Letters to Editor

Dexmedetomidine as sedative and analgesic in a patient of sickle cell disease for total hip replacement Sir, A 40‑year‑old, 82 kg male with a fracture of neck of femur was admitted. Airway assessment revealed MPC II. Haemoglobin of 9 g/dl and haematocrit of 26.4% was noted. The peripheral blood smear showed sickle cells. Sickle cell solubility test was positive. The patient had no history of previous hospitalisation, blood transfusion, renal failure, chest pain or any neurologic deficits. Avascular necrosis of bilateral femoral heads and splenic infarcts were noted. Laboratory investigations and chest X‑ray were normal. A total hip replacement was planned. An epidural catheter was introduced at L2‑L3 level. Initial bolus of 14 ml of 2% xylocaine with adrenaline after test dose was given to obtain a sensory level of T10 and infusion of 7 ml/hour of 0.5% bupivacaine was used. Adequate oxygenation, hydration and normotension and normothermia were ensured preoperatively and intra‑operatively. Intravenous dexmedetomidine, in a bolus of 0.5 µg/kg (40 µg) was infused over 20 min prior to positioning the patient lateral, followed by an infusion of 0.5 µg/kg/hour. Blood loss of 350 ml was managed using warm crystalloids. Intraoperative period was uneventful. Postoperative pain was managed with an epidural infusion containing 0.2% ropivacaine at 5 ml/hour and dexmedetomidine in a dose of 0.5 µg/kg/hour. No NSAIDS/opioids or sedatives were required in the immediate post‑operative period of 24 hours. The pain intensity scale of 3‑4 and Ramsay sedation score of 2‑3 were charted in the high dependence unit. The epidural catheter was removed after 24 hours and the patient was mobilised. Oral NSAIDs were started. The patient was discharged on the fifth post‑operative day without any adverse events. Sickle cell disease (SCD) is determined by a complex interplay between genetic and environmental factors. The basis of anaesthetic management has traditionally been avoiding the factors known to increase erythrocyte sickling and precipitate the vicious cycle of vaso‑occlusive episodes (VOC), Indian Journal of Anaesthesia | Vol. 57 | Issue 4 | Jul-Aug 2013

such as volume depletion, hypoxemia, infection, acidosis, hypothermia, hyperthermia, decrease in 2, 3 DPG.[1] Sickled cells have increased adherence to endothelium leading to micro‑vascular infarction and pain, the basis of VOC.[2] The risk intrinsic to the type of surgery should be considered. Among orthopaedic procedures, hip surgery and hip replacement are associated with a high risk of complications.[3] Pre‑operative examinations should aim to find the risk of SCD‑related organ dysfunction. The main goals of the anaesthetic management in this case were adequate analgesia, early mobilization to prevent stasis and deep vein thrombosis, oxygenation to avoid hypoxic episodes,[1] adequate hydration and thermoregulation. Our choice was based on the advantages of dexmedetomidine. It has a rapid onset and offset, predictable mode of metabolism and excretion not requiring end organ‑function, no deleterious cardiovascular effect, amnestic effect, no depressant effect on respiration, gas exchange, or pulmonary mechanics.[4] Infusion maintains unique ‘conscious sedation’. Its action at the spinal cord alpha2 receptors diminishes sympathetic tone and serves as an analgesic at the dorsal horn,[4] thus, decreasing the requirement of local anaesthetic epidurally. Studies comparing dexmedetomidine with either opioids or other alpha2 agonist namely clonidine have been documented.[4] Only one case of its use in acute sickle cell crisis for pain relief has been reported.[5] Intraoperative dexmedetomidine infusion is effective in prevention of post‑anaesthesia shivering,[6] thereby preventing the increased oxygen demand. Opioids used for pain relief may cause respiratory depression.[5] Dexmedetomidine has opioid sparing effect, thus offering an advantage.

Tasneem Dhansura, Shakir Kapadia1, Shweta Gandhi 1

Departments of Anaesthesiology and Perioperative Care, Orthopedics, Saifee Hospital, Mumbai, Maharashtra, India Address for correspondence: Dr. Tasneem Dhansura, Sunrise 12, 4th Pasta Lane, Colaba, Mumbai, Maharashtra, India. E‑mail: [email protected]

REFERENCES 1.

