 50-70 mmHg during CPB. Systemic temperature was permitted to drift to 33°C during CPB, and patients were actively rewarmed to 37°C at cessation of CPB.
HR and MAP were recorded at baseline, after induction, after skin incision, after sternotomy, 10 min after end of CPB, and after sternum closure. Other parameters were also recorded, such as duration of surgery, duration of CPB, and duration of aortic cross-clamping time (all in minutes). Total dose of fentanyl used, need for inotropic support and its total dose, and numbers of DC shocks if needed were also recorded.
After closure of the skin and ending of the procedure, patients were transferred to the pediatric ICU with monitor and pediatric ventilator.
In the ICU, the patients were connected to mechanical ventilation, and ICU parameters were recorded in the form of HR, MAP, time of extubation, pain score using Objective Pain Discomfort Score; ICU stay and total hospital stay were also recorded. Analgesia was administered in the form of paracetamol (120-240 mg) when needed.
All patients were extubated within 6 h postoperatively in the ICU. Residuals of opioids and neuromuscular block were reversed after stabilizing patients' hemodynamics.
From the surgical point of view, standard median sternotomy approach was used. The ascending aorta, superior vena cava (SVC), and IVC were cannulated for the CPB (nonpulsatile roller pump flow) at an average rate of 100-150 ml/min, initiated with ACT greater than 400 s, using heparin (300 IU/kg).
All patients received cardioplegia (30 ml/kg). Hematocrit was maintained between 20 and 25% during CPB; blood supplementation was done when needed.
Data were statistically analyzed with the mean, SD, Student's t-test, the c2 -test, and the Mann-Whitney test using the Statistical Package for the Social Sciences (SPSS, version 17.0; SPSS Inc., Chicago, Illinois, USA).
Description of quantitative (numerical) variables was performed in the form of mean ± SD. Description of qualitative (categorical) data was performed in the form of number of cases and percentage. Error bars represent 95% confidence interval. Analysis of unpaired numerical variable was performed using the unpaired Student t-test, whereas analysis of paired numerical variables was performed using repeated measure general linear model analysis of variance. Analysis of categorical data was performed using Fisher's exact test or the c2 -test, whenever appropriate. The significance level was set at a P-value of 0.05 or less, and a P-value of 0.01 or less was considered highly significant.
Sample size calculation
The required sample size was calculated using IBM© SPSS© Sample Power© version 3.0.1 (IBM© Corp., Armonk, New York, USA) with the following parameters: time of extubation was used as the primary goal, where power of the study was 80%, SD was ± 2, mean was 20, and a-error was 0.05. Thus, a sample size of 30 patients for each study group was estimated (total 60 patients).
| Results|| |
In the current study, an overall 60 patients were recruited, group D (n = 30) and group P (n = 30). There was no significant difference between groups as regards age, sex, weight, and the surgical procedure type (P > 0.05) [Table 1].
There were significant differences between the two groups. HR was significantly higher in the P group, whereas MAP was significantly higher in the D group [Figure 1] and [Figure 2]. In addition, there was significant difference between the two groups with regard to total dose of fentanyl used intraoperatively [Table 2]. Other intraoperative data such as duration of surgery, duration of CPB, duration of aortic cross-clamp, duration of intraoperative support, and number of DC shock showed no significant differences between the two groups [Table 2].
|Figure 1: Heart rate (beats/min) intraoperatively in the studied groups. Data are presented as mean and SD (P < 0.05, significant)|
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|Figure 2: Mean arterial pressure (MAP) (mmHg) intraoperatively in the studied groups. Data are presented as mean and SD (P < 0.05, significant)|
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There was a statistically significant difference between the two groups with regard to postoperative data in ICU; HR was higher in the P group and MAP was higher in the D group [Table 3].
There was a statistically significant difference between the two groups as regards time of extubation, postoperative pain score, and total dose of postoperative analgesia needs; all were significantly higher in group P [Table 4] and [Table 5]. There was no significant difference between the two groups with regard to the total length of hospital stay [Table 4].
| Discussion|| |
Dexmedetomidine is a potent, highly selective and specific a2 -adrenoreceptor agonist. It was introduced into the market initially as an antihypertensive. Nowadays, it is used for many other purposes such as sedation, analgesia, anxiolysis, and as an adjunct in general anesthesia.
