#PAGE_PARAMS# #ADS_HEAD_SCRIPTS# #MICRODATA#

A Combination of Dexmedetomidine with Ketamine and Opioids Results in Significant Inhibition of Hemodynamic Changes Associated with Laparoscopic Cholecystectomy and in Prolongation of Postoperative Analgesia


Authors: J. Málek;  F. Mareček;  L. Hess *;  A. Kurzová;  M. Očadlík **;  M. Votava ***
Authors place of work: Klinika anesteziologie a resuscitace 3. LF UK a FNKV, přednosta: prof. MUDr. Jan Pachl, CSc. ;  Pracoviště experimentální medicíny IKEM *;  Chirurgická klinika 3. LF UK a FNKV, přednosta: prof. MUDr. Robert Gürlich, CSc. **;  Ústav farmakologie 3. LF UK, přednosta ústavu: prof. MUDr. Miloslav Kršiak, DrSc. ***
Published in the journal: Rozhl. Chir., 2010, roč. 89, č. 5, s. 275-281.
Category: Monothematic special - Original

Summary

The aim of the study:
Recently, alpha2 sympathoadrenergic drugs are used in premedication to improve the perioperative course. The aim of our study was to compare a premedication with a new alpha2 sympathoadrenergic drug and standard premedication.

Methods:
After ethic committee approval and written patient consent, in a randomised, double-blinded study, combination of dexmedetomidine 1.0 μg.kg-1 + ketamine 0.5 mg.kg-1 + fentanyl 1.0 μg.kg-1 + atropine 0.5 mg (group FNT), dexmedetomidine 1.0 μg.kg-1 + ketamine 0.5 mg.kg-1 + alfentanil 5.0 μg.kg-1 + atropine 0.5 mg (group ALFNT), or pethidine 1.0 mg.kg-1 + atropine 0.5 mg (group Dolsin) was administered to a deltoid muscle 15 min. before anaesthesia (GA) in patients elicited for laparoscopic cholecystectomy (LCHE). GA was performed in a standard way, ECG, NIBP, respiration rate, SpO2, onset of effect, Observers Assessment of Alertness Sedation Score (OAASS) before GA, circulatory reaction to intubation and capnoperitoneum, fentanyl consumption during GA, time to the first request for post-operative analgesia and postoperative nausea and vomiting were measured. The data were processed by Kruskal-Wallis and Fisher tests. P-value < 0.05 was considered significant.

Results:
There were 16 patients in FNT and Dolsin and 15 patients in ALFNT with no differences in demography except for younger age in ALFNT. The main differences were in hypertension during capnoperitoneum: 0/16 FNT and 1/15 ALFNT vs. 11/16 Dolsin, both p < 0.001, per-operative fentanyl consumption: FNT 31.5 μg vs. Dolsin 165.0 μg, p < 0.001 and ALFNT 50.0 μg, p < 0.05 (ALFNT vs. Dolsin, p < 0.01) and request to the first analgesic post surgery: FNT 1.3 h. vs. Dolsin 0.45 h., p < 0.05 vs. ALFNT 0.8 h., p < 0.01. There were no differences in side effects except for bradycardia in ALFNT (p < 0.05).

Conclusions:
Dexmedetomidine-ketamine-fentanyl-atropine combination is superior to pethidine-atropine combination in suppressing of adverse hemodynamic effects of capnoperitoneum, decreased need for analgesia during GA and prolonged postoperative analgesia.

Key words:
surgery – hemodynamic changes – premedication – dexmedetomidine – ketamine – fentanyl – alfentanil


Zdroje

1. Pandharipande, P., Ely, E. W., Maze, M. Alpha-2 agonists: can they modify the outcomes in the Postanesthesia Care Unit? Curr. Drug Targets, 2005; 6: 749–754.

2. Carollo, D. S., Nossaman, B. D., Ramadhyani, U. Dexmedetomidine: a review of clinical applications. Curr. Opin. Anaesthesiol., 2008; 21: 457–461.

3. Gurbet, A., Basagan-Mogol, E., Turker, G., Ugun, F., Kaya, F. N., Ozcan, B. Intraoperative infusion of dexmedetomidine reduces perioperative analgesic requirements. Can. J. Anaesth., 2006; 53: 646–652.

4. Al-Zaben, K. R., Qudaisat, I. Y., Al-Ghanem, S. M., Massad, I. M., Al-Mustafa, M. M., Al-Oweidi, A. S., Abu-Halaweh, S. A., Abu-Ali, H. M., Saleem, M. M. Intraoperative administration of dexmedetomidine reduces the analgesic requirements for children undergoing hypospadius surgery. Eur. J. Anaesthesiol., 2009.

