EFFECTS OF DEXMEDITOMIDINE INFUSION FOR FESS UNDER LOCAL ANAESTHESIA

1. EFFECTS OF DEXMEDITOMIDINE INFUSION FOR FESS UNDER LOCAL ANAESTHESIA COAUTHORS PROF&HEAD : 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

2. INTRODUCTION • FESS - GA / LA • Under LA – Adequate sedation,analgesia, with nil or minimal side effects • Patient’s comfort • Surgeon’s comfort • Need anesthesiologist or anaesthetic agent

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

4. 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

5. 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 4%Lignocaine & Adrenaline

6. 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 - 2%lignocaine & adrenaline • 0.7μg/kg/hr infusion as maintenance • Maintenance infusion stopped 15 mins before the end of surgery • Group S- NS

7. 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 < 50/min) ,severe hypotension MAP<60mmhg-study drug will be stopped and treated accordingly

8. POST OP MONITORING • Duration of analgesia-time to reach VAS score >4 • Inj .Diclofenac 75 mg im given • No of episodes of nausea ,vomiting – noted & treated

9. 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

10. 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.

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

12. STATISTICAL ANALYSIS • CHI-SQUARE TEST • MANN-WHITNEY U TEST

13. DEMOGRAPHIC DATAS

14. SEX WEIGHT

15. PRE OP HR & MAP

16. PRE OP HR PRE OP MAP

17. 0-15 MINS

18. 0-15 MINS HR MAP

19. 0-15 MINS HR MAP

20. 15-75 MINS

21. 15-75 MINS HR MAP

22. 15-75 MINS HR MAP

23. SPO2

24. RAMSAY SEDATION SCORE

25. SEDATION GROUP D GROUP S

26. BLEEDING GRADE

27. DURATION OF ANALGESIA

28. PONV

29. 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

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

31. HEMODYNAMIC EFFECTS • Initially acts on peripheral alpha 2 receptors-increase in BP/HR-15 mins • Postsynaptic activation of α2 adrenoceptors in the central nervous system (CNS) • Inhibits sympathetic activity and • Decrease blood pressure and heart rate

32. 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 surgeon’s comfort in group D

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

34. 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.

35. Thank You!