Journal of Anesthesia & Clinical Care Category: Clinical Type: Case Report
A New Approach for Procedural Sedation in Children: The Intramuscular Dextroketamine and Dexmedetomidine Association
- Renato Lucas Passos De Souza1*, Waynice Neiva De Paula Garcia1, Waledya Araújo Lopes De Melo1, Luís Vicente Garcia1, Jyrson Guilherme Klamt1, João Abrão1
- 1 Hospital Das Clinicas Da Faculdade De Medicina De Ribeirao Preto, USP, HCFMRP-USP, Brazil
*Corresponding Author:Renato Lucas Passos De Souza
Hospital Das Clinicas Da Faculdade De Medicina De Ribeirao Preto, USP, HCFMRP-USP, Brazil
Received Date: Jun 26, 2019 Accepted Date: Jun 28, 2019 Published Date: Jun 05, 2019
Ketamine, an NMDA receptor antagonist, is an effective drug for sedation, analgesia, and amnesia and has been widely used as an alternative to the use of inhalational agents in order to reduce the incidence of Sevoflurane agitation and with the advantage of not causing respiratory depression . Dexmedetomidine, a highly specific alpha-2 agonist, also has sedative, analgesic and anxiolytic effects, without significant respiratory depression at clinical doses . Even used by non-anesthesiologists, Ketamine and dexmedetomidine have been proven safe and effective to ensure successful sedation .
Intramuscular route provides rapid systemic action, with near 80% of biodisponibility and plasma concentration peak in about 15 minutes, and is indicated for uncooperative patients or for those who cannot take oral medications. Then, the intramuscular route of both Ketamin and Dexmedetomidine can be an interesting option for procedural sedation in children, usually non-cooperatives, who do not calmly accept the mask for inhaled anesthesia, are agitated or have difficult venous accesses.
We present the use of an intramuscular Ketamine-Dexmedetomidine combination for procedural sedation in a thirteen-year-old child with acute ventriculitis that had to be submitted to a transhepatic central venous access for parenteral antibiotic therapy.
The child did not respond to the infiltration of lidocaine by the radiologist, and remained immobile throughout the process, which lasted 35 minutes (Figure 2). Eupneic, hemodynamically stable, heart rate between 80 and 90 beats per minute, non-invasive arterial pressure ranged from 100x60 to 110x70 mmHg, peripheral oxygen saturation of 98%, supplemental oxygen was not necessary and the procedure was successfully done (Figure 3). The child was referred to the post-anesthetic room and after 20 minutes of spontaneous breathing, was discharged to the room.
Figure 3: Suprahepatic vein puncture.
In our patient anesthetic management, concerns included the need to provide effective sedation to perform a potencial painful procedure without ventilatory or hemodynamic compromise.
The use of ketamine provides several benefits as the provision of analgesia, which is not present dexmedetomidine, an increase in Heart Rate (HR) and Blood Pressure (BP) to offset the bradycardia of dexmedetomidine, and a more rapid onset when compared to dexmedetomidine alone. Dexmedetomidine prevents several of the potentially deleterious effects of ketamine including emergence agitation, excessive salivation, and stimulation of the cardiovascular system (increased HR and BP) .
Clinical experience with the combination of dexmedetomidine and ketamine continues to increase showing its efficacy in prospective trials, case series, and isolated case reports [7-11]. However, despite its efficacy as the sole agent for sedation during non-painful radiologic imaging, dexmedetomidine may fail when used as the sole agent for painful procedures [12-14]. In our patient, effective sedation was provided by a single intramuscular dose of ketamine and dexmedetomidine.
Mester et al retrospectively reviewed this combination for sedation during cardiac catheterization in children with heart disease . An intravenous bolus dose of ketamine (2mg/kg) and dexmedetomidine (1mg/kg) was administered over 3 minutes followed by a continuous infusion of dexmedetomidine. No patient reacted to the infiltration of the groin and placement of the arterial and venous cannula. Two patients developed upper airway obstruction resolved with the airway repositioning. No central apnea was noted and the maximum value of PaCo2 was 48 mmHg.
McVey and Tobias described the successful use of dexmedetomidine and ketamine for procedural sedation during lumbar puncture for spinal anesthesia in 12 pediatric patients . The dosing regimen for the ketamine and dexmedetomidine was similar to that reported by Mester et al. Other studies have also shown that the association of ketamine and dexmedetomidine even at low doses, allows safe and effective sedation for children in various surgical procedures [15,16].
Joseph Tobias has consistently demonstrated the utility of dexmedetomidine in conjunction with ketamine for procedures in which a deep level of sedation is required while maintaining spontaneous breathing . Several reports have included patients with significant co-morbid conditions, including pulmonary hypertension, sleep apnea, tracheal compression from a mediastinal mass, congenital heart disease, as well as compromised cardiac and respiratory function. These reports demonstrate that a dexmedetomidine-ketamine combination effectively achieves the desired level of sedation while minimizing the potential for adverse effects. Tobias also concluded that the most effective regimen for procedural sedation seems to be the use of an intravenous bolus dose of both agents, dexmedetomidine (1 μg/kg) and ketamine (1-2 mg/kg), to initiate sedation and, used in such a scenario, the two agents can be co-administered from a single syringe .
Due to Ketamine’s unique properties and versatility, it has gained increasing popularity in pre hospital and emergency medicine, throughout the world. When intravenous access is difficult, the use of intramuscular, oral or intranasal ketamine has been described with good effect . Dexmedetomidine can also be used intravenous and intramuscular; the suggested dose for premedication is 0, 33-0, 67 mcg/kg IV or 2, 5 mcg/kg IM, an injection given 15minutes before procedure . Thus, the use of the intramuscular mixture of both drugs would be something natural to happen.
To the best of our knowledge, we have not found publications regarding the use of dexmedetomidine and Dextroketamine by the intramuscular route in humans. There is a publication of a study that associates both drugs intramuscularly in swine, showing the safety of the combination and the efficient sedation . It this case report it was observed that both the association of the drugs in the same syringe and the application intramuscularly in bolus, at the recommended doses, showed to be extremely painless, effective and conferred safety for the accomplishment of a procedure free from agitation, guaranteeing hypnosis, analgesia, preventing hypoventilation or any change in respiratory pattern, being an excellent alternative for sedation in children with co-morbidities. Ketodex is a very versatile mixture in anesthesia practice, finding a place in an increasing number of clinical procedures. We demonstrated that the use of the mixture, intramuscularly in a single syringe is a viable alternative in sedation for surgical procedures in children.
Regardless of the agents used for procedural sedation, there is a potential for not only hemodynamic, but also respiratory depression. Given these concerns, appropriate monitoring and access to resuscitation medications plus airway equipment are mandatory during procedural sedation. With these caveats in mind, we believe that the use of combined Dextroketamine and Dexmedetomidine (Ketodex) Intramuscular should be considered as an interesting choice for procedural sedation in children, even with co-morbidities, as it has been proved in the described case and in other clinical scenarios.
Future clinical trials comparing different sedation regimens with other sedatives and routes of administration may provide valid information about safety, time of awakening, and cost effectiveness.
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Citation:Lucas RPS, Paula-Garcia WN, Melo WAL, Garcia LV, Klamt JG, et al. (2019) A New Approach for Procedural Sedation in Children: The Intramuscular Dextroketamine and Dexmedetomidine Association. J Anesth Clin Care 6: 38.
Copyright: © 2019 Renato Lucas Passos de Souza, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.