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Dexmedetomidine for sedation during fetoscopic procedures under spinal anesthesia.
Abstract Number: FCI-180
Abstract Type: Case Report Case Series
BACKGROUND. Fetoscopy is a minimally invasive intervention that allows prenatal procedures with significant impact in fetal morbidity and mortality. Delivering anesthesia for these procedures is challenging and their requirements can be met by general, neuraxial, or monitored anesthesia care. So far, there is no consensus regarding the safest anesthesia management. There has been growing awareness of possible anesthesia-induced neurotoxicity from animal studies, but it is unknown whether these concerns are justified since evidence has failed to translate to human studies. Nevertheless, avoiding medications that might trigger deleterious neurological effects during the antenatal period is desirable. Dexmedetomidine is an α2-adrenoceptor agonist with sedative, analgesic, sympatholytic, anxiolytic and neuroprotective properties. It has been previously used in obstetric anesthesia with a degree of placental transfer of 0.68 and so far, no adverse effects on the neonate.
We present 2 cases where IV dexmedetomidine was used as an adjuvant for sedation during fetoscopic procedures under spinal anesthesia.
Two patients with monochorionic twin pregnancies who were diagnosed with Quintero stage III twin–twin transfusion syndrome (TTTS) underwent fetoscopic laser photocoagulation at 17(A) and 19(B) weeks of gestation. Written informed consent was obtained. Patients received a single shot spinal with 10mg hyperbaric bupivacaine+25mcg fentanyl. A co-load bolus of 500mL of ringer’s and norepinephrine 0.05μg/k/m (titrated to 90% initial PAS) were given. Concomitantly, dexmedetomidine (0.05μg/k/h) and remifentanil (TCI 1ng/mL) were started. Supplemental oxygen was administered. Remifentanil was titrated to ≥2 score in the Observer Assessment of Alertness/Sedation Scale. Procedures were completed in 30(B) and 45(A) min with adequate fetal immobility and 100% surgeon satisfaction. Patient B had 3 episodes of respiratory rate <8 with no episodes of apnea >30sec or SpO2<90%. Same patient also had 2 episodes of HR <50 requiring atropine 0.4mg. No significant changes were detected at the end of the procedure in fetal heart rate compared to baseline. Patient satisfaction, pain, sedation and nausea were assessed upon arrival to PACU, 30min and 1h later. Patient A required to keep norepinephrine infusion at PACU for 40 minutes. No other complications were recorded until discharge. Patient A underwent emergency cesarean section for persistent TTTS and placental insufficiency at 29w, patient B is close to term with adequate fetal growth.
Intravenous dexmedetomidine has many desirable properties valuable for the obstetric anesthesiologist. Research is warranted to enlarge evidence on its use.