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      The efficacy of pre-emptive dexmedetomidine versus amiodarone in preventing postoperative junctional ectopic tachycardia in pediatric cardiac surgery

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          Abstract

          Objective:

          The objective of this study was to assess the effectiveness of pre-emptive dexmedetomidine versus amiodarone in preventing junctional ectopic tachycardia (JET) in pediatric cardiac surgery.

          Design:

          This is a prospective, controlled study.

          Setting:

          This study was carried out at a single university hospital.

          Subjects and Methods:

          Ninety patients of both sexes, American Society of Anesthesiologists Physical Status II and III, age range from 2 to 18 years, and scheduled for elective cardiac surgery for congenital and acquired heart diseases were selected as the study participants.

          Interventions:

          Patients were randomized into three groups (30 each). Group I received dexmedetomidine 1 mcg/kg diluted in 100 ml of normal saline intravenously (IV) over a period of 20 min, and the infusion was completed 10 min before the induction followed by a 0.5 mcg/kg/h infusion for 72 h postoperative, Group II received amiodarone 5 mg/kg diluted in 100 ml of normal saline IV over a period of 20 min, and the infusion was completed 10 min before the induction followed by a 10–15 mcg/kg/h infusion for 72 h postoperative, and Group III received 100 ml of normal saline IV. Primary outcome was the incidence of postoperative JET. Secondary outcomes included vasoactive-inotropic score, ventilation time (VT), pediatric cardiac care unit stay, hospital length of stay, and perioperative mortality.

          Measurements and Main Results:

          The incidence of JET was significantly reduced in Group I and Group II ( P = 0.004) compared to Group III. Heart rate while coming off from cardiopulmonary bypass (CPB) was significantly low in Group I compared to Group II and Group III ( P = 0.000). Mean VT, mean duration of Intensive Care Unit stay, and length of hospital stay (day) were significantly short ( P = 0.000) in Group I and Group II compared to Group III ( P = 0.000).

          Conclusion:

          Perioperative use of dexmedetomidine and amiodarone is associated with significantly decreased incidence of JET as compared to placebo without significant side effects.

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          Most cited references23

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          Sedative, amnestic, and analgesic properties of small-dose dexmedetomidine infusions.

          This research determined the safety and efficacy of two small-dose infusions of dexmedetomidine by evaluating sedation, analgesia, cognition, and cardiorespiratory function. Seven healthy young volunteers provided informed consent and participated on three occasions with random assignment to drug or placebo. Heart rate, blood pressure, respiratory rate, ETCO(2), O(2) saturation, and processed electroencephalogram (bispectral analysis) were monitored. Baseline hemodynamic measurements were acquired, and psychometric tests were performed (visual analog scale for sedation; observer's assessment of alertness/sedation scale; digit symbol substitution test; and memory). The pain from a 1-min cold pressor test was quantified with a visual analog scale. After a 10-min initial dose of saline or 6 microg. kg(-1). h(-1) dexmedetomidine, volunteers received 50-min IV infusions of saline, or 0.2 or 0.6 microg. kg(-1). h(-1) dexmedetomidine. Measurements were repeated at the end of infusion and during recovery. The two dexmedetomidine infusions resulted in similar and significant sedation (30%-60%), impairment of memory (approximately 50%), and psychomotor performance (28%-41%). Hemodynamics, oxygen saturation, ETCO(2), and respiratory rate were well preserved throughout the infusion and recovery periods. Pain to the cold pressor test was reduced by 30% during dexmedetomidine infusion. Small-dose dexmedetomidine provided sedation, analgesia, and memory and cognitive impairment. These properties might prove useful in a postoperative or intensive care unit setting. IMPLICATIPNS: The alpha(2) agonist, dexmedetomidine, has sedation and analgesic properties. This study quantified these effects, as well as cardiorespiratory, memory and psychomotor effects, in healthy volunteers. Dexmedetomidine infusions resulted in reversible sedation, mild analgesia, and memory impairment without cardiorespiratory compromise.
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            Clinical uses of alpha2 -adrenergic agonists.

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              Postoperative pharmacokinetics and sympatholytic effects of dexmedetomidine.

              Dexmedetomidine is a selective alpha2-adrenoceptor agonist with centrally mediated sympatholytic, sedative, and analgesic effects. This study evaluated: 1) pharmacokinetics of dexmedetomidine in plasma and cerebrospinal fluid (CSF) in surgical patients; 2) precision of a computer-controlled infusion protocol (CCIP) for dexmedetomidine during the immediate postoperative period; and 3) dexmedetomidine's sympatholytic effects during that period. Dexmedetomidine was infused postoperatively by CCIP for 60 min to eight women, targeting a plasma concentration (Cp) of 600 pg/mL. Before, during, and after infusion, blood was sampled to determine plasma concentrations of norepinephrine, epinephrine, and dexmedetomidine, and CSF was sampled to determine dexmedetomidine concentrations (C[CSF]). Heart rate and arterial blood pressure were measured continuously from 5 min before until 3 h after the end of infusion. During the infusion, Cp values generally exceeded the target value: median percent error averaged 21% and ranged from -2% to 74%; median absolute percent error averaged 23% and ranged from 4% to 74%. After infusion, C(CSF) was 4% +/- 1% of Cp. Because C(CSF) barely exceeded the assay's limit of quantitation, CSF pharmacokinetics were not determined. During the infusion, norepinephrine decreased from 2.1 +/- 0.8 to 0.7 +/- 0.3 nmol/L; epinephrine decreased from 0.7 +/- 0.5 to 0.2 +/- 0.2 nmol/L; heart rate decreased from 76 +/- 15 to 64 +/- 11 bpm; and systolic blood pressure decreased from 158 +/- 23 to 140 +/- 23 mm Hg. We conclude that infusion of dexmedetomidine by CCIP using published pharmacokinetic parameters overshoots target dexmedetomidine concentrations during the early postoperative period. Hemodynamic and catecholamine results suggest that dexmedetomidine attenuates sympathetic activity during the immediate postoperative period. We studied the pharmacokinetic and sympatholytic effects of dexmedetomidine during the immediate postoperative period and found that during this period, the published pharmacokinetic data slightly overshoot target plasma dexmedetomidine concentrations. We also found that heart rate, blood pressure, and plasma catecholamine concentrations decrease during dexmedetomidine infusion.
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                Author and article information

                Journal
                Ann Card Anaesth
                Ann Card Anaesth
                ACA
                Annals of Cardiac Anaesthesia
                Medknow Publications & Media Pvt Ltd (India )
                0971-9784
                0974-5181
                Oct-Dec 2016
                : 19
                : 4
                : 614-620
                Affiliations
                [1]Department of Anesthesia and Surgical ICU, Faculty of Medicine, Tanta University, Tanta, Egypt
                [1 ]Department of Pediatrics, Tanta University Hospital, Tanta, Egypt
                [2 ]Department of Cardiothoracic Surgery, Tanta University Hospital, Tanta, Egypt
                Author notes
                Address for correspondence: Dr. Nagat S. El-Shmaa, Department of Anesthesia and Surgical ICU, Faculty of Medicine, Tanta University, Tanta, Egypt. E-mail: nagat_elshmaa@ 123456yahoo.com
                Article
                ACA-19-614
                10.4103/0971-9784.191564
                5070320
                27716691
                d2615bf3-87f7-493b-9440-533ba56d4a65
                Copyright: © 2016 Annals of Cardiac Anaesthesia

                This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

                Categories
                Original Article

                amiodarone,children,dexmedetomidine,junctional ectopic tachycardia,postoperative arrhythmia

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