Safe Sedation and Hypnosis using Dexmedetomidine for Minimally Invasive Spine Surgery in a Prone Position
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Dexmedetomidine, an imidazoline compound, is a highly selective α2-adrenoceptor agonist with sympatholytic, sedative, amnestic, and analgesic properties. In order to minimize the patients’ pain and anxiety during minimally invasive spine surgery (MISS) when compared to conventional surgery under general anesthesia, an adequate conscious sedation (CS) or monitored anesthetic care (MAC) should be provided. Commonly used intravenous sedatives and hypnotics, such as midazolam and propofol, are not suitable for operations in a prone position due to undesired respiratory depression. Dexmedetomidine converges on an endogenous non-rapid eye movement (NREM) sleep-promoting pathway to exert its sedative effects. The great merit of dexmedetomidine for CS or MAC is the ability of the operator to recognize nerve damage during percutaneous endoscopic lumbar discectomy, a representative MISS. However, there are 2 shortcomings for dexmedetomidine in MISS: hypo-tension/bradycardia and delayed emergence. Its hypotension/bradycardiac effects can be prevented by ketamine intraoperatively. Using atipamezole (an α2-adrenoceptor antagonist) might allow doctors to control the rate of recovery from procedural sedation in the future. MAC, with other analgesics such as ketorolac and opioids, creates ideal conditions for MISS. In conclusion, dexmedetomidine provides a favorable surgical condition in patients receiving MISS in a prone position due to its unique properties of conscious sedation followed by unconscious hypnosis with analgesia. However, no respiratory depression occurs based on the dexmedeto-midine-related endogenous sleep pathways involves the inhibition of the locus coeruleus in the pons, which facilitates VLPO firing in the anterior hypothalamus.
Abstract
Dexmedetomidine, an imidazoline compound, is a highly selective α2-adrenoceptor agonist with sympatholytic, sedative, amnestic, and analgesic properties. In order to minimize the patients’ pain and anxiety during minimally invasive spine surgery (MISS) when compared to conventional surgery under general anesthesia, an adequate conscious sedation (CS) or monitored anesthetic care (MAC) should be provided. Commonly used intravenous sedatives and hypnotics, such as midazolam and propofol, are not suitable for operations in a prone position due to undesired respiratory depression. Dexmedetomidine converges on an endogenous non-rapid eye movement (NREM) sleep-promoting pathway to exert its sedative effects. The great merit of dexmedetomidine for CS or MAC is the ability of the operator to recognize nerve damage during percutaneous endoscopic lumbar discectomy, a representative MISS. However, there are 2 shortcomings for dexmedetomidine in MISS: hypo-tension/bradycardia and delayed emergence. Its hypotension/bradycardiac effects can be prevented by ketamine intraoperatively. Using atipamezole (an α2-adrenoceptor antagonist) might allow doctors to control the rate of recovery from procedural sedation in the future. MAC, with other analgesics such as ketorolac and opioids, creates ideal conditions for MISS. In conclusion, dexmedetomidine provides a favorable surgical condition in patients receiving MISS in a prone position due to its unique properties of conscious sedation followed by unconscious hypnosis with analgesia. However, no respiratory depression occurs based on the dexmedeto-midine-related endogenous sleep pathways involves the inhibition of the locus coeruleus in the pons, which facilitates VLPO firing in the anterior hypothalamus.
