Anesthesia & Gestosis 2004

8/8/2019 Anesthesia & Gestosis 2004

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The Study Of DexmedetomidineThe Study Of Dexmedetomidine

Versus Morphine For Pain AndVersus Morphine For Pain And

Blood Pressure Control AfterBlood Pressure Control AfterCesarean Section ForCesarean Section For

E.P.H. Gestotic PatientsE.P.H. Gestotic Patients


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Reem H. El-Kabarity, MDDepartment of Anesthesia.

Abdelmegeed I. Abdelmegeed, MD

Department of Ob/Gyn.

Ain Shams University,

Cairo, Egypt.


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Introduction:Introduction:

EPHEPH--Gestosis is a high riskGestosis is a high riskpregnancy condition. It is characterisedpregnancy condition. It is characterised

by Edema (abnormal body gain ofby Edema (abnormal body gain ofweight water retention), and/orweight water retention), and/orProteinuria (excretion of pathologicalProteinuria (excretion of pathologicalamounts of urinary proteins) and/oramounts of urinary proteins) and/orHypertension (elevated systolic andHypertension (elevated systolic anddiastolic blood pressure).diastolic blood pressure).


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3210

>180160-179140-159Less

than 140Systolic BP

(mmHg)

>110100-10990-99Less

than 90

Diastolic BP

(mmHg)

GeneralizedLegs

abdomen

Legs

edema

Occult

or legEdema

> 1 gm/litre

+++

> 0.5-1 gm/L

++

0.5 gm/L

+

Nil or

traceProteinuria

EL-Kabarity Modified Gestosis Index


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The current protocol of management of EPH-

Gestosis has the following principles:

11-- Team approachTeam approach..

22-- Obstetric intensive care management.Obstetric intensive care management.

33-- MgSoMgSo44 administration.administration.

44-- Control of hypertension.Control of hypertension.

55-- Termination of pregnancy after stabilizationTermination of pregnancy after stabilization

sof general condition.sof general condition.

66-- Control of pain to avoid emergence ofControl of pain to avoid emergence of

patient into convulsive fits.patient into convulsive fits.


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SelectiveSelective 2 adrenoreceptor agonist.2 adrenoreceptor agonist.

Half life 2.3hours.Half life 2.3hours.

DMED isDMED is Central and peripheral sympatholyticCentral and peripheral sympatholyticeffecteffect inhibit N.E. release.inhibit N.E. release.

Stimulates 2 adrenoceptorStimulates 2 adrenoceptor

spinal cordspinal cord in locus ceruleusin locus ceruleus

analgesia.analgesia. sedation.sedation.


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ObjectivesObjectives

Comparison betweenComparison between

dexmedetomidine anddexmedetomidine and

morphine for pain control andmorphine for pain control and

decrease of blood pressuredecrease of blood pressure

for EPHfor EPH--Gestotic patientsGestotic patientsafter C.S.after C.S.


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Patients and MethodsPatients and Methods

42 parturient ladies with severe EPH42 parturient ladies with severe EPH

Gestosis, antepartum and intrapartumGestosis, antepartum and intrapartumeclampsia delivered by C.S.eclampsia delivered by C.S.

MgSo4 (4 gm slowly iv as a loadingMgSo4 (4 gm slowly iv as a loading

dose then I gm/2hrs for24 hrs).dose then I gm/2hrs for24 hrs). They were randomized equally into twoThey were randomized equally into two

groups.groups.


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Group (I):Group (I): ReceivedReceived dexmedetomidinedexmedetomidine 11 g/kgg/kgoverover1010 minutes (loading) followed byminutes (loading) followed by 00..44

g/kg/hr forg/kg/hr for22 hours (maintenance) in the posthours (maintenance) in the post--anesthesia care unit (PACU).anesthesia care unit (PACU).

Group (II):Group (II): Received single bolus ofReceived single bolus ofmorphinemorphine

sulphatesulphate 00..0808 mg/kg.mg/kg. Both drugs were started intravenouslyBoth drugs were started intravenously 1010minutes before endof surgery.minutes before endof surgery.

