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Table of Contents
EDITORIAL
Year : 2016  |  Volume : 32  |  Issue : 2  |  Page : 144-145

Dexmedetomidine: The game changer or a team player?


Department of Anesthesia and Critical Care, Army Hospital (R and R), New Delhi, India

Date of Web Publication10-May-2016

Correspondence Address:
Rakhee Goyal
Department of Anesthesia and Critical Care, Army Hospital (R and R), New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9185.182084

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How to cite this article:
Goyal R. Dexmedetomidine: The game changer or a team player?. J Anaesthesiol Clin Pharmacol 2016;32:144-5

How to cite this URL:
Goyal R. Dexmedetomidine: The game changer or a team player?. J Anaesthesiol Clin Pharmacol [serial online] 2016 [cited 2021 May 7];32:144-5. Available from: https://www.joacp.org/text.asp?2016/32/2/144/182084

They say "Be a game changer, the world has enough followers." A few decades back, an alpha agonist named dexmedetomidine (DEX) was introduced, and the US Food and Drug Administration gave its approval as sedative for mechanically ventilated adults in intensive care units in 1999. In 2008, the approval was extended for procedures outside the operating room in nonintubated adults. This was soon followed by a plethora of off-label uses. [1],[2] An editorial published in this journal about 5 years back, exhaustively reviewed the emerging role of DEX. [3]

In the initial years of clinical use, there were apprehensions regarding the hypotension and bradycardia (hypertension initially or with use of larger doses). Over the years, it was realized that most side effects are dose-dependent and occur in volume-depleted patients. As further studies poured in and the literature built up its strength, so did the confidence of the users. The time has come where DEX has become an essential, if not an inescapable part of routine anesthesia drug trolley. DEX is conventionally administered as an infusion, but reports of its safe and convenient use as rapid boluses have also started being published. [4] This would make its use less cumbersome in routine practice.

In recent years, the drug has been either used as part of premedication in oral/nasal/buccal/nebulized/intravenous form or as an adjunct to induction to attenuate the stress of laryngoscopy and intubation. [5] It has also been an adjunct for maintenance of anesthesia and part of the reversal process (to facilitate smooth extubation and reduce emergence agitation). [6],[7],[8] Several researchers have used DEX for inducing controlled hypotension during ENT surgeries. [9],[10] The anti-shivering and antisialagogue properties of the drug in the perioperative period have also been studied. DEX has been effectively used in difficult airway during awake fiberoptic intubation, especially in patients who pose a life-threatening risk of intubation under general anesthesia. [11] There are several reports of its use in awake craniotomy, spine surgeries, and deep brain stimulator placement, in adults and children. [12],[13],[14]

As an adjuvant, DEX is known to improve the quality and duration of spinal, epidural, and caudal anesthesia. [15] Likewise, the drug has shown improved block characteristics, sedation, and hemodynamic stability in several peripheral nerve blocks. [16] Today, based on the animal studies, DEX has been found to be neuroprotective and, therefore, can be probably given to the children safely. [17]

On the other hand, in spite of its multifarious usability as when used alone DEX can neither be a sole induction agent nor it can maintain the depth of anesthesia or achieve regional anesthesia alone. The dosages required for procedural sedation at deeper levels may hamper hemodynamic stability. [18] It has most of the properties of an ideal anesthetic agent, but its sole use is inadequate for most indications. DEX at best is not a game changer; it is a team player, a good adjuvant that we need at almost every step in the field of anesthesia and critical care. It is a very useful drug, but its sole use for any indication should be discouraged. It is a drug you could do without, and yet it is a drug you could do better with.

A different avatar of DEX, as a combination with ketamine, has appealed to me for very long. Its usability for procedural sedation has been explored in a large number of clinical scenarios such as gastrointestinal endoscopic procedures, cardiac catheterization, burns dressing, awake fiberoptic intubation, extracorporeal shockwave lithotripsy, muscle biopsy, and cataract surgery. [19],[20],[21]

Some of the favorable properties of these two drugs are complementary, whereas some side effects counterbalance each other. The effect of sedation and analgesia is additive in its time of onset and quality. Both the drugs preserve spontaneous breathing as well as the airway reflexes in routine doses. On the other hand, the cardiovascular stimulatory effects of ketamine balance the hypotension and bradycardia that may occur because of DEX. DEX also helps in attenuating ketamine-induced salivation and emergence complications. The recovery profile of this drug combination following procedural sedation is good. Further studies would determine whether this combination could be safely used for daycare procedures.

This issue of the journal deals with some of the studies and reports on the use of DEX in its diverse role as an adjuvant in our routine anesthesia practice. One study shows the effect of DEX premedication in lowering intraocular pressure and the pressor response to laryngoscopy and intubation. In another study, the authors have compared DEX with nitroglycerine and esmolol for induced hypotension during functional endoscopic sinus surgery. They have showed that DEX group had better hemodynamic stability, operative field visibility, reduced analgesic requirements, and prolonged postoperative sedation. Intravenous DEX was also compared with propofol for sedation during a subarachnoid block, showing early onset and recovery with propofol but better patient satisfaction and prolonged analgesia in the DEX group. DEX was compared with clonidine and tramadol for postoperative shivering. Two studies have used DEX as an adjuvant to bupivacaine, one in intrathecal and the other in epidural space, and found good results.

We hope these studies would give further insight into the subject and impart deeper understanding to the art of using DEX in the most beneficial way.

