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Table of Contents
LETTER TO EDITOR
Year : 2020  |  Volume : 36  |  Issue : 3  |  Page : 427-428

Optimal utilization of sedative and analgesic potential of dexmedetomidine in a child with severe kyphoscoliosis for vitreoretinal surgery


Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India

Date of Submission15-Apr-2019
Date of Acceptance29-Oct-2019
Date of Web Publication26-Sep-2020

Correspondence Address:
Dr. Kanil R Kumar
Assistant Professor, Room No 5011, Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joacp.JOACP_106_19

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How to cite this article:
Kumar KR, Saeed Z, Chhabra A. Optimal utilization of sedative and analgesic potential of dexmedetomidine in a child with severe kyphoscoliosis for vitreoretinal surgery. J Anaesthesiol Clin Pharmacol 2020;36:427-8

How to cite this URL:
Kumar KR, Saeed Z, Chhabra A. Optimal utilization of sedative and analgesic potential of dexmedetomidine in a child with severe kyphoscoliosis for vitreoretinal surgery. J Anaesthesiol Clin Pharmacol [serial online] 2020 [cited 2020 Nov 29];36:427-8. Available from: https://www.joacp.org/text.asp?2020/36/3/427/296189

Dear Editor,

Dexmedetomidine is a highly selective α-2 adrenergic agonist used for sedation and analgesia. It has been extensively studied for sedation in pediatric intensive care and radiology suite.[1] Here, we describe a child with severe kyphoscoliosis for ophthalmic surgery managed under dexmedetomidine and peribulbar block.

A 10-year-old 20-kg boy was scheduled for vitreoretinal surgery. He was a known case of congenital kyphoscoliosis involving cervical and thoracic spine. His breath-holding time was 8 s and effort tolerance was <4 metabolic equivalents. The chest radiograph revealed right dorsal scoliosis from D-2 to D-12 vertebrae with Cobb's angle of 105° [Figure 1]. The pulmonary function test revealed forced vital capacity (FVC) 30.04%, forced expiratory volume in 1 s (FEV1) 29.04%, and FEV1/FVC ratio of 100.8% suggestive of restrictive lung disease. There was mild pulmonary hypertension in echocardiography.
Figure 1: (a) Eutectic mixture of local anesthetics for peribulbar block and intravenous cannulation. (b) Severe kyphoscoliosis with Cobb's angle of 105°

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In view of severe restrictive lung disease, we proceeded with a peribulbar block under dexmedetomidine sedation. The procedure was explained to the child and consent was obtained from his father. They were reassured that there won't be pain or discomfort. In the pre-anesthesia room, the child was premedicated with 40 μg of dexmedetomidine intranasally. Eutectic mixture of local anesthetics (EMLA) was applied over a prominent vein in the dorsum of hand and over upper and lower eyelids [Figure 1]. After an hour, the child accompanied by his father was taken inside the operation room. Routine monitors (ECG, SPO2, and noninvasive blood pressure) were attached. Supplemental oxygen was provided through nasal prongs. An intravenous cannula was secured and dexmedetomidine infusion was started at 1 μg/kg/hr. After achieving Richmond Agitation and Sedation Scale (RASS) of 3, peribulbar block was performed with a 27-gauge needle. A total of 5 ml (2.5 ml of 2% lignocaine and 2.5 ml of 0.5% bupivacaine) was injected at inferotemporal region. The child did not show any movement in response to the injection. After 10 min, dexmedetomidine infusion was reduced to 0.5 μg/kg/hr. The total duration of surgery was 45 min and the child was awake at the end of surgery.

Scoliosis with Cobb's angle more than 100° is associated with severe restrictive lung disease, alveolar hypoventilation, ventilation-perfusion (VQ) mismatch, pulmonary hypertension, and increased perioperative morbidity.[2] General anesthesia in these patients further worsens the pulmonary function leading to postoperative mechanical ventilation and prolonged ICU stay. Regional anesthetic techniques are associated with less impairment of postoperative cardiorespiratory function.[3] But in children, regional anesthesia procedures are done under deep sedation or general anesthesia.[4] Nasal dexmedetomidine has high bioavailability thereby provides reliable and effective sedation. The sedation mimics a natural sleep but still easily arousable and cooperates during the procedure.[5] Unlike midazolam it provides analgesia, prevents vomiting, shivering, and emergence delirium. Respiratory depression or apnea is very rare. The nasal premedication reduced the need for loading dose of IV dexmedetomidine thereby provided stable hemodynamic conditions. The analgesic property of dexmedetomidine along with EMLA cream facilitated IV cannulation and peribulbar block without any movement. To summarize, dexmedetomidine can be safely used for sedation during monitored anesthesia care in kyphoscoliosis children. It provided smooth sedation and stable cardiorespiratory conditions.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that name and initials will not be published and due efforts will be made to conceal patientís identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Shukry M, Miller JA. Update on dexmedetomidine: Use in nonintubated patients requiring sedation for surgical procedures. Ther Clin Risk Manag 2010;6:111-21.  Back to cited text no. 1
    
2.
Issac E, Menon G, Vasu BK, George M, Vasudevan A. Predictors of postoperative ventilation in scoliosis surgery: A retrospective analysis. Anesth Essays Res 2018;12:407-11.  Back to cited text no. 2
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3.
Kafer ER. Respiratory and cardiovascular functions in scoliosis and the principles of anesthetic management. Anesthesiology 1980;52:339-51.  Back to cited text no. 3
    
4.
Shah RD, Suresh S. Applications of regional anaesthesia in paediatrics. Br J Anaesth 2013;111:114-24.  Back to cited text no. 4
    
5.
Borgeat A, Aguirre J. Sedation and regional anesthesia. Curr Opin Anaesthesiol 2009;22:678-82.  Back to cited text no. 5
    


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