Dexmedetomidine- Ketamine- Midazolam Combinati on for Sedati on in Endovascular Tre atment of Cerebral Arteri o- Veno us Malformati ons and Carotid Artery Stenosis

Czech version

Authors: J. Schreiberová ¹; L. Hess ²; A. Krajina ³; M. Lojík ³
Authors‘ workplace: Klinika anestezi ologi e, resuscitace a intenzivní medicíny LF UK a FN Hradec Králové ¹; Institut klinické a experimentální medicíny Praha, IPVZ Praha ²; Radi ologická klinika LF UK a FN Hradec Králové ³
Published in: Cesk Slov Neurol N 2008; 71/104(4): 446-452
Category: Original Paper

Studie byla podpořena grantem IGA MZ ČR č. NR 8508-3

Overview

Backgro und:
Immobility, analgesi a, anxi olysis, amnesi a, preserved pati ent co operati on and hemodynamic stability witho ut respiratory depressi on are the requirements for sedati on in endovascular tre atment of cerebral arteri oveno us malformati ons and carotid artery stenting. The go al of o ur study was to assess dexmedetomidine- ketamine- midazolam sedati on for this use and compare it with ro utine sufentanil- midazolam sedati on.

Methods:
62 pati ents undergo ing elective endovascular ne uro- interventi ons were randomly divided into two gro ups for sedati on. Gro up A: intraveno us bolus applicati on of dexmedetomidine 0.5 µg/ kg, ketamine 0.25 mg/ kg and midazolam 0.02 mg/ kg during five minutes followed by infusi on of dexmedetomidine 0.25 µg/ kg/ h and ketamine 0.25 mg/ kg/ h. Gro up B: bolus applicati on of sufentanil 10 µg and midazolam 0.02 mg/ kg. Sedati on was then titrated to keep the pati ent sedated, but responsive to vocal commands. Parameters which were monitored: blo od pressure, ECG, haemoglobin saturati on, respiratory rate, arteri al carbon di oxide tensi on, depth of sedati on, side effects, complicati ons and recovery. Pati ent co operati on (excellent- suffici ent- po or) was assessed by the radi ologist, who was blind to the method used. Statistical analysis: t- test, χ² test, ANOVA.

Results:
Decre ases of blo od pressure and he art rate were significantly more marked in gro up A (p < 0.001), tho ugh the number of episodes of hypotensi on or bradycardi a did not differ significantly. Vari ability of blo od pressure within individu al pati ents was lower in gro up A (p < 0.05). Co operati on was better in gro up A (p < 0.001). No other statistically significant differences were fo und. No clinically significant complicati ons were recorded.

Conclusi on:
Sedati on by dexmedetomidine-ketamin- midazolam combinati on seems to be a safe and suitable method for endovascular ne uro- interventi ons. It secures very go od co operati on with the pati ent and hemodynamic stability witho ut respiratory depressi on.

Key words:
endovascular ne uro- interventi ons – sedati on – dexmedetomidine- ketamine- midazolam combinati on

Sources

1. Armonda RA, Vo AH, Dunford J, Bell RS. Anesthesi a for endovascular surgery. Ne urosurgery 2006; 59(Suppl 3): 66– 76.

2. Schreiberová J, Bašta V, Krajina A. Analgosedace u endovaskulárních embolizací intrakrani álních arteri ovenózních malformací. Anest neodkl Péče 2000; 11(4): 149– 151.

3. Pino MR. The nature of anesthesi a and procedural sedati on o utside of the operating ro om. Curr Opin Anaesthesi ol 2007; 20: 347– 351.

4. Hess L. Dexmedetomidinum. Remedi a 2003; 13: 2– 10.

5. Paris A, Tonner PH. Dexmedetomidine in anaesthesi a. Curr Opin Anaesthesi ol 2005; 18(4): 412– 418.

6. Nelson LE, Lu J, Guo T, Saper CB, Franks NP, Maze M. The alfa2- adrenoceptor agonist dexmedetomidine converges on an endogeno us sleep- promoting pathway to exert its sedative effects. Anesthesi ology 2003; 98(2): 428– 436.

7. Vaculín Š, Franěk M, Hess L, Rokyta L. Ovlivnění nocicepce medetomidinem a jeho kombinací s ketaminem u laboratorního potkana. Psychi atri e 2002; 6 (Suppl 4): 14– 17.

8. Hall JE, Uhrich TD, Barney JA, Arain SR, Ebert JT. Sedative, amnestic, and analgesic properti es of smalldose dexmedetomidine infusi ons. Anesth Analg 2000; 90(3): 699– 705.

9. Mack PF, Perrine K, Kobylarz E, Schwartz TH, Li en CA. Dexmedetomidine and ne urocognitive testing in awake krani otomy. J Ne urosurg Anesthesi ol 2004; 16(1): 20– 25.

10. Bustillo MA, Lazar RM, Finck AD, Fitzsimmons B, Berman MF, Pile- Spellman J et al. Dexmedetomidine may impair cognitive testing during endovascular embolizati on of cerebral arteri oveno us malformati ons: A retrospective case report seri es. J Ne urosurg Anesthesi ol 2002; 14(3): 209– 212.

11. Ben- Shlomo B, adb- el- Khalim H, Ezry J,Zohar S, Tverskoy M. Midazolam acts synergistically with fentanyl for inducti on of anaesthesi a. Br J Anaest 1990; 64(1): 45– 47.

12. Kissin I, Vinik HR, Castillo R, Bradley EL jr. Alfentanil potenti ates midazolam- induced unconsci o usness in subanalgesic doses. Anesth Analg 1990; 71(1): 65– 69.

13. Larsen R, Drábková J (eds). Anestezi e. 7th ed. Praha: Grada Publishing 2004.

14. Bailey PL, Streisand JB, East KA, East TD, Isern S, Hansen TW et al. Differences in magnitude and durati on of opi o id- induced respiratory depressi on and analgesi a with fentanyl and sufentanil. Anesth Analg 1990; 70(1): 8– 15.

15. Hogue CW jr, Talke P, Stein PK, Richardson Ch, Dimitrovich PP, Sessler DI. Autonomic nervo us system responses during sedative infusi ons of dexmedetomidine. Anesthesi ology 2002; 97(3): 592– 598.

16. Ebert TJ, Hall JE, Barney JA, Uhrich TD, Colinco MD. The effects of incre asing plasma concentrati ons of dexmedetomidine in humans. Anesthesi ology 2000; 93(2): 382– 394.

17. Penttila J, Helminen A, Anttila M, Hinkka S, Scheinin H. Cardi ovascular and parasympathetic effects of dexmedetomidine in he althy subjects. Can J Physi ol Pharmacol 2004; 82(5): 359– 362.

18. Heidenreich JO, Hartli eb S, Stendel R, Pi etilä TA, Schlattmann P, Wolf KJ et al. Bleeding complicati ons agter endovascular therapy of cerebral arteri oveno us malformati ons. Am J Ne uroradi ol 2006; 27(2): 313– 316.

19. Buhk JH, Cepek L, Kna uth M. Hyperacute intracerebral hemorrhage complicating carotid stenting sho uld be distinguished from hyperperfusi on syndrome. AJNR Am J Ne uroradi ol 2006; 27(7): 1508– 1513.

20. Krajina A, Náhlovský J, Malec R, Němečková J, Drahoko upilová H, Pařízek J, Řehák S et al. Komplikace endovaskulárních ne uro intervenčních výkonů. Cesk Slov Ne urol N 1997; 60/ 93(1): 20– 26.