Dex and neurobehavioraldisordersWord格式文档下载.docx

Dex and neurobehavioraldisordersWord格式文档下载.docx

《Dex and neurobehavioraldisordersWord格式文档下载.docx》由会员分享，可在线阅读，更多相关《Dex and neurobehavioraldisordersWord格式文档下载.docx（12页珍藏版）》请在冰豆网上搜索。

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