Combined dexmedetomidine and glycopyrrolate infusion: Have we found our solution?

Dear Editor,

Sedation is frequently given to the patients undergoing surgery under regional anaesthesia to mitigate physical and psychological discomfort. Dexmedetomidine, a highly selective α2 agonist sedative, anxiolytic, analgesic, muscle relaxant, with minimal respiratory depression, and with sympatholytic properties is one of the preferred choices. But one has to be cautious, for it has serious cardiovascular side effects including bradycardia and hypotension, which is very commonly observed. We report use of glycopyrrolate infusion to counter hemodynamic side effects dexmedetomidine in a 62-year obese male undergoing open reduction and internal fixation surgery for the fracture of acetabulum and tibia under a combined spinal and epidural block.

The patient was prone for bradycardia with dexmedetomidine infusion and at the same time anxious and also had history of snoring. So, we decided to add 200 μg each of dexmedetomidine and glycopyrrolate with normal saline, to get the final concentration 4 μg/mL of both dexmedetomidine and glycopyrrolate in a single syringe.

Infusion was started with a bolus of 1 μg/kg for 10 min and maintained at 0.5 μg/kg/min for 2 h. Ramsay Sedation Scale was maintained between 3 and 4 while the heart rate was within normal limits throughout the duration. The highest recorded heart rate was 70 per min. Blood pressure fluctuations were within 10% of baseline. The surgery was uneventful and no adverse events were noted postoperatively.

Although pretreatment with anticholinergics has been tried earlier,[12] this is the first attempt at using it as infusion. As it is only a single case report, well-designed trials are needed to validate the concept of the simultaneous use of glycopyrrolate and dexmedetomidine and also to establish the optimum dose/regimen.

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