Effect of oral Clonidine as premedication on hemodynamic

responses and postoperative analgesia in patients

undergoing laparoscopic cholecystectomy

Presentation by Dr S.N.Bhagirath

Professor HemalathaProfessor and HoD –Dr P.N.Vishwanathan

Overview

Laparoscopic surgeries-increasingly used in varied fields of surgery.

Prerequisites for laparoscopic surgery- working cavity, positional changes

Working cavity (pneumoperitoneum and its associated side effects) – hemodynamic effects in terms of SBP, DBP, MAP

Clonidine oral premedication-

1. Attenuation of these hemodynamic variations

2. Extended post operative analgesia

3. Reduced nausea, vomiting and shivering

Pneumoperitoneum

Increased IAP>15 mm of Hg

Increased absorption of CO2

Decreased exsufflation of CO2

Hypercarbia50 – 70 mm of Hg

Acidosis

Trendelenburg’s position

• decreased cardiac contractility

• sensitization of myocardium to arrythmogenic effects of catecholamines

• systemic vasodilatation

• centrally mediated sympathetic stimulation

•Decreased CO

•Decreased SV

•Decreased pH

•Increased HR

•Increased BP

•Increased CVP

•Increased Epinephrine•Increased Nor Epinephrine

Hypercarbia, Acidosis

Clonidine

Patients, material & methods100 Adult ASA physical status I & II (aged 18 years – 50 years)

Group C (Clonidine) Group P (Placebo)

• 50 patients

• Tab. Clonidine 150 μg as

premedication -90 mins before

• 50 patients

• Tab. Ranitidine 150 mg as

premedication -90 mins before

• Obese patients, patients on antihypertensives and patients with severe CVS abnormalities excluded from either group

• SBP, DBP, MAP, HR, SpO2, EtCO2, ECG were recorded prior to induction, before pnp, 3, 15 and 30 mins after pnp, 5 mins after release of CO2 and 5 mins after extubation.

Anaesthesia

Monitors- SpO2, HR (pulseox), NBP, ECG, EtCO2

Induction-Thiopentone 5 mg Kg-1

Muscle relaxant for intubation-Suxamethonium 1.5 mg Kg-1

Maintained with 33 % O2 in N2O + 0.4 % Halothane

Relaxant-Vecuronium bromide 0.1 mg Kg-1

Analgesia-Fentanyl Citrate 1.5 μg Kg-1

EtCO2 maintained between 35-45 mm of Hg

Table position-reverse trendelenburg positionSBP, DBP, MAP, EtCO2, SpO2, ECG were recorded

Reversal with Neostigmine – 0.05 mg Kg-1 and

Glycopyrrolate 0.01 mg Kg-1

Degree of pain & sedation assessed with VAS & sedation score.

Observations

Changes in pulse pressure in two groups

Observations

Changes in systolic pressure in two groups

Observations

Changes in mean arterial pressure in two groups

Observations

Changes in diastolic blood pressure in two groups

Observations

VAS Score

Discussion

Hemodynamic changes assoc with pnp-first seen in 1947

Other drugs tried at attenuating hemodynamic response

1. Esmolol 2. Labetalol 3. Nifedipine

Aho et al: 4.5μg/kg of Clonidine-decreased MAP

Joris et al: 8μg/kg of Clonidine-decreased catecholamine levels

Malek et al: 150μg of Clonidine-hemodynamic stability-pnp

Sung et al: 150μg of Clonidine-hemodynamic stability-pnp

Yu et al: 150μg of Clonidine-hemodynamic stability-pnp

Ishizaki et al: Safe IAP in laparoscopic surgery (<14 mm of Hg)

ClonidineImidazoline derivativeCentrally acting selective

partial α-2 agonistα-2

Clonidine

Creates a false perception of high circulating levels of catecholamines

Reduced signal to adrenals

Decreased secretion of catecholamines

•Decreased HR• Decreased blood pressure

Conclusion

Clonidine provides stable hemodynamics during pnp.

Protects against stress response due to pneumoperitoneum

Reduced post operative pain.

Reduced nausea, vomiting and shivering.

References Booker WM, French DM, Molano PA. Further studies on the acute effects of intra

abdominal pressure. Am J Physiol 1947; 149: 292-8.

Aho M, Scheinin M, Lehtinen AM, et al. Intramuscularly administered dexmedetomidine attenuates haemodynamic and stress responses to gynaecologic laparoscopy. Anesth Analg 1992; 75: 932-9.

Joris J.L., J.D. Cliche, J.L.M. Canivet, N.J. Jacquet, J.J.Y. Legros and M.L. Lamy. Hemodynamic Changes Induced by Laparoscopy and Their Endocrine Correlates: Effects of Clonidine. JACC Vol. 32, No. 5 November 1, 1998:1389-96

Malek KJ, Knor J, Kurzova A, Lopourova M. Adverse haemodynamic changes during laparoscopic cholecystectomy and their possible suppression with clonidine premedication. Comparison with intravenous and intramuscular premedication. Rozhl Chir 1999; 78: 286-91.

Ishizaki Y, Bandae Y, Shimomura K, Abe H, Ohtomo Y, Idezuki Y. Safe intra abdominal pressure of carbon dioxide pneumoperitoneum during laparoscopic surgery. Surgery 1993; 114: 549-54.

Warm thanks to one and all..

Wish you all a happy year ahead..