Early Extubation for Infant Cardiac Surgery Supported by Dexmedetomidine Use.

Pediatric Critical Care Medicine www.pccmjournal. org 989 Fast-track care, which aims to enhance early recovery, is playing an increasingly important role and has significantly gained popularity in the field of perioperative care for pediatric cardiac surgery. Several studies have suggested the benefit of fast-track care in facilitating recovery of patients, decreasing the need of intensive care service, and ultimately decreasing medical costs (1, 2). In patients who have pediatric cardiac surgery, the main strategy for achieving fast-track care is early extubation (EE) (3, 4). Implementation of any specific, evidence-based protocols or manuals in clinical practice might be an option to facilitate dissemination of care. The Collaborative Learning Study developed a collaborative learning strategy to improve postoperative cardiac care (5). Multidisciplinary teams applied a shared learning model through site visits to develop a clinical practice guideline that focused on EE. In this issue of Pediatric Critical Care Medicine, Amula et al (6) investigated the effect of intervention consisting of reduced dosing of intraoperative opioids (total fentanyl dose < 10 μg/kg) on use of anesthetics. This implementation resulted in a decreased use of intraoperative opioids and benzodiazepines, and ultimately, EE, while no change was observed in exposure to volatile anesthetic agents. Decreased use of opioids and benzodiazepines has been replaced by increased intraoperative use of dexmedetomidine and increased postoperative use of acetaminophen. Interestingly, intraoperative dexmedetomidine administration was independently associated with EE, even after adjusting for implementation of the protocol (6). The study by Amula et al (6) suggests a major impact of anesthetic management on EE for infants with cardiac surgery, specifically due to the use of dexmedetomidine. However, several issues need to be discussed. Traditionally, high-dose opioids have been used for infant cardiac surgery to blunt surgical stress with a relatively small influence on hemodynamic status (7). However, this results in delayed recovery from anesthesia and a prolonged intubation time. When clinicians attempt to reduce the dose of opioids in the context of EE, the practice should be balanced with the possible increased risk of surgical stress, including pain in the postoperative period and hemodynamic instability. In fact, an increased Face, Leg, Activity, Cry, Consolability (FLACC) score and increased use of acetaminophen associated with a reduced use of opioids in the study by Amula et al (6) might represent a possible risk of increased painful and uncomfortable stress by reducing opioids. Pain or discomfort is frequently underrecognized by caregivers, specifically in infants. Therefore, a significant risk of stress associated with EE should be kept in mind. Clinicians can use other analgesic/sedative interventions as an alternative to opioids and benzodiazepines. Dexmedetomidine has potent sedative, anxiolytic, sympatholytic, and analgesic properties. Dexmedetomidine has become an attractive alternative and is useful in many diverse areas in pediatric anesthesia (8). The fast elimination half-life and low respiratory depressant property of dexmedetomidine has resulted in clinicians selecting it as an adjunctive anesthetic aiming to achieve an earlier recovery. However, hemodynamic compromise associated with dexmedetomidine could result in increased postoperative morbidity. Several studies have actually suggested an increased occurrence rate of bradyarrhythmia and hypotension due to the antisympathogenic effect of dexmedetomidine (9, 10). Using dexmedetomidine specifically for infants after cardiac surgery may be disadvantageous because most infants have a relatively limited cardiac reserve. A total of 14% of the infants in the dexmedetomidine group had arrhythmias requiring therapy, including life-threatening arrhythmia, and the occurrence rate was significantly greater compared with 6% in the control group (6). Conducting trials with detailed descriptions of intraoperative dexmedetomidine use, as well as evaluating predefined hemodynamic and pain outcomes, is suggested before concluding that dexmedetomidine can be used as an adjunctive anesthetic for infant cardiac anesthesia. Another disadvantage of using dexmedetomidine is that it is relatively expensive and is used as an off-label anesthetic worldwide. Other less-expensive, commonly usable drugs, including ketamine or local anesthesia, to compensate for increased postoperative pain due to limited use of intraoperative fentanyl should be investigated. Specifically, use of ketamine, which has a minimal effect on hemodynamics in children with congenital heart disease (11), should be compared with dexmedetomidine in a prospective manner. Finally, it should cautiously be considered that who might really benefit from an “enhanced recovery strategy. ” As mentioned above, EE and reduced use of opioids could expose children to an uncomfortable postoperative ICU status, as shown by an increased FLACC score. Furthermore, the benefit of reduced consumption of operating room or ICU might be different among situations with different health insurance systems. An example of this situation is that, in countries in which a per-diem based payment system is applied, ultra-short *See also p. 931.