Dex and neurobehavioraldisordersWord格式文档下载.docx
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autismorneurobehavioraldisorderssedatedwithdex-
medetomidineatChrisEvertChildren’sHospitalandIntroduction
KosairChildren’sHospitalwerereviewed.Demo-
graphicandsedation-relateddatawerecollected,in-Forseveralreasons,includingtactileaversion,decreasedcludingsedativedoses,timetosedation,efficacy,andabilitytoadapttoalteredroutines,diminishedabilitytopro-complications.Comparisonsofsedativedoses,efficacycesssituationalneeds,andbehaviordisorders,includingbetweenautismandneurobehavioralpatients,andpotentiallyprofoundaggression,childrenwithautismoranalysisofage-relatedfactorswereperformed.Inall,autismspectrumdisorderscanbedifficultpatientsin315patientsweresedated,mostcommonlyformag-whomtoperformprocedures[1-4].Evenrelativelysimpleneticresonanceimaging.Meaninductionandtotalproceduresmaybemetwithsuchoppositionandagitationdexmedetomidinedoseswere1.4±
0.6and2.6±
1.6thatbothpatientandcaregiverharmmayoccur.Autisticchil-mg/kg,respectively,withnodifferencesbetweenautismdrenalsohaveahighincidenceofneurologiccomorbidities,andneurobehaviorpatients.Mostpatients(90%)pa-however,particularlyseizuredisorders[5,6].Consequently,tientsreceivedconcomitantmidazolam.Therewasanevaluationwithelectroencephalography,magneticreso-age-relateddecreaseindexmedetomidinedose,inde-nanceimaging,orbothisoftendeemednecessaryinthispendentofmidazolamuse.Sevenpatientsrequiredin-population,anapproachsupportedbytheAmericanAcad-terventionforhypotension,bradycardia,orboth,andemyofPediatrics[7].
onlyoneadverserespiratoryevent(obstructionrequir-Becauseoftheirpotentialforsuppressingseizureorepi-ingnasopharyngealairwayplacement)occurred.leptiformandelectroencephalographicbackgroundactivity,Thereweretwoepisodesofovertrecovery-relatedagi-manycommonlyusedsedatives(includingbenzodiazepines,tation.Allbutfourproceduresweresuccessfullycom-barbiturates,andpropofol)cannotbeusedforsedationwithpleted(4/315,or98.7%).Dexmedetomidinewithorelectroencephalography.Someagents,particularlybarbitu-withoutmidazolamwasaneffectivesedativeinthisrates,arealsoassociatedwithsignificantrecovery-relatedpopulation.Theregimenappearedtobewelltoleratedagitation[8,9].Chloralhydrateiscommonlyusedforseda-withfewadverseevents,includingrecovery-relatedtioninelectroencephalography,butsedationfailuresandagitation,andappearstobeanattractiveoptionforadversebehavioralreactions,particularlyagitation,arethispopulation.Ó
2009byElsevierInc.Allrightsmorefrequentinchildrenwithneurobehavioraldisorders,reserved.makingitalessattractiveoptionforthisgroup[10].Fromthe*DepartmentofPediatrics,ChrisEvertChildren’sHospital,Communicationsshouldbeaddressedto:
FortLauderdale,Florida;
andtheDepartmentofPediatrics,UniversityofDr.Berkenbosch;
Pediatrics/PediatricCriticalCare;
UniversityofLouis-Louisville,Louisville,Kentucky.ville;
KosairChildren’sHospital;
571S.Floyd,Ste332;
Louisville,KY40202.
E-mail:
john.berkenbosch@louisville.edu
ReceivedOctober8,2008;
acceptedFebruary23,2009.
88PEDIATRICNEUROLOGYVol.41No.2Ó
2009byElsevierInc.Allrightsreserved.
doi:
10.1016/j.pediatrneurol.2009.02.006_0887-8994/09/$—seefrontmatterDexmedetomidine(tradename,Precedex)isaselectiveputedtomographyscan).Forlongerstudies(e.g.,magneticresonanceim-a-adrenoreceptoragonistthatisgainingpopularityforaging),amaintenanceinfusionwascommonlyusedandtitratedtoeffect.2Dosesweretitratedtomaintainmoderatetodeepsedation,dependingonnoninvasiveproceduralsedation[11-15].Ithasasevenfoldthedegreeofmovementthatcouldbetoleratedfortheexaminationper-greateraffinityforthea2vsthea1receptorthandoesclo-
nidine[16],permittingfewercardiovascularsideeffectsformed.Aftertheprocedure,patientsweremonitoreduntilbacktotheir
neurologicbaseline.Becauseofthepotentialforhypotension,patientsatatequivalentsedativedoses.Afterintravenousadministra-theFloridahospitaltypicallyreceived20mL/kgof0.9%salinepriortotion,ithasaneliminationhalflifeof2-3hoursafterhepaticorimmediatelyaftersedationinduction.
