Abstract
To evaluate the hemodynamic responses to nociceptive stimuli in children submitted to videolaparoscopic appendectomy under balanced anesthesia with isoflurane and dexmedetomidine. Randomized, double-blind and placebo-controlled study involving 26 children submitted to videolaparoscopic appendectomy carried out at Hospital São Lucas (PUCRS) between May 2004 and February 2005. Patients were assigned to two groups: (a) Dexmedetomidine group (n=13): infusion of 1 microg/kg over 10 minutes and maintenance dose of 0.5 microg/kg/h) as an adjuvant to inhaled isoflurane anesthesia; (b) Control group (n=13): normal saline infusion at a similar rate and volume of the dexmedetomidine infusion. During the different surgical and anesthetic periods, groups were compared regarding heart rate, systolic and diastolic arterial blood pressures as well as need of supplemental fentanyl infusion. Student's t test, ANOVA, and Finner's procedure were used for statistical analysis. During the strongest nociceptive stimuli (airway access and abdominal catheter placement), the heart rate and systolic blood pressure increased significantly (p<0.001) in the control group compared to the dexmedetomidine group. Compared to baseline levels, the hemodynamic responses to nociceptive stimuli were more stable when dexmedetomidine was used in combination with inhaled isoflurane anesthesia. The need for supplemental doses of fentanyl and the hemodynamic parameters were similar for both groups. Dexmedetomidine combined with inhaled isoflurane for anesthesia of children submitted to videolaparoscopic appendectomy, efficiently blocks the hemodynamic responses to nociceptive stimuli. When compared to placebo, the use of dexmedetomidine did not change the need for supplemental doses of fentanyl for maintenance of hemodynamic parameters during the intraoperative period.
Highlights
Technological advances and improved experience with videolaparoscopy have allowed this surgical technique to be increasingly used in pediatric surgical patients
systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured immediately after tracheal intubation; Moment 3 (M3): heart rate (HR), SBP and DBP measured immediately before surgical incision; Moment 4 (M4): HR, SBP and DBP measured immediately after surgical incision and during videolaparoscopic transumbilical trocar placement; Moment 5 (M5): HR, SBP and DBP measured at maximum pneumoperitoneum insufflation of 12mmHg of CO2; Moments 6 and 7 (M6 and M7): HR, SBP and DBP measured during placement of the second and third videolaparoscopy trocars on the right and left abdominal sides, respectively; All unexpected events which took place during the anesthetic induction and surgery time were recorded as adverse effects as well as the need for supplemental doses of fentanyl for maintenance of intraoperative hemodynamic parameters at a maximum 20% increase from baseline levels (M0)
The only exception was the length of preoperative fasting, which was longer (p=0.03) in the dexmedetomidine group
Summary
Technological advances and improved experience with videolaparoscopy have allowed this surgical technique to be increasingly used in pediatric surgical patients. Dexmedetomidine is a selective and potent α2-adrenoceptor agonist, with hypnotic, analgesic and sympatholytic properties.[2,3,4] In surgical patients, it reduces the use of other anesthetics,[5,6,7] minimizes sympathetic response to nociceptive stimuli[6,8] and improves intraoperative hemodynamic stability.[6]. Clinical trials addressing the use of dexmedetomidine in children are still scarce.[9] Most publications concerning pediatric patients are case reports disclosing the intraoperative use of dexmedetomidine,[10] its use as an adjuvant in assisted ventilation in the Intensive Care Unit (ICU);[11] and in the management of opioid dependency.[12]
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