Over two hours postoperatively in the PACU,Over two hours postoperatively in the PACU,the followingdata were registeredeverythe followingdata were registeredevery 1010minutes: HR,MAP,RR,Level of sedation andminutes: HR,MAP,RR,Level of sedation andanalgesia using the Visual Analogue Scoreanalgesia using the Visual Analogue Score

(VAS).(VAS).


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Exclusion CriteriaExclusion Criteria

History of psychiatric disorder on psychotropic medication.History of psychiatric disorder on psychotropic medication.

Organ failure Renal FailureOrgan failure Renal Failure

Hepatic FailureHepatic Failure

Respiratory FailureRespiratory Failure

Patients receiving Dexmedetomidine itself or other alpha 2Patients receiving Dexmedetomidine itself or other alpha 2

agonists as clonidine.agonists as clonidine.

Severe degrees of heart block as it causes bradycardia.Severe degrees of heart block as it causes bradycardia.


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Technique of AnaesthesiaTechnique of Anaesthesia

Calcuim channel blockers (10mg sublinguial).Calcuim channel blockers (10mg sublinguial).

MgSo4.MgSo4.

Continuous monitoring (ECG, NIBP,O2Continuous monitoring (ECG, NIBP,O

2saturation).saturation).

11--2mg/kg lidocaine before intubation.2mg/kg lidocaine before intubation.

5mg/kg soduim thiopental then succinyl choline5mg/kg soduim thiopental then succinyl choline

1mg/kg for intubation.1mg/kg for intubation.


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Post Anaesthetic Care Unit (PACU)Post Anaesthetic Care Unit (PACU)

OverOver22 hours postoperatively everyhours postoperatively every 1010 mins.mins.

The followingdata were registered:The followingdata were registered: HR, MAP,RRHR, MAP,RR

Addition of morphine doses.Addition of morphine doses.

Assessment of level of sedation andAssessment of level of sedation andanalgesia using Visual Analog Score (VAS).analgesia using Visual Analog Score (VAS).


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Demographicdata showedno statistically significantDemographicdata showedno statistically significantdifferencedifference (P>(P>00..0505).).

Group (I):

DMED

Group (II):

MorphineP Significance

Age (years)24.4

1.2 2

6.10

.8 > 0

.05 NS

Parity 0.91.3 0.81.1 > 0.05 NS

Gestational age at time

of T.O.P. (weeks) 35.32.3 34.21.8 > 0.05 NS

Body Mass Index

(kg/m2)28.01.3 27.41.9 > 0.05 NS


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Comparing bothgroupsComparing bothgroups as regards theas regards theintraoperative dataandthe hemodynamicvaluesintraoperative dataandthe hemodynamicvaluesbefore givingthe drug shows no statisticallybefore givingthe drug shows no statistically

significantdifferencesignificantdifferenceGroup (I)

DMED

Group (II)

MorphineP Significance

Operative time (min) 43.36.7 49.25.9 > 0.05 NS

End-tidal halothane (%) 0.60.3 0.70.2 > 0.05 NS

Crystalloids (ml) 1023257 1131303 > 0.05 NS

Estimated blood loss

(ml) 62690 709

104 > 0.05 NS

Heart rate (bpm) 8014 8518 > 0.05 NS

MAP (mmHg) 1018 1057 > 0.05 NS


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Heart rate (beats/min) values overHeart rate (beats/min) values over 1010 min aftermin afterinjection of the study drugs showed statisticalinjection of the study drugs showed statisticalsignificant difference(P


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MAP (mmHg) values overMAP (mmHg) values over 1010 min after injection showedmin after injection showedstatistical significant difference showed statisticalstatistical significant difference showed statistical

significant difference( P


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Heart rate (beats/min) value of the studied drugs inHeart rate (beats/min) value of the studied drugs inthe PACU showed statistical significant differencethe PACU showed statistical significant difference

( P


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MAP (mmHg) values of the studied drugsMAP (mmHg) values of the studied drugs showedshowedstatistical significant differencestatistical significant difference in the PACUin the PACU

( P


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Respiratory rate (breath/min) values of theRespiratory rate (breath/min) values of thestudied drugs in PACU showed no statisticalstudied drugs in PACU showed no statistical

difference ( P >difference ( P > 00..0505) .) .

