EFFECTS OF DEXMEDITOMIDINE INFUSION FOR FESS UNDER LOCAL ANAESTHESIA

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EFFECTS OF DEXMEDITOMIDINE INFUSION FOR
FESS UNDER LOCAL ANAESTHESIA

• COAUTHORS
• PROFHEAD 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

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INTRODUCTION

• FESS - GA / LA
• Under LA Adequate sedation,analgesia, with nil
  or minimal side effects
• Patients comfort
• Surgeons comfort
• Need anesthesiologist or anaesthetic agent

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AIM

• To assess the hemodynamic effects, sedation, and
  duration of analgesia of
• DEXMEDETOMIDINE INFUSION
• in patients undergoing FUNCTIONAL ENDOSCOPIC
  SINUS SURGERY
• under local anaethesia

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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

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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 4Lignocaine
  Adrenaline

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• 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 - 2lignocaine adrenaline
• 0.7µg/kg/hr infusion as maintenance
• Maintenance infusion stopped 15 mins before the
  end of surgery
• Group S- NS

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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 lt 50/min) ,severe hypotension
  MAPlt60mmhg-study drug will be stopped and treated
  accordingly

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POST OP MONITORING

• Duration of analgesia-time to reach VAS score gt4
• Inj .Diclofenac 75 mg im given
• No of episodes of nausea ,vomiting noted
  treated

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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

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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.

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ANALYSIS

• Demographic datas
• Hemodynamic parameters-HR,MAP,SPO2
• Sedation score
• Bleeding grade
• Nausea and vomiting

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STATISTICAL ANALYSIS

• CHI-SQUARE TEST
• MANN-WHITNEY U TEST

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DEMOGRAPHIC DATAS
GROUP AGE (MEDIAN2SD) SEX (M/F) WEIGHT (MEDIAN2SD)
D 26.16.766014 10/10 54.43.647638
S 26.15.766014 11/9 56.155.294237
P(gt0.05) INSIGNIFICANT 0.76 .755 0.376
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• SEX

• WEIGHT

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PRE OP HR MAP
GROUP PRE OP HR MEDIAN 2SD PRE OP MAP MEDIAN 2SD
D 81.3 3.22 98.467.25
S 80.23.12 97.546.89
P(gt0.05) INSIGNIFICANT 0.563 0.989
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• PRE OP HR

• PRE OP MAP

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0-15 MINS
GROUP HR 0-15MINS (Median 2SD) MAP 0-15MINS (Median 2SD)
D 100.83.233 86.81.22
S 105.43.766 96. 11.32
P(lt0.05) 0.091 INSIGNIFICANT 0.000 SIGNIFICANT
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0-15 MINS

• HR

• MAP

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0-15 MINS

• HR

• MAP

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15-75 MINS
GROUP HR (Median 2SD) MAP (Median2SD)
D 68.562.43 68.471.98
S 96.672.88 97.22.01
P(lt0.05) SIGNIFICANT O.OOO O.OOO
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15-75 MINS

• HR

• MAP

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15-75 MINS

• HR

• MAP

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SPO2
GROUP MEDIAN 2SD P(gt0.05)
SPO2 D 98.441.56
SPO2S 98.431.77 0.910 INSIGNIFICANT
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RAMSAY SEDATION SCORE
GROUP Median 2SD P(lt0.05)
D 3.0940.1155 SIGNIFICANT
S 2.1110.1612 0.000
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SEDATION

• GROUP D

• GROUP S

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BLEEDING GRADE
GROUP Median 2SD P(lt0.05)
D 1.750.444 SIGNIFICANT
S 3.250.444 0.000
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DURATION OF ANALGESIA
GROUP Median 2SD P(lt0.05)
D 233.2520.408
S 97.2517.731 0.000
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PONV
GROUP Mean Rank P(lt0.05)
D 17.425 INSIGNIFICANT
S 23.575 0.069
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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

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ANALGESIC EFFECT
?2 Agonists
Inhibit sympathetic- mediated pain
Peripheral nociceptors
Inhibit release of SP and glutamate
Primary afferent neurons
Inhibit firing
Second order neurons
Decrease emotive aspects
Subcortical cortex
Disinhibit A5/A7 noradrenergic pathways
Descending inhibitory pathways
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HEMODYNAMIC EFFECTS

• Initially acts on peripheral alpha 2
  receptors-increase in BP/HR-15 mins
• Postsynaptic activation of a2 adrenoceptors in
  the central nervous system (CNS)
• Inhibits sympathetic activity and
• Decrease blood pressure and heart rate

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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 surgeons comfort in group D

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CONCLUSION

• DEXMEDETOMIDINE
• Good Sedative , Analgesic Can Be Used As a
  Hypotensive Anesthetic To Control Bleeding With
  Out Respiratory Depression For
• FESS UNDER LOCAL ANAESTHESIA

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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.

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Thank You!