5. Unlugenc, H., Gunduz, M., Guler, T., Yagmur, O., Isik, G. The effect of pre-anaesthetic administration of intravenous dexmedetomidine on postoperative pain in patients receiving patient-controlled morphine. Eur. J. Anaesthesiol., 2005; 22: 386–391.

6. Aantaa, R., Jalonen, J. Perioperative use of alpha2-adrenoceptor agonists and the cardiac patient. Eur. J. Anaesthesiol., 2006; 23: 361–372.

7. Iravani, M., Wald, S. H: Dexmedetomidine and ketamine for fiberoptic intubation in a child with severe mandibular hypoplasia. J. Clin. Anesth., 2008; 20: 455–457.

8. Levanen, J., Makela, M. L., Scheinin, H. Dexmedetomidine premedication attenuates ketamine-induced cardiostimulatory effects and postanesthetic delirium. Anesthesiology, 1995; 82: 1117–1125.

9. Bell, R. F., Dahl, J. B., Moore, R. A., Kalso, E. Perioperative ketamine for acute postoperative pain. Cochrane Database Syst. Rev., 2006; CD004603.

10. Berti, M., Baciarello, M., Troglio, R., Fanelli, G. Clinical uses of low-dose ketamine in patients undergoing surgery. Curr. Drug Targets, 2009; 10: 707–715.

11. Ebert, T. J., Hall, J. E., Barney, J. A., Uhrich, T. D., Colinco, M. D. The effects of increasing plasma concentrations of dexmedetomidine in humans. Anesthesiology, 2000; 93: 382–394.

12. Khan, Z. P., Ferguson, C. N., Jones, R. M. Alpha-2 and imidazoline receptor agonists. Their pharmacology and therapeutic role. Anaesthesia, 1999; 54: 146–165.

13. Databáze registrovaných léčivých přípravků. [on line, cit. 2010-11-01]. Dostupný na WWW: http://www.sukl.cz/modules/medication/search.php

14. Angst, M. S., Clark, J. D. Opioid-induced hyperalgesia: a qualitative systematic review. Anesthesiology, 2006; 104: 570–587.

15. Málek, J., Ševčík, P., a kol. Léčba pooperační bolesti. Praha, Aeskulap Mladá Fronta, 2009.

16. Wijeysundera, D. N., Bender, J. S., Beattie, W. S. Alpha-2 adrenergic agonists for the prevention of cardiac complications among patients undergoing surgery. Cochrane Database Syst. Rev., 2009; CD004126.

17. Paris, A., Tonner, P. H. Dexmedetomidine in anaesthesia. Curr. Opin. Anaesthesiol., 2005; 18: 412–418.

18. Wijeysundera, D. N., Naik, J. S., Beattie, W. S. Alpha-2 adrenergic agonists to prevent perioperative cardiovascular complications: a meta-analysis. Am. J. Med., 2003; 114: 742–752.

19. Isik, B., Arslan, M., Tunga, A. D., Kurtipek, O. Dexmedetomidine decreases emergence agitation in pediatric patients after sevoflurane anesthesia without surgery. Paediatr. Anaesth., 2006;16: 748–753.

20. Maldonado, J. R., Wysong, A., van der Starre, P. J., Block, T., Miller, C., Reitz, B. A. Dexmedetomidine and the reduction of postoperative delirium after cardiac surgery. Psychosomatics, 2009; 50: 206–217.

21. Takada, K., Clark, D. J., Davies, M. F., Tonner, P. H., Krause, T. K., Bertaccini, E., Maze, M. Meperidine exerts agonist activity at the alpha(2B)-adrenoceptor subtype. Anesthesiology, 2002; 96: 1420–1426.

22. Elvan, E. G., Oc, B., Uzun, S., Karabulut, E., Coskun, F., Aypar, U. Dexmedetomidine and postoperative shivering in patients undergoing elective abdominal hysterectomy. Eur. J. Anaesthesiol., 2008; 25: 357–364.

23. Blaine Easley, R., Brady, K. M., Tobias, J. D. Dexmedetomidine for the treatment of postanesthesia shivering in children. Paediatr. Anaesth., 2007; 17: 341–346.

24. Bicer, C., Esmaoglu, A., Akin, A., Boyaci, A. Dexmedetomidine and meperidine prevent postanaesthetic shivering. Eur. J. Anaesthesiol., 2006; 23: 149–153.