0

5

10

15

20

0 30 60 90 120

DMED

Mor i


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Oxygen saturation (%) values of the studiedOxygen saturation (%) values of the studieddrugs in PACU showed no statistical differencedrugs in PACU showed no statistical difference

(P >(P > 00..0505):):

94

95

96

97

98

99

100

030

60

90

120

Ti ( i )

2

t

r

tion

(

)

DM ED

M or ine


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Cumulative added doses of morphine (mg) forCumulative added doses of morphine (mg) forcontrol of pain in the PACU was statisticallycontrol of pain in the PACU was statistically

significant in the morphine group.significant in the morphine group.

0

2

4

6

8

10

0 30 60 90 120

Time (min)

Dose

DMED

Morphine


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The mean total dose/patient of morphine (mg)The mean total dose/patient of morphine (mg)overover 22 hours period in the PACU washours period in the PACU was

statistically significant in the morphine group.statistically significant in the morphine group.

0

2

4

6

8

10

DMED Group Morphine Group

Dose


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The mean total dose/patient of morphine additions (mg)The mean total dose/patient of morphine additions (mg)in ward throughin ward through 22--1212 hours postoperatively washours postoperatively was

statistically significant in the morphine group.statistically significant in the morphine group.


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Discussion:Discussion:

EE22--receptors regulate the autonomic andreceptors regulate the autonomic andcardiovascular system.cardiovascular system.

They are located in locus ceruleus and dorsal hornThey are located in locus ceruleus and dorsal horn

of spinal cord leading to sedation and analgesia.of spinal cord leading to sedation and analgesia. Lawerence andDe Lange (Lawerence andDe Lange (19971997)) reported areported a

biphasic effect on hemodynamic after IV DMED.biphasic effect on hemodynamic after IV DMED.

Venn andGround(Venn andGround(20012001)) found that DMED is safefound that DMED is safe

and acceptable sedative agent in ICU patient forand acceptable sedative agent in ICU patient forsedation.sedation.

Aho andhis collegues(Aho andhis collegues(19911991)) concluded thatconcluded thatDMED relieves pain and opioid drug request afterDMED relieves pain and opioid drug request afterlaparoscopic tubal ligation.laparoscopic tubal ligation.


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Bhana andhis collegues (2000)Bhana andhis collegues (2000) showedshowed

sedative, analgesic and anxiolytic effectssedative, analgesic and anxiolytic effects

after IV DMED in post surgical patients inafter IV DMED in post surgical patients inICU.ICU.

Coursin andhis collegues (2001)Coursin andhis collegues (2001) foundfound

DMED stimulatesDMED stimulates EE22 receptors in locusreceptors in locuscerulus in spinal cord to provide sedationcerulus in spinal cord to provide sedation

and enhance analgesia.and enhance analgesia.

Arain and

Ebert (2002)Arain and

Ebert (2002) found also thatfound also thatadministration of DMED versus propofoladministration of DMED versus propofol

showed more sedation, lower MAP,showed more sedation, lower MAP,

improved analgesia in the recovery room.improved analgesia in the recovery room.


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In our study, we found that parturients receivingIn our study, we found that parturients receivingdexmedetomidine for postoperative Cesarean Sectiondexmedetomidine for postoperative Cesarean Section

pain and blood pressure control for EPHpain and blood pressure control for EPH--Gestosis hadGestosis had

significantly slower postoperative HR, decrease insignificantly slower postoperative HR, decrease in

MAP without intial increase.MAP without intial increase.

This may be due to small dose infused,This may be due to small dose infused,

increased duration of infusion and the ability of volatileincreased duration of infusion and the ability of volatile

anesthetics directly to relax vascular smooth muscles.anesthetics directly to relax vascular smooth muscles.Hence they required less morphine in the PACUHence they required less morphine in the PACU

compared with the control group who received onlycompared with the control group who received only

morphine.morphine.

SummarySummary


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ConclusionConclusion

The use of dexmedetomidine as a postoperativeC.S. analgesic resulted in significantly lessaddition of pain-relief medications, slower HR as

well as lower MAP than the other group thatreceived only morphine. These results may provethat dexmedetomidine is more advantageous andbeneficial for gestotic patients; who might be

jeopardized by the higher risk of postoperativepain, hypertension, tachycardia, respiratorydepression as well as the need of using larger doses of morphine.


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Anesthesia & Gestosis 2004