Comparison of intravenous dexmedetomidine and lignocaine infiltration to attenuate the hemodynamic response to skull pin holder during craniotomy

 

Catherine Kapoor¹, D Aruna², D Ashok Kumar^3*, Sanjana S⁴

 

Abstract              Background: The purpose of the study is to compare the effectiveness of intravenous dexmedetomidine or lignocaine infiltration in attenuating the hemodynamic response to skull pin holder during craniotomy. For the study, 60 patients of the age group 18-70 years belonging to ASA PS I and PS II were selected and divided into two groups. The study design employed was a prospective randomized comparative study. Based on standard dosing, 1mcg/kg of dexmedetomidine diluted to 10 ml with 0.9% saline over 10 minutes was given before induction. Patients randomized to group lignocaine received infiltration of pin sites with 2% lignocaine 3 ml at each site. The timing of dexmedetomidine infusion was such that peak effect of the drug would coincide with the time of application. Heart rate and mean arterial pressure were comparable between the two groups during the study and were recorded at the following intervals pre-induction, pre-infiltration, post-infiltration, pre pin application, post pin application 10 and 15 minutes after pin application. We found that dexmedetomidine is more effective in controlling the hemodynamic response than local lignocaine infiltration during craniotomy. It was concluded that 1 mcg/kg of dexmedetomidine infused slowly over 10 minutes is superior when compared to local infiltration of 2% lignocaine in attenuating the hemodynamic response to skull pin holder during craniotomy. By attenuating the hemodynamic response, brain edema, increased intracranial pressure and intracranial hemorrhage can be prevented.

Keywords- Hemodynamic, Lidocaine, Dexmedetomidine, Craniotomy,skull pin holder

 

INTRODUCTION

Application of skull pin holder during craniotomy for neurosurgical procedure is extremely painful and is associated with abrupt increase in heart rate and mean arterial pressure. These adverse effects can lead to brain edema, increased intracranial pressure or hemorrhage. The Mayfield skull pin holder is used to support the head without any direct pressure on the face allowing access to the airway and can holds the head for optimal neurosurgical exposure. Different techniques have been used to blunt these deleterious hemodynamic changes. The hemodynamic response consists of autonomic response to noxious stimuli which increases the sympathetic tone which elevates the blood pressure and heart rate. The sudomotor responses consists of sweating whereas the hormonal response consists of release of corticosteroids, glucagon, and catecholamines due to activation of hypothalamic pituitary axis due to surgical stress. Dexmedetomidine, an alpha 2 agonist may blunt the hemodynamic response due to its sympatholytic and analgesic properties. Lignocaine being a local anaesthetic blocks the nerve conduction by decreasing the entry of sodium ions during upstroke of action potential thus decreasing the autonomic response.

 

MATERIALS AND METHODS

PATIENT SELECTION

Sixty consecutive ASA PS I and PS II aged between 18 to 70 years undergoing elective craniotomy for resection of supratentorial tumors with aid of skull pin holder were selected and randomized into two groups. Group 1 received intravenous dexmedetomidine and group 2 received local lignocaine infiltration.

EXCLUSION CRITERIA

• Hypertension
• Ischemic heart disease
• Heart block
• Pregnancy or lactation
• Signs and symptoms of raised intracranial pressure
• Previous craniotomy
• Tumors of hypophysis
• Head injury
• Patient not willing to participate

MATERIALS

• 18 G venflon
• Drugs -dexmedetomidine, 2% lignocaine
• Drugs for general anaesthesia-glycopyrrolate, propofol, atracurium, fentanyl
• Monitors-ECG,NIBP,Spo2,EtCO2
• This study was done in department of anaesthesia, RGGGH, Chennai

STATISTICAL ANALYSIS

Results for parametric data were reported as means+-SD. Demographic data were analyzed by student t-tests. Hemodynamic data were analyzed by independent t-test for differences between group and paired t-test for differences within groups. For post - hoc comparison, Bonferroni test. A value of <0.05 was considered statistically significant

 

METHODOLOGY

After ethical committee approval, patients satisfying inclusion criteria after obtaining consent were randomized by closed envelope method. Group 1 received intravenous dexmedetomidine 1 mcg/kg diluted to 10 mg of saline over 10 minutes before induction. These patients received infiltration of 0.9%saline at the pin site to ensure blinding of observer. Patients randomized to group 2 received 10 ml of 0.9% saline intravenously before induction and then received infiltration of pin sites with 2% lignocaine 3mg at each site. The heart rate and the mean arterial pressure were recorded at following time intervals

• Pre induction T1 (before intravenous dexmedetomidine)
• Pre infiltration T2 (before infiltration of 2%lignocaine)
• Post infiltration T3
• Pre pin application T4
• Post pin application T5
• 10 minutes after pin application T 10
• 15 minutes after pin application T 15

Surgery was proceeded with maintenance of general anaesthesia and after extubation, data compilation and statistical analysis was done

 

OBSERVATION AND ANALYSIS

Results for parametric data were reported as means + - SD. Demographic data were analyzed by Student t-tests. Hemodynamic data were analyzed by independent t-test for differences between group and paired t-test for differences within groups. For post - hoc comparison, Bonferroni test. A value of<0.05 was considered statistically significant While analyzing the age distribution, gender, ASA PS, among the intervention groups using unpaired t-test, the data was found to be statistically insignificant(p>0.05)

RESULTS

Table 1: Heart Rate

While analyzing the heart rate distribution among patients undergoing craniotomy using skull pin holder using unpaired t-test, it was observed that attenuation of heart rate in dexmedetomidine group was better than lignocaine and results were found to be statistically significant (p<0.05).

 

Table 2: Systolic BP

While analysing the systolic BP distribution among patients undergoing craniotomy using skull pin holder using unpaired t test,it was observed that attenuation of systolic BP in dexmedetomidine group was better than lignocaine and results were found to be statistically significant(p<0.05)

Table 3: Diastolic BP

While analysing the diastolic BP distribution among patients undergoing craniotomy using skull pin holder using unpaired t test,it was observed that attenuation of diastolic BP in dexmedetomidine group was better than lignocaine and results were found to be statistically significant (p<0.05)

 

 

 

 

 

Table 4: Mean arterial pressure

While analysing the mean arterial pressure distribution among patients undergoing craniotomy using skull pin holder using unpaired t test, it was observed that attenuation of mean arterial pressure in dexmedetomidine group was better than lignocaine and results were found to be statistically significant (p<0.05)

 

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