EFFECTS OF DEXMEDITOMIDINE INFUSION FOR FESS UNDER

LOCAL ANAESTHESIA

COAUTHORS

PROF&HEAD : Dr.I.CHANDRA SEKARAN. MD.,DA.PROF. Dr.S.C.GANESH PRABHU. MD.,DA.ASST.PROF. Dr.SHANMUGA SUNDARAM, MD

AUTHOR : Dr. K.M.LAKSHMANA RAJAN (PG)

INSTITUTE OF ANAESTHESILOGY,MMC,MADURAI

INTRODUCTION

• FESS - GA / LA

• Under LA – Adequate sedation,analgesia, with nil or minimal side effects

• Patient’s comfort

• Surgeon’s comfort

• Need anesthesiologist or anaesthetic agent

AIM

• To assess the hemodynamic effects, sedation, and duration of analgesia of

DEXMEDETOMIDINE INFUSION

in patients undergoing FUNCTIONAL ENDOSCOPIC SINUS SURGERY

under local anaethesia

STUDY DESIGN• Ethical committee approval & consent from patients • Prospective, placebo-controlled, randomised double blind

study• INCLUSION CRITERIA:

- 40 ASA I, II Patients undergoing FESS under local anaesthesia

-Age: 18-60Yrs• EXCLUSION CRITERIA: -multiple sinus disease-prolonged surgery

-heart block ,hypotension-hypersensitivity to study drugs

METHODOLOGY

• Assigned in 2 groups D & S(20 EACH)

• Baseline hemodynamic parameters recorded

• premedication(45 mins prior) -Inj.pethidine 50mg

-glycopyrrolate 0.2mg IM

• Nasal cavity packed with 4%Lignocaine & Adrenaline

• GROUP D- 15 mins prior to surgery IV bolus of dexmedetomidine

1μg/Kg infusion for 10 min

• surgery will be commenced with Infiltration of nasal mucosa - 2%lignocaine & adrenaline

• 0.7μg/kg/hr infusion as maintenance

• Maintenance infusion stopped 15 mins before the end of surgery

• Group S- NS

INTRAOPERATIVE MONITORING

• Done by theatre anesthetist– BP-Systolic & diastolic – PR every 10 min– SpO2– Sedation score- ramsay sedation scale– Grading of bleeding- bleeding graded by same

surgeon

Brady cardia(HR < 50/min) ,severe hypotension MAP<60mmhg-study drug will be stopped and treated accordingly

POST OP MONITORING

• Duration of analgesia-time to reach VAS score >4• Inj .Diclofenac 75 mg im given

• No of episodes of nausea ,vomiting – noted & treated

SEDATION SCORE

1- Patient anxious and agitated or restless

2- Patient co-operative, oriented, and tranquil

3- Patient responds to commands only

4- Patient exhibits brisk response to light glabellar tap or loud auditory stimulus

5- Patient exhibits a sluggish response to light glabellar tap or loud auditory stimulus

6- Patient exhibits no response

GRADING OF BLEEDING

Qualitative grading

• 1- Cadaveric condition; minimal suction

• 2- Minimal bleeding; infrequent suction

• 3- Brisk bleeding; frequent suction.

• 4- Bleeding covers field after removal of suction.

• 5- Uncontrolled bleeding ; Bleeding out of nose on removal of suction.

ANALYSIS

• Demographic datas

• Hemodynamic parameters-HR,MAP,SPO2

• Sedation score

• Bleeding grade

• Nausea and vomiting

STATISTICAL ANALYSIS

• CHI-SQUARE TEST

• MANN-WHITNEY U TEST

DEMOGRAPHIC DATAS GROUP

AGE(MEDIAN±2SD)

SEX(M/F)

WEIGHT(MEDIAN±2SD)

D 26.1±6.766014 10/1054.4±3.647638

S 26.1±5.766014 11/956.15±5.294237

P(>0.05)INSIGNIFICANT

0.76 .755 0.376

SEX WEIGHT

PRE OP HR & MAPGROUP

PRE OP HRMEDIAN ±2SD

PRE OP MAPMEDIAN ±2SD

D 81.3 ±3.2298.46±7.25

S 80.2±3.12 97.54±6.89

P(>0.05)INSIGNIFICANT

0.563 0.989

PRE OP HR PRE OP MAP

0-15 MINS

GROUPHR 0-15MINS (Median ±2SD)

