Athena F Zuppa1, Susan C Nicolson1, Nicole S Wilder2, Juan C Ibla3, Erin A Gottlieb4, Kristin M Burns5, Mario Stylianou6, Felicia Trachtenberg7, Hua Ni7, Tera H Skeen4, Dean B Andropoulos8. 1. Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA. 2. Department of Anesthesiology, C.S. Mott Children's Hospital, University of Michigan School of Medicine, Ann Arbor, MI, USA. 3. Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA. 4. Department of Pediatric Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA. 5. Heart Development and Structural Diseases Branch, Division of Cardiovascular Sciences, Bethesda, MD, USA. 6. Office of Biostatistics Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA. 7. New England Research Institutes, Watertown, MA, USA. 8. Department of Pediatric Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA. Electronic address: dra@bcm.edu.
Abstract
BACKGROUND: Dexmedetomidine (DEX) is increasingly used intraoperatively in infants undergoing cardiac surgery. This phase 1 multicentre study sought to: (i) determine the safety of DEX for cardiac surgery with cardiopulmonary bypass; (ii) determine the pharmacokinetics (PK) of DEX; (iii) create a PK model and dosing for steady-state DEX plasma levels; and (iv) validate the PK model and dosing. METHODS: We included 122 neonates and infants (0-180 days) with D-transposition of the great arteries, ventricular septal defect, or tetralogy of Fallot. Dose escalation was used to generate NONMEM® PK modelling, and then validation was performed to achieve low (200-300 pg ml-1), medium (400-500 pg ml-1), and high (600-700 pg ml-1) DEX plasma concentrations. RESULTS: Five of 122 subjects had adverse safety outcomes (4.1%; 95% confidence interval [CI], 1.8-9.2%). Two had junctional rhythm, two had second-/third-degree atrioventricular block, and one had hypotension. Clearance (CL) immediately postoperative and CL on CPB were reduced by approximately 50% and 95%, respectively, compared with pre-CPB CL. DEX clearance after CPB was 1240 ml min-1 70 kg-1. Age at 50% maximum clearance was approximately 2 days, and that at 90% maximum clearance was 18 days. Overall, 96.1% of measured DEX concentrations fell within the 5th-95th percentile prediction intervals in the PK model validation. Dosing strategies are recommended for steady-state DEX plasma levels ranging from 200 to 1000 pg ml-1. CONCLUSIONS: When used with a careful dosing strategy, DEX results in low incidence and severity of adverse safety events in infants undergoing cardiac surgery with cardiopulmonary bypass. This validated PK model should assist clinicians in selecting appropriate dosing. The results of this phase 1 trial provide preliminary data for a phase 3 trial of DEX neuroprotection. CLINICAL TRIALS REGISTRATION: NCT01915277.
BACKGROUND: Dexmedetomidine (DEX) is increasingly used intraoperatively in infants undergoing cardiac surgery. This phase 1 multicentre study sought to: (i) determine the safety of DEX for cardiac surgery with cardiopulmonary bypass; (ii) determine the pharmacokinetics (PK) of DEX; (iii) create a PK model and dosing for steady-state DEX plasma levels; and (iv) validate the PK model and dosing. METHODS: We included 122 neonates and infants (0-180 days) with D-transposition of the great arteries, ventricular septal defect, or tetralogy of Fallot. Dose escalation was used to generate NONMEM® PK modelling, and then validation was performed to achieve low (200-300 pg ml-1), medium (400-500 pg ml-1), and high (600-700 pg ml-1) DEX plasma concentrations. RESULTS: Five of 122 subjects had adverse safety outcomes (4.1%; 95% confidence interval [CI], 1.8-9.2%). Two had junctional rhythm, two had second-/third-degree atrioventricular block, and one had hypotension. Clearance (CL) immediately postoperative and CL on CPB were reduced by approximately 50% and 95%, respectively, compared with pre-CPB CL. DEX clearance after CPB was 1240 ml min-1 70 kg-1. Age at 50% maximum clearance was approximately 2 days, and that at 90% maximum clearance was 18 days. Overall, 96.1% of measured DEX concentrations fell within the 5th-95th percentile prediction intervals in the PK model validation. Dosing strategies are recommended for steady-state DEX plasma levels ranging from 200 to 1000 pg ml-1. CONCLUSIONS: When used with a careful dosing strategy, DEX results in low incidence and severity of adverse safety events in infants undergoing cardiac surgery with cardiopulmonary bypass. This validated PK model should assist clinicians in selecting appropriate dosing. The results of this phase 1 trial provide preliminary data for a phase 3 trial of DEX neuroprotection. CLINICAL TRIALS REGISTRATION: NCT01915277.
Keywords:
anaesthesia; congenital heart surgery; dexmedetomidine; pharmacokinetics; tetralogy of Fallot; transposition of the great arteries; ventricular septal defect
Authors: Lawrence I Schwartz; Mark Twite; Brian Gulack; Kevin Hill; Sunghee Kim; David F Vener Journal: Anesth Analg Date: 2016-09 Impact factor: 5.108
Authors: Amanda L Potts; Brian J Anderson; Guy R Warman; Jerrold Lerman; Susan M Diaz; Sanna Vilo Journal: Paediatr Anaesth Date: 2009-08-25 Impact factor: 2.556
Authors: Felice Su; Marc R Gastonguay; Susan C Nicolson; MaryAnn DiLiberto; Alanna Ocampo-Pelland; Athena F Zuppa Journal: Anesth Analg Date: 2016-05 Impact factor: 5.108
Authors: Kanecia O Zimmerman; Huali Wu; Matthew Laughon; Rachel G Greenberg; Richard Walczak; Scott R Schulman; P Brian Smith; Christoph P Hornik; Michael Cohen-Wolkowiez; Kevin M Watt Journal: Anesth Analg Date: 2019-12 Impact factor: 6.627
Authors: Ashley Stark; P Brian Smith; Christoph P Hornik; Kanecia O Zimmerman; Chi D Hornik; Sidart Pradeep; Reese H Clark; Daniel K Benjamin; Matthew Laughon; Rachel G Greenberg Journal: J Pediatr Date: 2021-09-02 Impact factor: 6.314
Authors: Nathan T James; Joseph H Breeyear; Richard Caprioli; Todd Edwards; Brian Hachey; Prince J Kannankeril; Jacob M Keaton; Matthew D Marshall; Sara L Van Driest; Leena Choi Journal: Br J Clin Pharmacol Date: 2022-01-28 Impact factor: 3.716