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Table of Contents
INVITED COMMENTARY  
Year : 2013  |  Volume : 16  |  Issue : 2  |  Page : 115-116
Is caudal dexmedetomidine in pediatric cardiac surgery a novel idea?


Department of Anesthesia and Critical Care, Armed Forces Medical College, Pune, Maharashtra, India

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Date of Web Publication29-Mar-2013
 

How to cite this article:
Sharma VK. Is caudal dexmedetomidine in pediatric cardiac surgery a novel idea?. Ann Card Anaesth 2013;16:115-6

How to cite this URL:
Sharma VK. Is caudal dexmedetomidine in pediatric cardiac surgery a novel idea?. Ann Card Anaesth [serial online] 2013 [cited 2019 Nov 12];16:115-6. Available from: http://www.annals.in/text.asp?2013/16/2/115/109746


It is now well-established that cardiac surgery in neonates and infants fosters an enormous stress response which is associated with adverse outcomes. [1],[2],[3] Hence, every effort must be made to minimize this stress response. Various methods are currently employed, with benefit, to combat this including perioperative intravenous steroids, modified ultrafiltration, peritoneal dialysis, high-dose intravenous opioids, and central neuraxial intervention. [3],[4],[5],[6],[7],[8] High-dose intravenous opioids lend hemodynamic stability but garner menaces of over sedation, respiratory depression, and prolonged mechanical ventilation after surgery. [8] Central neuraxial and regional techniques have been incorporated into most non-cardiac surgical practices to augment analgesia, limit opioid use, and obtund the stress response to noxious stimuli. The quality of analgesia and ability to inhibit the stress response with central neuraxial techniques is unparalleled. However, its use in cardiac surgery begets controversy because of the attendant theoretical risk of an epidural hematoma causing a significant and permanent neurological deficit. This risk is minimized by strict compliance to protocols established by elaborate guidelines, which are in place. [9] Till date, there is no report of a significant epidural hematoma in pediatric cardiac patients who have received neuraxial intervention followed by systemic heparinization prior to cardiopulmonary bypass (CPB).

The author has experience of over a 1000 pediatric cardiac surgical patients over a decade (unpublished data), where high thoracic epidural anesthesia was used including neonates and infants with complex congenital heart defects who underwent open heart surgery. No incidence of epidural hematoma causing neurological deficit was noted.

The various neuraxial interventions that have been used in pediatric cardiac anesthesia include, thoracic epidural, caudal epidural, subarachnoid approaches administering single bolus and continuous infusion of local anesthetics, opioids, and α-2-agonists. Most have shown a definite benefit in outcome, be it attenuation of surrogate markers of stress response, hemodynamic stability, time to extubation or length of stay in the intensive care unit.

Nasr and Abdelhamid, [10] in their article entitled "The efficacy of caudal dexmedetomidine on stress response and post-operative pain in pediatric cardiac surgery", have demonstrated a significant reduction in stress response validated by reduction of surrogate markers like serum cortisol and blood glucose levels in pediatric cardiac surgical patients who received a single bolus of dexmedetomidine and bupivacaine in the caudal epidural space. They noticed a concomitant decrease in heart rate, mean arterial pressure, better post-operative analgesia and a shorter time to extubation in comparison with patients who received a bolus dose of caudal fentanyl and bupivacaine. It is remarkable how a single caudal dose of dexmedetomidine 0.5 μg/kg and 2.5 mg/kg bupivacaine could achieve this advantage in patients undergoing a sternotomy and cardiac surgery that elicits a systemic stress response. The authors have injected a volume of 1.6 ml/kg to achieve a rostral spread to cover sternotomy. Possibly, blocking thoracic, lumbar, and sacral segments with this volume abetted this end.

Intravenous dexmedetomidine has shown numerous advantages in pediatric cardiac surgery viz. attenuation of the hemodynamic and neuroendocrine response of surgical trauma and CPB. [11] The authors and others [12] propose that α-2 analgesic effects are more pronounced after neuraxial than intravenous administration. The authors have brilliantly circumvented the illusionary risk of an epidural hematoma by using a single bolus of caudal bupivacaine and dexmedetomidine. It is indeed an interesting modality that needs further validation in a larger and perhaps a multicenter trial. It also inspires a hypothesis worth investigating that a high thoracic epidural infusion of a combination of dexmedetomidine and local anesthetic would be superior to the caudal approach.

 
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1.Gruber EM, Laussen PC, Casta A, Zimmerman AA, Zurakowski D, Reid R, et al. Stress response in infants undergoing cardiac surgery: A randomized study of fentanyl bolus, fentanyl infusion, and fentanyl-midazolam infusion. Anesth Analg 2001;92:882-90.  Back to cited text no. 1
    
2.Anand KJ, Hansen DD, Hickey PR. Hormonal-metabolic stress responses in neonates undergoing cardiac surgery. Anesthesiology 1990;73:661-70.  Back to cited text no. 2
    
3.Anand KJ, Hickey PR. Halothane-morphine compared with high-dose sufentanil for anesthesia and postoperative analgesia in neonatal cardiac surgery. N Engl J Med 1992;326:1-9.  Back to cited text no. 3
    
4.Duncan HP, Cloote A, Weir PM, Jenkins I, Murphy PJ, Pawade AK, et al. Reducing stress responses in the pre-bypass phase of open heart surgery in infants and young children: A comparison of different fentanyl doses. Br J Anaesth 2000;84:556-64.  Back to cited text no. 4
    
5.Peterson KL, DeCampli WM, Pike NA, Robbins RC, Reitz BA. A report of two hundred twenty cases of regional anesthesia in pediatric cardiac surgery. Anesth Analg 2000;90:1014-9.  Back to cited text no. 5
    
6.Hammer GB, Ngo K, Macario A. A retrospective examination of regional plus general anesthesia in children undergoing open heart surgery. Anesth Analg 2000;90:1020-4.  Back to cited text no. 6
    
7.Humphreys N, Bays SM, Parry AJ, Pawade A, Heyderman RS, Wolf AR. Spinal anesthesia with an indwelling catheter reduces the stress response in pediatric open heart surgery. Anesthesiology 2005;103:1113-20.  Back to cited text no. 7
    
8.Pirat A, Akpek E, Arslan G. Intrathecal versus IV fentanyl in pediatric cardiac anesthesia. Anesth Analg 2002;95:1207-14.  Back to cited text no. 8
    
9.Horlocker TT, Wedel DJ, Rowlingson JC, Enneking FK, Kopp SL, Benzon HT, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med 2010;35:64-101.  Back to cited text no. 9
    
10.Nasr DA, Abdelhamid HM. The efficacy of caudal dexmedetomidine on stress response and postoperative pain in pediatric cardiac surgery. Annals Card Anaesth 2013;16:109-14.  Back to cited text no. 10
    
11.Mukhtar AM, Obayah EM, Hassona AM. The use of dexmedetomidine in pediatric cardiac surgery. Anesth Analg 2006;103:52-6.  Back to cited text no. 11
    
12.Akin A, Ocalan S, Esmaoglu A, Boyaci A. The effects of caudal or intravenous clonidine on postoperative analgesia produced by caudal levobupivacaine in children. Paediatr Anaesth 2010;20:350-5.  Back to cited text no. 12
    

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Correspondence Address:
Vipul Krishen Sharma
Department of Anesthesia and Critical Care, Armed Forces Medical College, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


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