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LETTERS TO EDITOR
Year : 2019  |  Volume : 20  |  Issue : 1  |  Page : 46-47
 

Safe and effective use of dexmedetomidine in anaesthetic management of a pregnant patient with posterior fossa tumor posted for ventriculoperitoneal shunt


Department of Anaesthesiology, AIIMS, Rishikesh, Uttrakhand, India

Date of Web Publication6-May-2019

Correspondence Address:
Dr. Roshan Andleeb
Department of Anaesthesiology, AIIMS, Rishikesh, Uttrakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_7_19

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How to cite this article:
Andleeb R, Jain PK, Doley S, Barik AK. Safe and effective use of dexmedetomidine in anaesthetic management of a pregnant patient with posterior fossa tumor posted for ventriculoperitoneal shunt. Indian Anaesth Forum 2019;20:46-7

How to cite this URL:
Andleeb R, Jain PK, Doley S, Barik AK. Safe and effective use of dexmedetomidine in anaesthetic management of a pregnant patient with posterior fossa tumor posted for ventriculoperitoneal shunt. Indian Anaesth Forum [serial online] 2019 [cited 2019 Aug 26];20:46-7. Available from: http://www.theiaforum.org/text.asp?2019/20/1/46/257690




Sir,

Neurosurgery during pregnancy is a real challenge for anesthesiologist, due to maternal physiological changes and fetomaternal effect of anesthetic agents. The incidence of nonobstetric surgery during pregnancy is about 0.2%–0.79%, with seven cases of brain tumor per 125,000 pregnancies.[1] In a pregnant patient with increased intracranial pressure (ICP), the anesthetic considerations include smooth induction, with optimal operative conditions such as relaxed brain, maintenance of cerebral perfusion pressure, cerebral oxygenation, and the preservation of uteroplacental blood flow and stable hemodynamics.[2] Opioid-based total intravenous anesthesia (TIVA) is frequently used in neurosurgery because of its potential to reduce ICP.[3] The use of opioid in pregnant patient can cause respiratory depression and fetal bradycardia. Thus, dexmedetomidine may be used as an adjunct to general anesthesia because of its opioid-sparing effect. Dexmedetomidine, a highly selective α2 agonist, has shown to decrease intraoperative anesthetic requirements and provides cardiovascular stability with smooth recovery when used for intracranial surgery in nonpregnant patients.[4] There is limited literature on its use in obstetric patients for neurosurgery. We report the safe and effective use of dexmedetomidine in a 27-week pregnant patient with posterior fossa tumor with obstructive hydrocephalus posted for ventriculoperitoneal shunting (VP shunt).

A 28-year-old woman, G2P1L1 at 27th weeks of gestation posted for VP shunt following the diagnosis of posterior fossa tumor with obstructive hydrocephalus and features of raised ICP. MRI showed hyperdense lesion involving cerebellum, causing effacement of the 4th ventricle and dilatation of 3rd and lateral ventricles. Definitive surgery was planned after delivery. All other general and systemic examinations were within normal limits except central nervous system examination, which revealed drunken gait and past pointing without any deficit. Per abdominal examination revealed uterus of about 26 weeks size, transverse lie and fetal heart rate of 148/min. Preoperative abdominal ultrasound showed single live fetus of 29 weeks with transverse lie and adequate liquor. Fetal movement and cardiac activity were present. A written informed consent was obtained for the surgery, risk of premature delivery of the fetus and the possibility of the urgent need for cesarean section. After shifting the patient to the operating theater, standard monitors including bispectral index were connected. Loading dose of IV dexmedetomidine (1 μg/kg) was given over 10 min followed by maintenance infusion at 0.5 μg/kg/h. Before induction, a wedge was placed under the right hip for the left uterine displacement. After preoxygenation, rapid sequence induction with cricoid pressure was performed after giving fentanyl 1 μg/kg, propofol 2 mg/kg, and rocuronium 1 mg/kg. Anesthesia was maintained with 50% oxygen-air mixture, propofol infusion at 8 ml/h (~27 μg/kg/min) and vecuronium 1 mg intermittently. Fetal tococardiography monitoring was carried out throughout the surgery which showed heart rate between 114 and 125/min. Surgery lasted for 2 h and was uneventful. Thirty minutes before, the completion of surgery both infusions was stopped, and trachea was extubated when she followed the commands and became fully awake. The postoperative period was uneventful.

Analgesic, sedative, and sympatholytic properties with a reduction in anesthetics requirement are well documented with dexmedetomidine. In addition, it is also useful in neurosurgical patients because of intraoperative stable hemodynamic and immediate neurological evaluation after surgery.[5] It also reduces cerebral blood flow and ICP by directly acting as a potent venous vasoconstrictors and indirectly by its action on neurological pathways that modulate vascular effects. Despite its evident multiple benefits, the use of dexmedetomidine in parturient has not been well documented, suspecting its possible uteroplacental transfer, apprehending undesirable effects in the fetus. Dexmedetomidine has a high placental retention (0.77 maternal/fetal index), is highly lipophilic and as a result, it is retained in placental tissue. Therefore, it does not get transferred to the fetus.[6] It is classified as the US food and drug administration pregnancy category C drug because there are no well-controlled studies of its use in pregnant women. In this case, the use of dexmedetomidine was associated with reduced requirement of anesthetic medications along with rapid and smooth emergence, without any fetomaternal hemodynamic instability. This case shows the safe use of dexmedetomidine as an adjunct to TIVA to provide the optimal operative condition for the neurosurgical procedure in pregnant patient without causing any adverse effect on fetomaternal hemodynamics.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Isla A, Alvarez F, Gonzalez A, García-Grande A, Perez-Alvarez M, García-Blazquez M, et al. Brain tumor and pregnancy. Obstet Gynecol 1997;89:19-23.  Back to cited text no. 1
    
2.
Miller RD, Cucchiara RF, Miller ED. Anesthesia. 5th ed. Philadelphia: Churchill Livingstone; 2000;2:2053-5.  Back to cited text no. 2
    
3.
Cole CD, Gottfried ON, Gupta DK, Couldwell WT. Total intravenous anesthesia: Advantages for intracranial surgery. Neurosurgery 2007;61:369-77.  Back to cited text no. 3
    
4.
Tanskanen PE, Kyttä JV, Randell TT, Aantaa RE. Dexmedetomidine as an anaesthetic adjuvant in patients undergoing intracranial tumour surgery: A double-blind, randomized and placebo-controlled study. Br J Anaesth 2006;97:658-65.  Back to cited text no. 4
    
5.
Sturatis M, Kroin J, Swamidoss CS, Moric M. Effect of intraoperative dexmedetomidine infusion on hemodynamic stability during brain tumor resection. Anesthesiology 2002;97:A310.  Back to cited text no. 5
    
6.
Tariq M, Cerny V, Elfaki I, Khan HA. Effects of subchronic versus acute in utero exposure to dexmedetomidine on foetal developments in rats. Basic Clin Pharmacol Toxicol 2008;103:180-5.  Back to cited text no. 6
    




 

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