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    -  Syeda S
    -  Palaniswamy SR
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LETTER TO EDITOR
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Dexmedetomidine as a Primary Systemic Analgesic for Craniotomy in an Obese Patient with Obstructive Sleep Apnea


 Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India

Correspondence Address:
Kamath Sriganesh,
Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru - 560 029, Karnataka
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.280650

PMID: 32189711




How to cite this URL:
Syeda S, Palaniswamy SR, Sriganesh K. Dexmedetomidine as a Primary Systemic Analgesic for Craniotomy in an Obese Patient with Obstructive Sleep Apnea. Neurol India [Epub ahead of print] [cited 2020 Apr 4]. Available from: http://www.neurologyindia.com/preprintarticle.asp?id=280650




To the Editor,

Opioids are routinely used during neurosurgery to alleviate perioperative pain. With awareness about problems of liberal opioid use, alternative analgesic techniques are increasingly adopted. We describe dexmedetomidine analgesia with scalp-block for brain tumor surgery in an obese patient with obstructive sleep apnea (OSA).

A 40-year-old gentleman with right frontoparietal glioma was scheduled for craniotomy. He was obese with body mass index of 32.87 kg/m 2 and was categorized as high risk for OSA with score of 4/8 (snoring, fatigue, neck circumference >40 cm and male gender) on STOP-BANG questionnaire. Anesthesia was induced with thiopentone 5 mg/kg. Fentanyl 1 μg/kg, lidocard 1.5 mg/kg, and vecuronium 0.15 mg/kg were used to blunt hemodynamic response and facilitate intubation. Anesthesia was maintained with O2/air/isoflurane and anesthetic depth was titrated to state entropy of 40-60. Scalp-block with 25 ml of 0.25% bupivacaine was performed bilaterally before skull-pin fixation. Dexmedetomidine 0.5 μg/kg/h was used as the primary analgesic from anesthetic induction till skin closure. During the 5-hour surgery, only 50 μg of fentanyl was administered for intraoperative analgesia. At dural closure, patient received paracetamol 1 g, phenytoin 100 mg, and dexamethasone 8 mg. The incision site was infiltrated with 20 ml of 0.25% bupivacaine at the end of surgery. The time for extubation and response to verbal commands after discontinuation of anesthesia was 2 and 5 minutes, respectively. No coughing or hemodynamic activation was observed. There was no postoperative nausea and vomiting (PONV), shivering, sedation, respiratory depression/obstruction or pain (numerical rating scale [NRS] score at 15 and 60 minutes was 0/10). The NRS score remained <4/10 till discharge with diclofenac 150 mg/d.

Perioperative opioids are associated with undesirable side-effects such as respiratory depression, prolonged sedation, PONV, itching, ileus, urinary retention, hyperalgesia, and immune suppression which contribute to morbidity, costs, delayed discharge, and patient discomfort. Alternative analgesic techniques to opioids are therefore used in patients with obesity, OSA, obstructive lung disease, chronic pain, opioid addiction, in bariatric and oncosurgery.[1] Our dexmedetomidine-based analgesia with scalp block and incision-site infiltration minimized opioid requirement and provided good perioperative pain-relief. Dexmedetomidine-based technique provides better pain-relief and fewer complications than fentanyl-based analgesia for spine surgeries.[2] Meta-analysis involving 674 neurosurgical patients showed reduced opioid consumption and pain intensity with intraoperative dexmedetomidine.[3] Recently, dexmedetomidine was shown to be noninferior to fentanyl for craniotomy.[4]

To conclude, we report successful use of dexmedetomidine-based minimal opioid analgesia technique for intracranial surgery in an obese patient with OSA. Multimodal analgesia approach was found to be opioid-sparing and had favorable effect on respiratory outcome. Stable hemodynamics, good perioperative analgesia without the opioid-related complications were other important advantages.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sultana A, Torres D, Schumann R. Special indications for opioid free anaesthesia and analgesia, patient and procedure related: Including obesity, sleep apnoea, chronic obstructive pulmonary disease, complex regional pain syndromes, opioid addiction and cancer surgery. Best Pract Res Clin Anaesthesiol 2017;31:547-60.  Back to cited text no. 1
    
2.
Turgut N, Turkmen A, Gökkaya S, Altan A, Hatiboglu MA. Dexmedetomidine based versus fentanyl-based total intravenous anesthesia for lumbar laminectomy. Minerva Anestesiol 2008;74:469-74.  Back to cited text no. 2
    
3.
Liu Y, Liang F, Liu X, Shao X, Jiang N, Gan X. Dexmedetomidine reduces perioperative opioid consumption and postoperative pain intensity in neurosurgery: A meta-analysis. J Neurosurg Anesthesiol 2018;30:146-55.  Back to cited text no. 3
    
4.
Sriganesh K, Syeda S, Shanthanna H, Venkataramaiah S, Palaniswamy SR. Comparison of intraoperative fentanyl with dexmedetomidine for perioperative analgesia and opioid consumption during craniotomies: A randomised controlled pilot study with non-inferiority design. Int J Clin Pract 2019;73:e13338.  Back to cited text no. 4
    




 

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