Dexmedetomidine as an Anesthetic Adjunct in Off-Pump Coronary Artery Bypass Grafting: A Case Report

Abstract

Abstract

Introduction: This case report describes the implementation of a dexmedetomidine (Precedex) infusion in a patient undergoing off-pump coronary artery bypass grafting (OPCABG). The focus of this case report is to analyze the impact dexmedetomidine has on perioperative opioid consumption, postoperative recovery, and hemodynamic effects that result. This case is important to analyze because OPCABG is a surgery encountered globally and advances in medicine have made this procedure more accessible to patients. The addition of dexmedetomidine in the anesthetic plan of care resulted in positive outcomes for this patient.

Case Presentation: An OPCABG was performed on a 52-year-old male who had a history of hypertension, multivessel coronary artery disease, NSTEMI, congestive heart failure, end stage renal disease on hemodialysis, and type 2 diabetes mellitus. The patient had a 20-pack year history of smoking and previous surgeries showed no anesthetic complications. Invasive monitoring for the procedure included the use of an arterial line and pulmonary artery catheter. A multimodal anesthetic approach was used which incorporated the use of volatile anesthetics, neuromuscular blockers, opioids, benzodiazepines, and a dexmedetomidine infusion. The dexmedetomidine infusion was started at 0.2 mcg/kg/hr intraoperatively and was continued over into the cardiovascular ICU (CVICU). The patient was able to emerge from anesthesia comfortably and was extubated before leaving the operating room without any complications. The patient’s narcotic usage during the first 48 hours post procedure was recorded. The patient remained hemodynamically stable and required no vasopressor support on emergence and during the entire stay in the CVICU. The patient was transferred out of the CVICU on post op day 2 without any complications.

Discussion: The addition of a dexmedetomidine infusion to the anesthetic plan of care in patients undergoing OPCABG is supported by current literature. Dexmedetomidine has many advantageous effects including analgesia, improvement in hemodynamic stability, and offers cardiac protection.¹ The end result may lead to decreased narcotic requirements which may enable earlier extubation times and an overall decreased length of stay in the ICU.^1,2,3 Intraoperative hemodynamic instability resulting from fluctuations in plasma levels of norepinephrine and epinephrine due to surgical stimulation are attenuated by dexmedetomidine due to the reduction in sympathetic output as a result of alpha-2 agonism.⁴ Heart rate, mean arterial pressure, and systemic vascular resistance will be lower intraoperatively and postoperatively as a result.^4,5 Incidence rates of arrythmias occurring perioperatively such as atrial fibrillation, premature atrial contractions, premature ventricular contractions, and heart blocks are decreased with the use of dexmedetomidine.^4,6 Dexmedetomidine is shown to be a safe and useful anesthetic adjunct in patients undergoing OPCABG.

Keywords

Precedex, dexmedetomidine, off-pump coronary artery bypass grafting, alpha-2 agonist, cardiac surgery