Bharati S, Das S, Majee P, Mandal S. Anesthetic management of a patient with sickle β thalassemia. Saudi J Anaesth 2011;5:98‑100. 425

Letters to Editor 2. Ingle SS, Ubale P. Anesthetic management of a patient with sickle cell disease for common bile duct exploration. J Anaesthesiol Clin Pharmacol 2011;27:547‑9. 3. Christine S Rinder. Hematologic Disorders. In: Paul AK, Editor. Stoelting’s Anesthesia and Co‑existing Disease. 5th ed. New Delhi: Elsevier; 2012. p. 448‑79. 4. Bajwa SJ, Arora V, Kaur J, Singh A, Parmar SS. Comparative evaluation of dexmedetomidine and fentanyl for epidural analgesia in lower limb orthopedic surgeries. Saudi J Anaesth 2011;5:365‑70. 5. Phillips WJ, Gadiraju S, Dickey S, Galli R, Lerant AA. Dexmedetomidine relieves pain associated with acute sickle cell crisis. J Pain Symptom Manage 2007;34:346‑9. 6. Elvan  EG, Oç B, Uzun  S, Karabulut  E, Coşkun F, Aypar  U. Dexmedetomidine and post‑operative shivering in patients undergoing elective abdominal hysterectomy. Eur J Anaesthesiol 2008;25:357‑64. Access this article online Quick response code Website: www.ijaweb.org

DOI: 10.4103/0019-5049.118521

Beware! defects in pipeline supplies can occur: Be aware of this possibility after engineering work in related areas of the hospital Sir, Fatal accidents caused by piped gases are an ever present danger to patients in the operating room. I present details of accidental hypoxia caused by pipeline misconnection. A child with no comorbid conditions had induction of anaesthesia using 100% oxygen and sevoflurane while an intravenous line was being secured. Cyanosis and bradycardia developed, followed by cardiac arrest. He responded to cardiopulmonary resuscitation only after the anaesthesia machine was connected to an alternative oxygen outlet in the same room. A stable cirulation was achieved and spontaneous breathing resumed. He was later transferred to the nearest tertiary hospital for further care. Unfortunately, serious hypoxic brain damage became evident and the patient died after 10 days, from a respiratory infection. 426

The anaesthetic machine had been checked before anaethesia started and an oxygen cyclinder was provided on the machine. Although the machine was equipped with an analyser for the oxygen mixture, this was not functional. When the complications occurred, rather than switching on the oxygen cylinder, the anaesthetist involved decided to connect the oxygen pipeline to an alternative suppy. An enquiry revealed that the operating rooms had been closed for renovation before the incident. The pipeline engineers had noticed that this particular operating room (in a suite of four rooms) had the sequence of the gas outlets N2O – O2 – vacuum and not the usual sequence of O2 – N2O – vacuum as in the other operating rooms in the theatre suite. The room had been used previously as a recovery room and had later been converted into an operating room, when the N2O pipe‑line was added. The engineers changed  the sequence of the outlets to O2 – N2O – vacuum and the colour coding to white – blue – yellow. However, the pipe‑lines from the manifold room were not reconnected to correspond to the changed outlets and the gas composition delivered from the outlets were not checked by analysis after the renovations. The operating room management team were not informed about this change in gas outlets. In an unfortunate coincidence of errors, the O2 analyser on the anaesthesia machine was not working. After this incident, the pipeline engineers realigned the outlets with the gas pipes from the manifold room. The department arranged to have oxygen analysers with all anaesthesia machines in the operating rooms. Technical staff made sure that a full oxygen cylinder was attached to every machine. A pipeline error caused two deaths in a teaching hospital in Japan in 1987.[1] A mistake in the labelling and identification of medical gases resulted in cross‑connection of oxygen and air and caused perioperative hypoxia in Belgium in 2010.[2] In India, these incidents are rarely reported, except by the press, but are probably relatively frequent. In Lucknow, 11 neonatal incubator deaths were reported in 2001 and other neonatal incubator deaths were reported from Kurnool, AP in September 2011. Both events were alleged to be caused by misconnection of oxygen pipelines. A case of brain damage due to alleged administration of N2O instead of O2 was reported in February of 2012, in a hospital in South India. Indian Journal of Anaesthesia | Vol. 57 | Issue 4 | Jul-Aug 2013

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Dexmedetomidine as sedative and analgesic in a patient of sickle cell disease for total hip replacement.

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