참고문헌 (30)
- Newman-Tancredi A, "Actions of alpha2 adrenoceptor ligands at alpha2A and 5-HT1A receptors: the antagonist, atipamezole, and the agonist, dexmedetomidine, are highly selective for alpha2A adrenoceptors", Naunyn Schmiedebergs Arch Pharmacol, 358, pp.197~206 (1998)
- Gertler R, "Dexmedetomidine : a novel sedative-analgesic agent", Proc (Bayl Univ Med Cent), 14, pp.13~21 (2001)
- Chrysostomou C, "Dexmedetomidine: sedation, analgesia and beyond", Expert Opin Drug Metab Toxicol, 4, pp.619~627 (2008)
- Bylund DB, "International Union of Pharmacology nomenclature of adrenoceptors", Pharmacol Rev, 46, pp.121~136 (1994)
- Insel PA, "Seminars in medicine of the Beth Israel Hospital, Boston. Adrenergic receptors--evolving concepts and clinical implications", N Engl J Med, 334, pp.580~585 (1996)
- Haselman MA, "Dexmedetomidine: a useful adjunct to consider in some high-risk situations", AANA J, 76, pp.335~339 (2008)
- Correa-Sales C, "A hypnotic response to dexmedetomidine, an alpha 2 agonist, is mediated in the locus coeruleus in rats", Anesthesiology, 76, pp.948~952 (1992)
- Nelson LE, "The alpha2-adrenoceptor agonist dexmedetomidine converges on an endogenous sleep-promoting pathway to exert its sedative effects", Anesthesiology, 98, pp.428~436 (2003)
- Nelson LE, "The sedative component of anesthesia is mediated by GABA(A)receptors in an endogenous sleep pathway", Nat Neurosci, 5, pp.979~984 (2002)
- Saper CB, "Hypothalamic regulation of sleep and circadian rhythms", Nature, 437, pp.1257~1263 (2005)
- Huupponen E, "Electroencephalogram spindle activity during dexmedetomidine sedation and physiological sleep", Acta Anaesthesiol Scand, 52, pp.289~294 (2008)
- Khan ZP, "alpha-2 and imidazoline receptor agonists. Their pharmacology and therapeutic role", Anaesthesia, 54, pp.146~165 (1999)
- Hsu YW, "Dexmedetomidine pharmacodynamics : part I : crossover comparison of the respiratory effects of dexmedetomidine and remifentanil in healthy volunteers", Anesthesiology, 101, pp.1066~1076 (2004)
- Guo TZ, "Dexmedetomidine injection into the locus ceruleus produces antinociception", Anesthesiology, 84, pp.873~881 (1996)
- Li SS, "Involvement of spinal microglia and interleukin-18 in the anti-nociceptive effect of dexmedetomidine in rats subjected to CCI", Neurosci Lett, 560, pp.21~25 (2014)
- Funai Y, "Systemic dexmedetomidine augments inhibitory synaptic transmission in the superficial dorsal horn through activation of descending noradrenergic control: an in vivo patch-clamp analysis of analgesic mechanisms", Pain, 155, pp.617~628 (2014)
- Fan QQ, "Activation of α2 adrenoceptors inhibited NMDA receptor-mediated nociceptive transmission in spinal dorsal horn of mice with inflammatory pain", Neuropharmacology, 77, pp.185~192 (2014)
- Seyrek M, "Interaction between dexmedetomidine and α-adrenergic receptors : emphasis on vascular actions", J Cardiothorac Vasc Anesth, 25, pp.856~862 (2011)
- Bloor BC, "Effects of intravenous dexmedetomidine in humans. II. Hemodynamic changes", nesthesiology, 77, pp.1134~1142 (1992)
- Sulaiman S, "The effects of dexmedetomidine on attenuation of stress response to endotracheal intubation in patients undergoing elective off-pump coronary artery bypass grafting", Ann Card Anaesth, 15, pp.39~43 (2012)
- Kallio A, "Effects of dexmedetomidine, a selective alpha 2-adrenoceptor agonist, on hemodynamic control mechanisms", Clin Pharmacol Ther, 46, pp.33~42 (1989)
- Shukry M, "Update on dexmedetomidine : use in nonintubated patients requiring sedation for surgical procedures", Ther Clin Risk Manag, 6, pp.111~121 (2010)
- Carollo DS, "Dexmedetomidine : a review of clinical applications", Curr Opin Anaesthesiol, 21, pp.457~461 (2008)
- Gerlach AT, "Dexmedetomidine : an updated review", Ann Pharmacother, 41, pp.245~252 (2007)
- Tobias JD, "Dexmedetomidine and ketamine: an effective alternative for procedural sedation?", Pediatr Crit Care Med, 13, pp.423~427 (2012)
- Pomarol-Clotet E, "Psychological effects of ketamine in healthy volunteers. Phenomenological study", Br J Psychiatry, 189, pp.173~179 (2006)
- 김경훈, "Use of Lidocaine Patch for Percutaneous Endoscopic Lumbar Discectomy", The Korean Journal of Pain, 24(2), pp.74~80 (2011), 대한통증학회
- Triltsch AE, "Bispectral index-guided sedation with dexmedetomidine in intensive care: a prospective, randomized, double blind, placebo-controlled phase II study", Crit Care Med, 30, pp.1007~1014 (2002)
- Johansen JW, "Update on bispectral index monitoring", Best Pract Res Clin Anaesthesiol, 20, pp.81~99 (2006)
- Kasuya Y, "The correlation between bispectral index and observational sedation scale in volunteers sedated with dexmedetomidine and propofol", Anesth Analg, 109, pp.1811~1815 (2009)