In this study, we noted that the use of intraoperative infusion of dexmedetomidine results in the reduction of hemodynamics from baseline both intraoperatively and postoperatively in the ICU. This is due to peripheral and central mechanisms, resulting in reduction in sympathetic tone, mediated by a reduction in norepinephrine release at the neuroeffector junction, with a significant reduction in circulating catecholamines and decrease in the blood pressure and HR. This helps in attenuation of the responses to surgical stimuli. These findings are supported by Vargas-Tujilio and Alvarez-Rosales , who proved that use of dexmedetomidine attenuates stress response in patients undergoing CABG.
The other important finding in the current study is the reduction in the total dose of intraoperative fentanyl and the pain score postoperatively in the dexmedetomidine group. This finding is supported by Afanador et al. , who used dexmedetomidine to evaluate its effect on anesthetic requirement and time to tracheal extubation in elective adult heart surgery. This finding may be attributed to the analgesic effect of dexmedetomidine. It is believed that activation of a2 -adrenorecptors in the spinal cord lowers the transmission of nociceptive signals to brain centers. Moreover, dexmedetomidine inhibits the release of substance P from the dorsal horn leading to an analgesic effect .
There was shortening in the time of extubation in group D. This is due to the low doses of fentanyl used, less need for inhalational anesthetic drugs, and the hemodynamic stability together with the early regain of consciousness, as all drugs used have short duration of action; this finding is supported by Mester et al.  [Table 6].
| Conclusion|| |
Use of dexmedetomidine as an adjuvant during anesthesia in children undergoing noncomplex cardiac surgery helps in reducing anesthetic requirements and facilitates early postoperative tracheal extubation and reduces ICU stay, thus reducing risks and costs and improving both patient and parent satisfaction.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Heard GG, Lamberti JJJr, Park SM, Waldman JD, Waldman J. Early extubation after surgical repair of congenital heart disease. Crit Care Med 1985; 13:830-832.
Mittnacht AJ, Hollinger I. Fast-tracking in pediatric cardiac surgery - the current standing. Ann Card Anaesth 2010; 13:92-101.
Lawrence EJ, Nguyen K, Morris SA, Hollinger I, Graham DA, et al.
Economic and safety implications of introducing fast tracking in congenital heart surgery. Circ Cardiovasc Qual Outcomes 2013; 6:201-207.
Cheng DC, Karski J, Peniston C, Asokumar B, Raveendran G, et al.
Morbidity outcome in early versus conventional tracheal extubation after coronary artery bypass grafting: a prospective randomized controlled trial. J Thorac Cardiovasc Surg 1996; 112:755-764.
Abuchaim DC, Bervanger S, Medeiros SA, Abuchaim JS, Burger M, et al
. Early extubation in the operating room in children after cardiac heart surgery. Rev Bras Cir Cardiovasc 2010; 25:103-108.
Chaney MA. Thoracic epidural anaesthesia in cardiac surgery - the current standing. Ann Card Anaesth 2009; 12:1-3.
Eren G, Cukurova Z, Demir G, Hergunsel O, Kozanhan B, et al
. Comparison of dexmedetomidine and three different doses of midazolam in preoperative sedation. J Anaesthesiol Clin Pharmacol 2011; 27:367-372.
Maze M, Tranquilli W. Alpha-2 adrenoceptor agonists: defining the role in clinical anesthesia. Anesthesiology 1991; 74:581-605.
Vargas-Tujilio C, Alvarez-Rosales H. Dexymedatomidine en pacienten can hipertension arterial en cirguia de revascularizaionCoronaria. Revista Mexican de Anesthesia 2005; 78:91-95.
Afanador C, Marulanda L, Torres G, Marín A, Vidal C, Silva G. Effect of intraoperative use of dexmedetomidine on anesthetic requirements and time to tracheal extubation in elective adult heart surgery patients. A retrospective cohort study.Internet J Anesthesiol 2010; 22:24.
Eisenach JC. Mechanism of antiarrhythmic effect of dexmedetomidine on epinephrine-induced arrhythmias. Anesthesiology 1991; 75: 1116-1117.
Mester R, Easley RB, Brady KM, Chilson K, Tobias JD. Monitored anesthesia care with a combination of ketamine and dexmedetomidine during cardiac catheterization. Am J Ther 2008; 15:24-30.
Kiessling AH, Huneke P, Reyher C, Bingold T, Zierer A, et al.
Risk factor analysis for fast track protocol failure. J Cardiothorac Surg 2013; 8:47.
Haselman MA. Dexmedetomidine: a useful adjunct to consider in some high-risk situations. AANA J 2008; 76:335-339.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]