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

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

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

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

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

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

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

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

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

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.

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

STATISTICAL ANALYSIS CHI-SQUARE TEST MANN-WHITNEY U TEST

DEMOGRAPHIC DATAS GROUP AGE (MEDIAN±2SD) SEX (M/F) WEIGHT (MEDIAN±2SD) D26.1± / ± S26.1± / ± P(>0.05) INSIGNIFICANT

SEXWEIGHT

PRE OP HR & MAP GROUP PRE OP HR MEDIAN ±2SD PRE OP MAP MEDIAN ±2SD D81.3 ± ±7.25 S80.2± ±6.89 P(>0.05) INSIGNIFICANT

PRE OP HRPRE OP MAP

0-15 MINS GROUP HR 0-15MINS (Median ±2SD) MAP 0-15MINS (Median ±2SD) D100.8± ±1.22 S105.4± ±1.32 P(<0.05) INSIGNIFICANT SIGNIFICANT

0-15 MINS HRMAP

0-15 MINS HRMAP

15-75 MINS GROUP HR (Median ±2SD) MAP (Median±2SD) D68.56± ±1.98 S96.67± ±2.01 P(<0.05) SIGNIFICANT O.OOO

15-75 MINS HRMAP

15-75 MINS HRMAP

SPO2 GROUP MEDIAN ±2SD P(>0.05) SPO2 D98.44±1.56 SPO2S98.43± INSIGNI FICANT

RAMSAY SEDATION SCORE GROUP Median ± 2SD P(<0.05) D3.094± SIGNIFIC ANT S2.111±

SEDATION GROUP DGROUP S

BLEEDING GRADE GROUPMedian ±2SDP(<0.05) D1.75±0.444 SIGNIFICA NT S3.25±

DURATION OF ANALGESIA GROUPMedian ±2SD P(<0.05) D233.25± S97.25±

PONV GROUPMean Rank P(<0.05) D INSIGNIFI CANT S

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

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

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

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( hrs) No respiratory depression in both the groups Better patient and surgeon’s comfort in group D

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

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.

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