Applications of Dexmedetomidine in Palliative and Hospice Care.

Although the use of dexmedetomidine is currently approved by the US Food and Drug Administration in the adult population for monitored anesthesia care and sedation during mechanical ventilation, clinical experience suggests the potential application of dexmedetomidine in the palliative care arena. The medication can provide sedation with lower risk of delirium, control or minimize the adverse effects of other medications, and augment analgesia from opioids. We conducted a computerized bibliographic search of the literature regarding dexmedetomidine use for the treatment of pain and provision of sedation during palliative and hospice care in adult and pediatric patients. The objective was to provide a general descriptive account of the physiologic effects of dexmedetomidine and review its potential applications in the field of palliative and hospice care in adult and pediatric patients. The sedative and analgesic effects of dexmedetomidine have been well studied in animal and human models. Published experience from both single case reports and small case series has demonstrated the potential therapeutic applications of dexmedetomidine in palliative and hospice care. In addition to intravenous administration, case reports have demonstrated its successful use by both the intranasal and subcutaneous routes. Although these experiences have suggested its safety and efficacy, larger series and additional clinical experience with prospective comparison to other agents are needed to further define its efficacy and role in palliative and hospice care.

Sugammadex to Reverse Neuromuscular Blockade Prior to Withdrawal of Life Support.

In certain end-of-life scenarios, pharmacologic reversal of neuromuscular blockade may be indicated. However, given the depth of blockade frequently necessitated in the ICU setting, rapid reversal of neuromuscular blockade is generally not feasible with conventional reversal agents such as neostigmine that inhibit acetylcholinesterase. Sugammadex is a novel pharmacologic agent for the reversal of neuromuscular blockade that acts by directly encapsulating steroidal neuromuscular blocking agents and providing effective 1:1 binding of rocuronium or vecuronium. This unique mechanism of action is rapid and allows for complete reversal and recovery of neuromuscular function. We report the use of sugammadex to reverse neuromuscular blockade prior to compassionate extubation in three pediatric patients. Its clinical use in children is reviewed, potential applications in the palliative care arena discussed, and dosing algorithms presented.

Hyponatremia and Hyporeninemic-Hypoaldosteronism in a Pediatric Intensive Care Unit Patient.

Hyponatremia is one of the most commonly encountered electrolyte abnormalities encountered in the pediatric world. Defined as a serum or plasma sodium less than 135 mEq/L, the etiology of hyponatremia is one that can typically be determined by performance of a thorough history. However, occasionally the etiology of a patient's hyponatremia is more elusive and determined only after laboratory evaluation. We present a 6-year-old girl with a complex medical history including spinal muscular atrophy, tracheostomy and ventilator dependence, who was admitted to the pediatric intensive care unit for treatment and evaluation of seizures with hyponatremia that was initially thought to be due to syndrome of inappropriate anti-diuretic hormone or cerebral salt wasting. However, during her hospital course, it was determined that the hyponatremia was more indicative of a rarer and much less common cause of hyponatremia, hyporeninemic-hypoaldosteronism. The physiological factors controlling serum sodium are reviewed, the etiologies of hyponatremia are presented and the treatment of hyporeninemic-hypoaldosteronism is discussed.

Etiology and Treatment of Intraoperative Hyperkalemia During Posterior Spinal Fusion in an Adolescent.

Hyperkalemia, defined as a serum or plasma potassium greater than 5.5 mEq/L, while an uncommon occurrence in children, is a serious medical problem that warrants immediate attention as it can result in serious cardiac arrhythmias and death. Although hyperkalemia may occur in the critically ill patient or in the setting of renal failure and insufficiency, there are limited reports of its occurrence during intraoperative care. The authors report a previously healthy, 18-year-old patient, who developed hyperkalemia intraoperatively during posterior spinal fusion to treat adolescent idiopathic scoliosis. The potential etiologies of hyperkalemia are reviewed, a differential diagnosis for the possible etiologies presented, and treatment modalities discussed.

Distal slit valve and clinically relevant CSF overdrainage in children with hydrocephalus.

INTRODUCTION: Distal slit valve (DSV) is a system designed for the treatment of hydrocephalus. It has been assumed that, by dispensing with an anti-siphon (AS) mechanism, the DSV induces a set of clinical symptoms associated with fluid overdrainage in patients. Nonetheless, there is no published evidence to support this assumption. MATERIALS AND METHODS: Thus, to determine whether such an association is valid, we reviewed the records of 101 hydrocephalic patients (150 procedures) who had DSVs placed at our institution. The records of 40 hydrocephalic patients (69 procedures) in whom anti-siphon devices (AS) were placed were also reviewed. RESULTS: One DSV patient presented with slit ventricle syndrome (SVS) and low intracranial pressure (ICP). No DSV patients had postoperative subdural collection. One AS patient had a postoperative subdural collection. Thirty-one DSV patients (31%) each required one revision, and 8 (8%) required more than one revision. Twelve AS patients (30%) required one revision and 8 AS patients (20%) required more than one revision. No significant differences were found between the DSV and AS groups in number of revisions, infections or overdrainage. CONCLUSION: We did not find a direct correlation between clinically relevant CSF overdrainage and DSV.