An open label pilot study of a dexmedetomidine‐remifentanil‐caudal anesthetic for infant lower abdominal/lower extremity surgery: The T REX pilot study
Year: 2018
Type: article
Study design: Clinical Trial
Abstract: BACKGROUND: Concern over potential neurotoxicity of anesthetics has led to growing interest in prospective clinical trials using potentially less toxic anesthetic regimens, especially for prolonged anesthesia in infants. Preclinical studies suggest that dexmedetomidine may have a reduced neurotoxic profile compared to other conventional anesthetic regimens; however, coadministration with either anesthetic drugs (eg, remifentanil) and/or regional blockade is required to achieve adequate anesthesia for surgery. The feasibility of this pharmacological approach is unknown. The aim of this study was to determine the feasibility of a remifentanil/dexmedetomidine/neuraxial block technique in infants scheduled for surgery lasting longer than 2 hours. METHODS: Sixty infants (age 1-12 months) were enrolled at seven centers over 18 months. A caudal local anesthetic block was placed after induction of anesthesia with sevoflurane. Next, an infusion of dexmedetomidine and remifentanil commenced, and the sevoflurane was discontinued. Three different protocols with escalating doses of dexmedetomidine and remifentanil were used. RESULTS: One infant was excluded due to a protocol violation and consent was withdrawn prior to anesthesia in another. The caudal block was unsuccessful in two infants. Of the 56 infants who completed the protocol, 45 (80%) had at least one episode of hypertension (mean arterial pressure >80 mm Hg) and/or movement that required adjusting the anesthesia regimen. In the majority of these cases, the remifentanil and/or dexmedetomidine doses were increased although six infants required rescue 0.3% sevoflurane and one required a propofol bolus. Ten infants had at least one episode of mild hypotension (mean arterial pressure 40-50 mm Hg) and four had at least one episode of moderate hypotension (mean arterial pressure <40 mm Hg). CONCLUSION: A dexmedetomidine/remifentanil neuraxial anesthetic regimen was effective in 87.5% of infants. These findings can be used as a foundation for designing larger trials that assess alternative anesthetic regimens for anesthetic neurotoxicity in infants.
Source: Pediatric Anesthesia
DOI: 10.1111/pan.13544
Authors: Peter Szmuk, Dean Andropoulos, Francis McGowan, Ansgar Brambrink, Christopher Lee, Katherine J. Lee, Mary Ellen McCann, Yang Liu, Rita Saynhalath, Choon Looi Bong, Brian J. Anderson, Charles Berde, Jurgen C. De Graaff, Nicola Disma, Dean Kurth, Andreas Loepke, Beverley Orser, Daniel I. Sessler, Justin J. Skowno, Britta S. von Ungern‐Sternberg, Laszlo Vutskits, Andrew Davidson
Institutions: Cleveland Clinic, The University of Texas Southwestern Medical Center, Texas Children's Hospital, Children's Hospital of Philadelphia, Oregon Health & Science University, Cincinnati Children's Hospital Medical Center, The University of Melbourne, Murdoch Children's Research Institute, Boston Children's Hospital, KK Women's and Children's Hospital, University of Auckland, Erasmus MC - Sophia Children’s Hospital, National Health Service, Great Ormond Street Hospital for Children NHS Foundation Trust, Istituto Giannina Gaslini, University of Toronto, Children's Hospital at Westmead, The University of Western Australia, Princess Margaret Hospital for Children, Perth Children's Hospital, University Hospital of Geneva, Royal Children's Hospital
Language: English
Subfield: Anesthesiology and Pain Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W2901977308