 
  References Top

1.
Mantz J, Josserand J, Hamada S. Dexmedetomidine: New insights. Eur J Anaesthesiol 2011;28:3-6.  Back to cited text no. 1
    
2.
Mason KP, Lerman J. Review article: Dexmedetomidine in children: Current knowledge and future applications. Anesth Analg 2011;113:1129-42.  Back to cited text no. 2
    
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Grewal A. Dexmedetomidine: New avenues. J Anaesthesiol Clin Pharmacol 2011;27:297-302.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
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Dawes J, Myers D, Görges M, Zhou G, Ansermino JM, Montgomery CJ. Identifying a rapid bolus dose of dexmedetomidine (ED50) with acceptable hemodynamic outcomes in children. Paediatr Anaesth 2014;24:1260-7.  Back to cited text no. 4
    
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Yuen VM, Hui TW, Irwin MG, Yuen MK. A comparison of intranasal dexmedetomidine and oral midazolam for premedication in pediatric anesthesia: A double-blinded randomized controlled trial. Anesth Analg 2008;106:1715-21.  Back to cited text no. 5
    
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Dahmani S, Stany I, Brasher C, Lejeune C, Bruneau B, Wood C, et al. Pharmacological prevention of sevoflurane- and desflurane-related emergence agitation in children: A meta-analysis of published studies. Br J Anaesth 2010;104:216-23.  Back to cited text no. 6
    
7.
Ibacache ME, Muñoz HR, Brandes V, Morales AL. Single-dose dexmedetomidine reduces agitation after sevoflurane anesthesia in children. Anesth Analg 2004;98:60-3.  Back to cited text no. 7
    
8.
Guler G, Akin A, Tosun Z, Ors S, Esmaoglu A, Boyaci A. Single-dose dexmedetomidine reduces agitation and provides smooth extubation after pediatric adenotonsillectomy. Paediatr Anaesth 2005;15:762-6.  Back to cited text no. 8
    
9.
Turan G, Dincer E, Ozgultekin A, Uslu C, Akgun N. Comparison of dexmedetomidine, remifentanyl and esmolol in controlled hypotensive anaesthesia. Eur J Anaesthesiol 2008;25:65-6.  Back to cited text no. 9
    
10.
Shams T, El Bahnasawe NS, Abu-Samra M, El-Masry R. Induced hypotension for functional endoscopic sinus surgery: A comparative study of dexmedetomidine versus esmolol. Saudi J Anaesth 2013;7:175-80.  Back to cited text no. 10
[PUBMED]  Medknow Journal  
11.
Bergese SD, Khabiri B, Roberts WD, Howie MB, McSweeney TD, Gerhardt MA. Dexmedetomidine for conscious sedation in difficult awake fiberoptic intubation cases. J Clin Anesth 2007;19:141-4.  Back to cited text no. 11
    
12.
Souter MJ, Rozet I, Ojemann JG, Souter KJ, Holmes MD, Lee L, et al. Dexmedetomidine sedation during awake craniotomy for seizure resection: Effects on electrocorticography. J Neurosurg Anesthesiol 2007;19:38-44.  Back to cited text no. 12
    
13.
Mahmoud M, Sadhasivam S, Sestokas AK, Samuels P, McAuliffe J. Loss of transcranial electric motor evoked potentials during pediatric spine surgery with dexmedetomidine. Anesthesiology 2007;106:393-6.  Back to cited text no. 13
    
14.
Maurtua MA, Cata JP, Martirena M, Deogaonkar M, Rezai A, Sung W, et al. Dexmedetomidine for deep brain stimulator placement in a child with primary generalized dystonia: Case report and literature review. J Clin Anesth 2009;21:213-6.  Back to cited text no. 14
    
15.
Tong Y, Ren H, Ding X, Jin S, Chen Z, Li Q. Analgesic effect and adverse events of dexmedetomidine as additive for pediatric caudal anesthesia: A meta-analysis. Paediatr Anaesth 2014;24:1224-30.  Back to cited text no. 15
    
16.
Esmaoglu A, Yegenoglu F, Akin A, Turk CY. Dexmedetomidine added to levobupivacaine prolongs axillary brachial plexus block. Anesth Analg 2010;111:1548-51.  Back to cited text no. 16
    
17.
Sanders RD, Sun P, Patel S, Li M, Maze M, Ma D. Dexmedetomidine provides cortical neuroprotection: Impact on anaesthetic-induced neuroapoptosis in the rat developing brain. Acta Anaesthesiol Scand 2010;54:710-6.  Back to cited text no. 17
    
18.
Jalowiecki P, Rudner R, Gonciarz M, Kawecki P, Petelenz M, Dziurdzik P. Sole use of dexmedetomidine has limited utility for conscious sedation during outpatient colonoscopy. Anesthesiology 2005;103:269-73.  Back to cited text no. 18
    
19.
Tobias JD. Dexmedetomidine and ketamine: An effective alternative for procedural sedation? Pediatr Crit Care Med 2012;13:423-7.  Back to cited text no. 19
    
20.
Goyal R, Singh S, Bangi A, Singh SK. Case series: Dexmedetomidine and ketamine for anesthesia in patients with uncorrected congenital cyanotic heart disease presenting for non-cardiac surgery. J Anaesthesiol Clin Pharmacol 2013; 29:543-6.  Back to cited text no. 20
[PUBMED]  Medknow Journal  
21.
Goyal R, Singh S, Shukla RN, Patra AK, Bhargava DV. Ketodex, a combination of dexmedetomidine and ketamine for upper gastrointestinal endoscopy in children: A preliminary report. J Anesth 2013;27:461-3.  Back to cited text no. 21
[PUBMED]    



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