25. Málek J., Čtrnáctá E., Kurzová A. Obavy a prožitky pacientů v perioperačním období. Rozhl. Chir., 2004; 83: 406–410.

26. Massad, I. M., Mohsen, W. A., Basha, A. S., Al-Zaben, K. R., Al-Mustafa, M. M., Alghanem, S. M. A balanced anesthesia with dexmedetomidine decreases postoperative nausea and vomiting after laparoscopic surgery. Saudi Med. J., 2009; 30: 1537–1541.

27. Lin, T. F., Yeh, Y. C., Lin, F. S., Wang, Y. P., Lin, C. J., Sun, W. Z., Fan, S. Z. Effect of combining dexmedetomidine and morphine for intravenous patient-controlled analgesia. Br. J. Anaesth., 2009; 102: 117–122.

28. Tufanogullari, B., White, P. F., Peixoto, M. P., Kianpour, D., Lacour, T., Griffin, J., Skrivanek, G., Macaluso, A., Shah, M., Provost, D. A. Dexmedetomidine infusion during laparoscopic bariatric surgery: the effect on recovery outcome variables. Anesth. Analg., 2008; 106: 1741–1748.

29. Panzer, O., Moitra, V., Sladen, R. N. Pharmacology of sedative-analgesic agents: dexmedetomidine, remifentanil, ketamine, volatile anesthetics, and the role of peripheral mu antagonists. Crit. Care Clin., 2009; 25: 451–469

30. Málek J., Knor J.,Kurzová A., Lopourová M. Nežádoucí hemodynamické změny během laparoskopických cholecystektomií a možnost jejich potlačení clonidinem v premedikaci. Srovnání intravenózní a intramuskulární premedikace. Rozhl. Chir., 1999; 78: 286–291.

31. Hirvonen, E. A., Poikolainen, E. O., Paakkonen, M. E., Nuutinen, L. S. The adverse hemodynamic effects of anesthesia, head-up tilt, and carbon dioxide pneumoperitoneum during laparoscopic cholecystectomy. Surg. Endosc., 2000; 14: 272–277.

32. Dorsay, D. A., Greene, F. L., Baysinger, C. L. Hemodynamic changes during laparoscopic cholecystectomy monitored with transesophageal echocardiography. Surg. Endosc., 1995; 9: 128–133.

33. McLaughlin, J. G., Scheeres, D. E., Dean, R. J., Bonnell, B. W. The adverse hemodynamic effects of laparoscopic cholecystectomy. Surg. Endosc., 1995; 9: 121–124.

34. Joris, J. L., Chiche, J. D., Canivet, J. L., Jacquet, N. J., Legros, J. J., Lamy, M. L. Hemodynamic changes induced by laparoscopy and their endocrine correlates: effects of clonidine. J. Am. Coll. Cardiol., 1998; 32: 1389–1396.

35. Erkola, O., Korttila, K., Aho, M., Haasio, J., Aantaa, R., Kallio, A. Comparison of intramuscular dexmedetomidine and midazolam premedication for elective abdominal hysterectomy. Anesth. Analg., 1994; 79: 646–653.

36. Virkkila, M., Ali-Melkkila, T., Kanto, J., Turunen, J., Scheinin, H. Dexmedetomidine as intramuscular premedication in outpatient cataract surgery. A placebo-controlled dose-ranging study. Anaesthesia, 1993; 48: 482–487.

37. Scheinin, H., Jaakola, M.L., Sjovall, S., Ali-Melkkila, T., Kaukinen, S., Turunen, J., Kanto, J. Intramuscular dexmedetomidine as premedication for general anesthesia. A comparative multicenter study. Anesthesiology, 1993; 78: 1065–1075.

38. Aantaa, R., Jaakola, M. L., Kallio, A., Kanto, J., Scheinin, M., Vuorinen, J. A comparison of dexmedetomidine, and alpha 2-adrenoceptor agonist, and midazolam as i.m. premedication for minor gynaecological surgery. Br. J. Anaesth., 1991; 67: 402–409.

39. Aantaa, R., Kanto, J., Scheinin, M. Intramuscular dexmedetomidine, a novel alpha 2-adrenoceptor agonist, as premedication for minor gynaecological surgery. Acta Anaesthesiol. Scand., 1991; 35: 283–288.

Štítky
Surgery Orthopaedics Trauma surgery

Článok vyšiel v časopise

Perspectives in Surgery

Číslo 5

2010 Číslo 5
Najčítanejšie tento týždeň
Najčítanejšie v tomto čísle
Prihlásenie
Zabudnuté heslo

Zadajte e-mailovú adresu, s ktorou ste vytvárali účet. Budú Vám na ňu zasielané informácie k nastaveniu nového hesla.

Prihlásenie

Nemáte účet?  Registrujte sa

#ADS_BOTTOM_SCRIPTS#