metabolismtoinactivemetabolites[17].DataCollection
Pertinenttopatientswithautism,apriorreportdescribes
minimaleffectsofclonidine(thea2-agonistpredecessorof
dexmedetomidine),ontheelectroencephalogram[1].Fur-Demographicdatawerecollectedincludingpatientage,weight,under-thermore,nosignificantrecovery-relatedagitationhasbeenlyingdiagnosis,andprocedureorproceduresperformed.Sedation-related
datacollectedincludeddexmedetomidinedoses(inductionandmainte-describedwithdexmedetomidine[11-14],includingaprelim-nance),durationofinduction(timefrominitiationoftheinductionbolusinaryreportinchildrenwithneurobehavioraldisorders[18].toasedationdepthadequatetobegintheprocedure),durationofdexmede-Becauseofearlysuccesses,sedationpractitionersatChristomidineadministration,recoverytime(timefromdexmedetomidinedis-EvertChildren’sHospital(FortLauderdale,FL)andKosaircontinuationtoreturntoneurologicbaseline),adjunctmedicationuse,Children’sHospital(Louisville,KY)beganroutinelyusingsedationsuccess(abilitytocompletethedesiredprocedureorprocedures),
recoverypatterns(includingrecovery-relatedagitation),andanyotherdexmedetomidinetosedatechildrenwithautismandothercomplications.Hypotensionandbradycardiaweredefinedas>
30%neurobehavioraldisordersfornoninvasiveexaminations.decreasesineitherbloodpressureorheartratefrombaseline.DescribedhereisthecombinedexperienceofthesetwoAspartoftheirqualityimprovementinitiatives,providersattheFloridacenterswithdexmedetomidineinthispopulation.hospitalhadimplementedaroutineprogramoftelephonefollow-upwith
familiesofchildrentheysedated,toevaluateforpost-sedationproblems
andtoassessparentalsatisfactionwiththeexperience.Thisphoneinter-MaterialsandMethodsviewconsistedofeightquestionsandoccurredwithin24hoursofthese-
dationencounter.SatisfactionwasratedonascalefromverydissatisfiedtoThisretrospectivereviewwasapprovedbytheInstitutionalReviewverysatisfied,witharequestforspecificcomments.ToevaluatetheeffectBoardofbothChrisEvertChildren’sHospital(hereafter,theFloridahos-ofachangefrompentobarbitalandchloralhydratesedation(singly,orinpital)andtheUniversityofLouisvilleforKosairChildren’sHospital(here-combination)todexmedetomidinesedation,acomparisonofthesesatis-after,theKentuckyhospital).Patientsreferredtosedationservicesateachfactionscoreswasperformedbetweenthe6monthsprecedingdexmedeto-hospitalwithadiagnosisofautismorotherneurobehavioraldisorderwhomidineintroduction(i.e.,thepentobarbitalandchloralhydrateera)andtheweresedatedwithdexmedetomidinefromAugust2003throughOctober6monthsafterdexmedetomidineintroduction.
2006wereidentifiedfromdatabasesmaintainedbythesedationservice
ateachhospitalandtheirrecordswerereviewed.DataAnalysis
SedationQuantitativedataarepresentedasthemeanÆ
standarddeviation.Dif-
ferencesininductionandmaintenancedexmedetomidinedosesandrecov-ProceduralsedationatbothhospitalsisperformedinaccordancewitherypatternsbetweenpatientswithautismandthosewithaneurobehaviorcurrentAmericanAcademyofPediatricsguidelines[19].Allpatientsdiagnosiswerecomparedusinganunpairedt-test.Analysisoftheeffectofhadbeenwithoutoralintakeforatleast2-8hours,dependingonage,ageondoserequirementsandsedationefficacywasperformedusingandhadafunctionalintravenouscatheter.Patientswerecontinuouslyregressionanalysis.AP-valueof<
0.05wasconsideredsignificant.monitoredbyatleastonesedation-credentialedpractitioner(physician,ad-
vancedpracticeregisterednurse,registerednurse,oracombinationofResults
these)throughouttheprocedure.Heartrate,respiratoryrate,andoxyhe-
moglobinsaturationwerecontinuouslymonitored.NoninvasivebloodDemographics
pressurewasmeasuredevery5minutesduringtheprocedureandevery
5-15minutesduringrecovery.End-tidalCO2wasmonitoredvianasal
cannulaatthediscretionofthesedationprovider.Atotalof315patientswereidentified,241fromtheFlor-Premedicationwithoralorintranasalmidazolamororaldexmedetomi-idahospitaland74fromtheKentuckyhospital.Patientsdinewasadministeredatthediscretionofthesedationprovider.Dexmede-rangedinagefrom8monthsto24years(mean,6.8Æ
tomidinewasdilutedin0.9%salinetoafinalconcentrationof4mg/mLand3.9years).Themostcommondiagnosiswasautism(n=administeredorally,intravenously,orbybothroutesbyasedation-creden-262)(83.1%)andthemostcommonprocedurewasmag-tialedphysician,advancedpracticeregisterednurse,orregisterednurse.neticresonanceimaging(n=245)(77.8%).ThediagnosesSedationpracticesatbothhospitalsweresimilar,inthatsedationwasandtheproceduresperformedaresummarizedinTables1accomplishedviaaloadingandinductiondoseofdexmedetomidinewithand2,respectively.Patientsintheautismgroupwereyoun-orwithoutamaintenanceinfusionuntiltheprocedurewascompleted.ger(5.5Æ
3.6vs8.6Æ
4.0years,P<
0.0001)andweighedInductionwasaccomplishedbysettingtheinfusionatarateof12mg/kg
perhour,yielding1mg/kgevery5minutes.Thisinfusionratewascontin-less(25.7Æ
16.9vs33.6Æ
16.2kg,P<
0.0001)thanthoseueduntilthepatientwasdeemedadequatelysedated,whereupontheinfu-intheneurobehaviorgroup.
sionwaseitherdiscontinuedordecreasedtomaintenanceinfusionrates.As
familiaritywithpatientresponsestodexmedetomidineincreased,routineSedation
useofahigherinductiondose(2-3mg/kg)wasimplementedattheFlorida
hospitalforyoungerchildrenandadolescentswithaknownhistoryofpar-Sedationwasachievedwithdexmedetomidinealoneinticularlyviolentoraggressivebehavior.Amaintenanceinfusionwasnot
routinelyusedforshorterstudies(e.g.,electroencephalographyorcom-32/315patients(10.2%)patients,and283/315
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