Dexmedetomidine- A New Short Term Sedative?

Interesting Review on "Dexmedetomidine", the most recent sedative approved by the FDA.

Dexmedetomidine: a novel sedative-analgesic agent Ralph Gertler, MD,1 H. Cleighton Brown, MD,1 Donald H. Mitchell, MD,1 and Erin N. Silvius, MD1 1From the Department of Anesthesiology and Pain Management, Baylor University Medical Center, Dallas, Texas; and Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center at Dallas. Corresponding author. Corresponding author: Ralph Gertler, MD, Department of Anesthesiology and Pain Management, Baylor University Medical Center, 3500 Gaston Avenue, Dallas, Texas 75246 (e-mail: Ralph_Gertler10@excite.com). Since the first report of clonidine, an α2-adrenoceptor agonist, the indications for this class of drugs have continued to expand. In December 1999, dexmedetomidine was approved as the most recent agent in this group and was introduced into clinical practice as a short-term sedative (<24 style="font-size: 0.8em; line-height: 0.8em; white-space: nowrap; ">2-Adrenoceptor agonists have several beneficial actions during the perioperative period. They decrease sympathetic tone, with attenuation of the neuroendocrine and hemodynamic responses to anesthesia and surgery; reduce anesthetic and opioid requirements; and cause sedation and analgesia. They allow psychomotoric function to be preserved while letting the patient rest comfortably. With this combination of effects, α2-adrenoceptor agonists may offer benefits in the prophylaxis and adjuvant treatment of perioperative myocardial ischemia. Furthermore, their role in pain management and regional anesthesia is expanding. Side effects consist of mild to moderate cardiovascular depression, with slight decreases in blood pressure and heart rate. The development of new, more selective α2-adrenoceptor agonists with improved side effect profiles may provide a new concept for the administration of perioperative anesthesia and analgesia. This review aims to give background information to improve understanding of the properties and applications of the novel α2-adrenoceptor agonist, dexmedetomidine.

Neuromonitoring & Peadiatric Cardiopulmonary bypass surgical procedures?:- Boosts Evidence Based practice & Best Practice?

Usage of intraoperative neurophysiologic monitoring during Peadiatric cardiopulmonary bypass surgical procedures reported in the following research papers, addition of IONM tothe surgical team has helped them to improve the post surgical neurological complications. Two of the following studies one published recently in Sept-Oct 2008 and the other in 2007, both in peer reveiwed journals discuss the importance of IONM usage in terms of reducing neurological risk, patient safety and faster discharge of patients that could be benefitial to both the patients and the hospitals.

The influence of neurophysiologic monitoring on the management of pediatric cardiopulmonary bypass.

ASAIO J. 2008 Sep-Oct;54(5):467-9

Kimatian SJ, Saliba KJ, Soler X, Valentine EA, Coleman ML, Kunselman AR, Schuler HG, Barnes ML,Thirumala PD, Myers JL.

Department of Anesthesiology, Penn State College of Medicine, Hershey, Pennsylvania 17033, USA. skimatian@hmc.psu.edu

We describe a process by which we sought to determine how the addition of intraoperative neurophysiologic monitoring (IONM) impacted the management of cardiopulmonary bypass (CPB) during pediatric cardiac surgery.

While maintaining a consistent team of surgeons, anesthesiologists, nurses, and perfusionists, a multi-modal, IONM program was established consisting of Near Infrared Spectroscopy, Transcranial Doppler, and eight channel electroencephalography. A retrospective review of cases from 1 year before the institution of the IONM program was compared with data obtained from cases performed after neurophysiologic monitoring was established as a standard of care for pediatric patients on CPB.

This comparative analysis of CPB management revealed a significant increase in the use of donor blood added to the CPB circuit prime as well as in the maintenance of a higher hematocrit during the bypass period after the implementation of IONM.

These changes in the management of pediatric CPB correlated with recommendations of previous studies that examined postoperative neurophysiologic outcomes, suggesting that these changes were not only consistent with best practices, but that the presence of IONM data facilitated a transition to evidence-based practice.

Benefit of neurophysiologic monitoring for pediatric cardiac surgery.

Austin EH 3rd, Edmonds HL Jr, Auden SM, Seremet V, Niznik G, Sehic A, Sowell MK, Cheppo CD, Corlett KM.

Department of Surgery, University of Louisville School of Medicine, Ky., USA.

BACKGROUND: Pediatric patients undergoing repair of congenital cardiac abnormalities have a significant risk of an adverse neurologic event. Therefore this retrospective cohort study examined the

potential benefit of interventions based on intraoperative neurophysiologic monitoring in decreasing both postoperative neurologic sequelae and length of hospital stay as a cost proxy.

METHODS: With informed parental consent approved by the institutional review board,

electroencephalography, transcranial Doppler ultrasonic measurement of middle cerebral artery blood flow velocity, and transcranial near-infrared cerebral oximetry were monitored in 250 patients.

An interventional algorithm was used to detect and correct specific deficiencies in cerebral perfusion or oxygenation or to increase cerebral tolerance to ischemia or hypoxia. RESULTS: Noteworthy changes in brain perfusion or metabolism were observed in 176 of 250 (70%) patients. Intervention that altered patient management was initially deemed appropriate in 130 of 176 (74%) patients with neurophysiologic changes.

Obvious neurologic sequelae (i.e., seizure, movement, vision or speech disorder) occurred in five of 74 (7%) patients without noteworthy change, seven of 130 (6%) patients with intervention, and 12 of 46 (26%) patients without intervention (p = 0.001). Survivors' median length of stay was 6 days in the no-change and intervention groups but 9 days in the no-intervention group. In addition, the percentage of patients in the no-intervention group discharged from the hospital within 1 week (32%) was significantly less than that in either the intervention (51%, p = 0.05) or no-change (58%, p = 0.01) groups.

On the basis of an estimated hospital neurologic complication cost of $1500 per day, break-even analysis justified a hospital expenditure for neurophysiologic monitoring of $2142 per case. CONCLUSIONS:

Interventions based on neurophysiologic monitoring appear to decrease the incidence of postoperative neurologic sequelae and reduce the length of stay. Inasmuch as the break-even cost for neurophysiologic monitoring is more than four times the actual average charge, both patients and hospital may profit from this service.

Because this study was not a truly randomized clinical trial, unintentional statistical bias may have occurred and caution is urged in interpreting the magnitude of apparent intergroup outcome differences.