MAP 0-15MINS(Median ±2SD)

D 100.8±3.233 86.8±1.22

S 105.4±3.766 96. 1±1.32

P(<0.05)0.091

INSIGNIFICANT0.000

SIGNIFICANT

0-15 MINSHR MAP

0-15 MINS

HR MAP

15-75 MINS

GROUP HR

(Median ±2SD)MAP

(Median±2SD)

D 68.56±2.43 68.47±1.98

S 96.67±2.88 97.2±2.01

P(<0.05)SIGNIFICANT

O.OOO O.OOO

15-75 MINS

HR MAP

15-75 MINS

HR MAP

SPO2

GROUPMEDIAN

±2SDP(>0.05)

SPO2 D 98.44±1.56

SPO2S 98.43±1.770.910

INSIGNIFICANT

RAMSAY SEDATION SCORE

GROUPMedian ±

2SDP(<0.05)

D 3.094±0.1155

SIGNIFICANT

S 2.111±0.1612 0.000

SEDATION

GROUP D GROUP S

BLEEDING GRADEGROUP Median ±2SD P(<0.05)

D 1.75±0.444SIGNIFICA

NT

S 3.25±0.444 0.000

DURATION OF ANALGESIA

GROUP Median ±2SD P(<0.05)

D 233.25±20.408

S 97.25±17.731 0.000

PONV

GROUP Mean RankP(<0.05)

D 17.425INSIGNIFI

CANT

S 23.575 0.069

MECHANISM FOR SEDATION

• Hyper polarization of locus ceruleus neurons

– 2A-Adrenoreceptor subtype

– Activation of K+ channels

– Inhibition of Ca++ channels

– Inhibition of adenylyl cyclase

Firing rate of locus caeruleus neurons

Activity in ascending noradrenergic pathway

• ACTIVATES NATURAL SLEEP PATHWAYS

ANALGESIC EFFECT

Disinhibit A5/A7 Disinhibit A5/A7 noradrenergic pathwaysnoradrenergic pathways

Descending inhibitory Descending inhibitory pathwayspathways

Decrease emotive Decrease emotive aspectsaspects

Subcortical + cortexSubcortical + cortex

Inhibit firingInhibit firingSecond order neuronsSecond order neurons

Inhibit release of Inhibit release of SP and glutamateSP and glutamate

Primary afferent Primary afferent neuronsneurons

Inhibit sympathetic- Inhibit sympathetic- mediated painmediated pain

Peripheral nociceptorsPeripheral nociceptors

2 2 AgonistsAgonists

HEMODYNAMIC EFFECTS

• Initially acts on peripheral alpha 2 receptors-increase in BP/HR-15 mins

• Postsynaptic activation of α2 adrenoceptors in the central nervous system (CNS)

• Inhibits sympathetic activity and

• Decrease blood pressure and heart rate

SUMMARY

• RDB study in 40 pts ASA I & II for FESS under LA

• Dexmedetomidine and saline

• Hemodynamics ,sedation,bleeding grade,duration of analgesia,PONV

• Reduction in HR ,MAP in group D than group S

• Slow rising high ramsay sedation score in group D

• Better surgical field with low bleeding grade in group D than S

• Prolonged duration of pain relief (3.30 hrs to 4 hrs ) in group D than group S(0.40-1.40 hrs)

• No respiratory depression in both the groups

• Better patient and surgeon’s comfort in group D

CONCLUSION

DEXMEDETOMIDINE

Good Sedative , Analgesic & Can Be Used As a Hypotensive Anesthetic To Control

Bleeding With Out Respiratory Depression For

FESS UNDER LOCAL ANAESTHESIA

REFERENCES

• EUROPEAN JOURNAL OF ANESTHESIOLOGY JAN 2008

Goksu, S.; Arik, H.; Demiryurek, S.; Mumbuc, S.; Oner, U.; Demiryurek, A. T

• J CLIN ANAESTHESIA 2008 SEP

• Effectiveness of dexmedetomidine in reducing bleeding during septoplasty and tympanoplasty operations

• Ayouglu H ,Yapakci O,Ugur MB,Uzun L,Altunkaya H,Ozer Y,Uyanik R.

Thank You!