Effect Of Dexmedetomidine Preoperative Nasal Spray On The Quality Of The Recovery Period And Intraoperative Hemodynamics With Ketamine Anesthesia In Operation Of Children

Background and ObjectivesKetamine is a quick-acting anaesthetic derivative of phencyclidine, which iseasily administered and has widely been applied to anesthesia or combined anesthesia,especially in fields of pediatric anesthesia. Its unique dissociative anesthesia raises therate of postoperative agitation, and sympathetic activation increases blood pressure,intracranial pressure and intra-ocular pressure. Now it has become a clinical researchfocus how to reduce and control the toxic and side effects of ketamine.Dexmedetomidine is a clinically applied, high-efficacy, high-selectivity and specificalpha-2adrenergic agonists, and has dose-dependent sedative, antalgic, anxiolytic andanti-sympathetic activity and non-inhibiting effect on respiratory center. It can beadministered to produce conscious sedation of ICU patients and its antalgic andanti-sympathetic activity can maintain hemodynamic stability[2]. Combination ofdexmedetomidine and ketamine has pharmacological significance, enhances sedativeeffect and exerts slight effect on respiratory and cardiovascular function; and canprevent adverse effect on each other. For example, dexmedetomidine can preventtachycardia, hypertension, intraoperative awareness and postoperative agitation whileketamine can prevent bradycardia and hypotension and maintain hemodynamicstability. It has been studied that nose-sprayed dexmedetomidine can be effectively absorbed with the same pharmacodynamics as intravenous administration but causelagged peak of plasma drug concentration by30to40minutes[3]. Despite foreignreports of dexmedetomidine applied to pediatric anesthesia, the applications are notincluded in the specifications. No foreign or domestic report about nose-sprayeddexmedetomidine applied to children has been made so far.30minutes beforeketamine combined general anesthesia, this author nose sprayed different doses ofdexmedetomidine to children undergoing ophthalmologic operations and observedeffect of dexmedetomidine on haemodynamics and quality of recovery period toprovide basis for clinical medication and clinical reference for recovery period ofpediatric general anesthesia.MethodsThis research program has been approved by Ethics Committee of the FirstAffiliated Hospital of Zhengzhou University and all children’s guardians have agreedand signed informed consents.This author selected90cases of ASA Grade I ophthalmologic operations undergeneral anesthesia which were arranged from February2013to July2013at theHospital (the First Affiliated Hospital of Zhengzhou University). The patients wereaged from3to7and weighed from13to30kilograms. Those with the followingconditions were excluded: hepatic and nephritic insufficiency, pulmonary infection,electrocardiographic abnormality before operation, allergy to the researched medicine,emaciation, obesity, blood diseases, metabolic disorders, special medical histories andrecent administration of sedatives or pain killers.The90patients were randomly divided into3groups (Group D1, Group D2andGroup C, n=30) and administered with0.5μg/kg of dexmedetomidine (Group D1),1.0μg/kg of dexmedetomidine (Group D2) and nose-sprayed normal saline (Group C)30minutes before the operation. Patients of Group D1and D2were nose sprayed with1ml of dexmedetomidine (Batch No:11110834, manufactured by Jiangsu Heng RuiMedicine Co., Ltd.) diluted with normal saline and patents of Group C were nosesprayed with normal saline of equal volume. Put patients on their back with headleaning back and make sure the nasal cavity is lower than oropharynx to prevent the solution from going directly into throat which may affect drug absorption. Sprayedthe solution into nostrils on either side in turns. Anesthesia nurses used specialsprayer at anesthesia induction room in accompany with patients’ parents and underelectrocardiograph monitor. The monitoring indicators included: ECG, NIBP, P, SPO2.When necessary (SPO2<95%), applied oxygen mask. After30minutes, the patientswere sent into operating room. Patients who were non-cooperative could beintravenously administered with1.0mg/kg of ketamine before being sent foroperation.Administer0.01mg/kg of atropine and0.1mg/kg of dexamethasone, beforeanesthesia induction; anesthesia induction:2.0mg/kg of ketamine,2.0μg/kg offentanyl,1.5mg／kg of propofol and0.15mg/kg of Cisatracurium; maintenance ofanesthesia: intravenous pumping of propofol (2-8mg.kg-1.h-1) and remifentanil(0.1-0.3μg.kg-1.min-1), and Cisatracurium when necessary. Keep NI level between40and60with Narcotrend.30minutes before the end of operation, administered nomore Cisatracurium. Suspended administration and sucked