Transcript ENGE 122 Facilitation

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)
D
26.1±6.766014
10/10
S
26.1±5.766014
11/9
P(>0.05)
INSIGNIFICANT
0.76
.755
AGE
30
25
20
DAGE
SAGE
15
10
5
0
DAGE
SAGE
WEIGHT
(MEDIAN±2SD)
54.4±3.647638
56.15±5.294237
0.376
SEX
WEIGHT
70
12
68
66
10
64
8
62
DWT
M
6
60
SWT
F
58
4
56
54
2
52
50
0
DSEX
SSEX
DWT
SWT
PRE OP HR & MAP
PRE OP MAP
MEDIAN ±2SD
GROUP
PRE OP HR
MEDIAN ±2SD
D
81.3 ±3.22
98.46±7.25
S
80.2±3.12
97.54±6.89
P(>0.05)
INSIGNIFICANT
0.563
0.989
PRE OP MAP MEAN
100
95
90
100
85
80
D
75
S
98
D
96
70
S
65
94
60
92
55
50
D
S
90
D
S
PRE OP HR
PRE OP MAP
0-15 MINS
GROUP
HR 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
INSIGNIFICANT
0.000
SIGNIFICANT
0-15 MINS
HR
MAP
0-15 MINS
HR
MAP
HR 0-15MINS (Mean)
MAP 0-15MINS (Mean)
106
98
105
96
104
94
92
103
D
D
S
102
90
S
88
101
86
100
84
99
82
D
98
D
S
S
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
100
100
80
80
60
60
DEX
SAL
40
SAL
40
20
20
0
0
DEX
SAL
DEX
DEX
SAL
15-75 MINS
HR
MAP
SPO2
MEAN
GROUP
SPO2 D
SPO2S
MEDIAN
±2SD
P(>0.05)
98.44±1.56
98.43±1.77
0.910
INSIGNI
FICANT
100
99.5
99
98.5
98
97.5
97
96.5
96
95.5
95
DEX
SAL
DEX
SAL
RAMSAY SEDATION SCORE
GROUP
Median ±
2SD
P(<0.05)
SIGNIFIC
ANT
3.094±0.1155
0.000
2.111±0.1612
D
S
Mean
SSED
DSED
SSED
DSED
0
1
2
3
4
5
SEDATION
GROUP D
GROUP S
BLEEDING GRADE
GROUP
Median ±2SD
P(<0.05)
D
1.75±0.444
SIGNIFICA
NT
S
3.25±0.444
0.000
Mean
S
D
S
D
0
1
2
3
4
DURATION OF ANALGESIA
GROUP
Median ±2SD
D
233.25±20.408
S
97.25±17.731
P(<0.05)
0.000
Mean
S
D
S
D
0
50
100
150
200
250
PONV
GROUP
Mean Rank
D
17.425
INSIGNIFI
CANT
S
23.575
0.069
P(<0.05)
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
2 Agonists
Peripheral nociceptors
Inhibit sympatheticmediated pain
Primary afferent
neurons
Inhibit release of
SP and glutamate
Second order neurons
Inhibit firing
Subcortical + cortex
Decrease emotive
aspects
Descending inhibitory
pathways
Disinhibit A5/A7
noradrenergic pathways
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!