sputum when theoperation was finished. In case of heart rate drop by30%, administered0.02mg/kg ofatropine or repeatedly if necessary. In case of blood pressure higher or lower by30%than the base level, administered ephedrine or urapidil.Monitored and recorded the patients’ blood pressure (MAP) and heart rate attimes of pre-nose-spray (T0), anesthesia induction (T1), immediate trachea cannula(T2), operation end (T3), immediate tracheal extubation (T4) and5minutes aftertracheal extubation (T5), anesthesia recovery time after the administration wassuspended (time of respiratory recovery, eye opening response, orientation andtracheal extubation). Recorded the dosage of propofol and observed patients’emergence agitation, coughing, nausea, vomiting, shivering and respiratorydepression.Results1. General case: no statistical significance derived from the comparison amonggroups of patients’ gender, age, weight, and operation time (p>0.05).2. Hemodynamics Mean arterial pressure: no statistical significance derived from blood pressurecomparison among groups at the time of T0(P>0.05). At the time of T1, T2, T3, T4andT5, blood pressures of Group C were obviously higher than those of Group D torender the comparison among groups statistically significant (P<0.05); there was nostatistical significance derived from comparison between Group D1and D2(P>0.05).Patients of Group C had increased blood pressure at the time of T2, T4and T5. Bycontrast with T0, comparison inside the group was statistically significant (P<0.05); atthe time of trachea cannula and tracheal extubation, patients of Group D1and D2hadslightly increased blood pressure. By contrast with T0, comparison inside the groupwas statistically insignificant (P>0.05). During operation, no patient showedmalignant hypertension.Heart rate: at the time of T0, heart rate comparison among three groups wasstatistically insignificant (P>0.05). At the time of T1, T2, T3,T4and T5, heart rates ofGroup C patients were obviously higher than those of Group D to render thecomparison among groups statistically significant (P<0.05); comparison amongGroup D1and D2was statistically insignificant (P>0.05). Patients of Group C showedobviously increased heart rate at the time of T2, T4and T5. By contrast with T0,comparison inside the group was statistically significant (P<0.05); at the time oftrachea cannula and tracheal extubation, patients of Group D1and D2showed slightlyincreased heart rate. By contrast with T0, comparison inside the group wasstatistically insignificant (P>0.05). No patient showed bradycardia (HR <60beats/min) or malignant arrhythmia.3. Recovery time: time of respiratory recovery, eye opening response, orientationrecovery and tracheal extubation: patients of Group D took obviously shorter periodsof time than Group C to render the comparison among groups statistically significant(P<0.05); comparison among Group D1and D2was statistically insignificant(P>0.05).4. Dosage of propofol: patients of Group D were given obviously less propofolthan Group C to render the comparison among groups statistically significant(p<0.05); propofol dosage comparison among Group D1and D2was statisticallyinsignificant (P>0.05). 5. Recovery complications: Group D1had3cases of emergence agitation (theoccurrence rate was10%). Group D2had2cases of emergence agitation (theoccurrence rate was6.7%), and Group C had8cases of emergence agitation (theoccurrence rate was26.7%) with an obvious higher rate than Group D to render thecomparison among groups statistically significant (p<0.05); emergence agitationcomparison between Group D1and D2was statistically insignificant (P>0.05).Patients of Group C had obviously higher coughing rating than Group D (p<0.05) torender the comparison among groups statistically significant; coughing ratingcomparison between Group D1and D2was statistically insignificant. During trachealextubation, Group C had4cases with drop in SPO2(SPO2<95%) which wererelieved by oxygen uptake. Group D1and D2patients showed no respiratorydepression (SPO2<95%). Group C had6cases of nausea (the occurrence rate was20%) and3cases of vomiting (the occurrence rate was10%) during trachealextubation; Group D showed no nausea or vomiting to render the comparison amonggroups statistically significant (p<0.05). No patient showed shivering after theoperation.Conclusion1. Nose spray0.5μg/kg and1.0μg/kg of dexmedetomidine30minutes beforethe operation to patients with ketamine combined general anesthesia to maintainhemodynamic stability during operation and recovery period, shorten recovery time,reduce complications such as emergence agitation and coughing, and improve thequality of anesthesia recovery in a safe manner;2. Comparison between dexmedetomidine effects of0.5μg/kg and1.0μg/kgwas statistically insignificant.