Anesth Pain Med.  2019 Apr;14(2):236-240. 10.17085/apm.2019.14.2.236.

Fatal pulmonary aspiration during balanced sedation with dexmedetomidine and midazolam: A case report

• Park JH
• Kim SY
• Kwon MA

• KMID: 2447976
• DOI: http://doi.org/10.17085/apm.2019.14.2.236

Abstract

Recently, balanced sedation has commonly been used during procedural sedation. Dexmedetomidine is known for its relative safety to cause "conscious sedation" with little respiratory depression but has some limitations such as frequent awakening and hemodynamic instability during surgery. To facilitate sedation, a small dose of midazolam can be co-administered rather than escalating the dose of dexmedetomidine, especially in elderly patient. Despite the respiratory safety profile of dexmedetomidine, the overall safety of co-administration has not been clarified. We describe the first case of fatal pulmonary aspiration that developed in an elderly patient during balanced sedation with spinal anesthesia for elective femur fracture surgery.

Keyword

Conscious sedation; Dexmedetomidine; Respiratory aspiration of gastric contents

MeSH Terms

Aged
Anesthesia, Spinal
Conscious Sedation
Dexmedetomidine*
Femur
Hemodynamics
Humans
Midazolam*
Respiratory Aspiration of Gastric Contents
Respiratory Insufficiency
Dexmedetomidine
Midazolam

Figure

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  Fig. 1 Chest X rays (A) preoperative, (B) intraoperative, and (C) postoperative.

Reference

1. Boyd BC, Sutter SJ. Dexmedetomidine sedation for awake fiberoptic intubation of patients with difficult airways due to severe odontogenic cervicofacial infections. J Oral Maxillofac Surg. 2011; 69:1608–12. DOI: 10.1016/j.joms.2010.11.004. PMID: 21392875.

2. Mahmoud M, Mason KP. Dexmedetomidine: review, update, and future considerations of paediatric perioperative and periprocedural applications and limitations. Br J Anaesth. 2015; 115:171–82. DOI: 10.1093/bja/aev226. PMID: 26170346.

3. Green SM, Mason KP, Krauss BS. Pulmonary aspiration during procedural sedation: a comprehensive systematic review. Br J Anaesth. 2017; 118:344–54. DOI: 10.1093/bja/aex004. PMID: 28186265.

4. Sun Y, Lu Y, Huang Y, Jiang H. Is dexmedetomidine superior to midazolam as a premedication in children?A meta-analysis of randomized controlled trials. Paediatr Anaesth. 2014; 24:863–74. DOI: 10.1111/pan.12391. PMID: 24666837.

5. Hong JY, Kim WO, Yoon Y, Choi Y, Kim SH, Kil HK. Effects of intravenous dexmedetomidine on low-dose bupivacaine spinal anaesthesia in elderly patients. Acta Anaesthesiol Scand. 2012; 56:382–7. DOI: 10.1111/j.1399-6576.2011.02614.x. PMID: 22220945.

6. Tryba M. Choices in sedation: the balanced sedation technique. Eur J Anaesthesiol Suppl. 1996; 13:8–12. DOI: 10.1097/00003643-199607001-00003. PMID: 8842671.

7. Salonen M, Reid K, Maze M. Synergistic interaction between alpha 2-adrenergic agonists and benzodiazepines in rats. Anesthesiology. 1992; 76:1004–11. DOI: 10.1097/00000542-199206000-00022.

8. Neuman MD, Rosenbaum PR, Ludwig JM, Zubizarreta JR, Silber JH. Anesthesia technique, mortality, and length of stay after hip fracture surgery. JAMA. 2014; 311:2508–17. DOI: 10.1001/jama.2014.6499. PMID: 25058085. PMCID: PMC4344128.

9. Koroglu A, Demirbilek S, Teksan H, Sagir O, But AK, Ersoy MO. Sedative, haemodynamic and respiratory effects of dexmedetomidine in children undergoing magnetic resonance imaging examination: preliminary results. Br J Anaesth. 2005; 94:821–4. DOI: 10.1093/bja/aei119. PMID: 15764627.

10. Yeom JH, Ahn DW, Kim KH. Comparison of several dosing schedules of intravenous dexmedetomidine in elderly patients under spinal anesthesia. Anesth Pain Med. 2017; 12:320–5. DOI: 10.17085/apm.2017.12.4.320.

11. Weerink MAS, Struys MMRF, Hannivoort LN, Barends CRM, Absalom AR, Colin P. Clinical Pharmacokinetics and Pharmacodynamics of dexmedetomidine. Clin Pharmacokinet. 2017; 56:893–913. DOI: 10.1007/s40262-017-0507-7. PMID: 28105598. PMCID: PMC5511603.

12. Bol CJ, Vogelaar JP, Tang JP, Mandema JW. Quantification of pharmacodynamic interactions between dexmedetomidine and midazolam in the rat. J Pharmacol Exp Ther. 2000; 294:347–55. PMID: 10871332.

13. Nason KS. Acute intraoperative pulmonary aspiration. Thorac Surg Clin. 2015; 25:301–7. DOI: 10.1016/j.thorsurg.2015.04.011. PMID: 26210926. PMCID: PMC4517287.

14. Kelly CR, Ihunnah C, Fischer M, Khoruts A, Surawicz C, Afzali A, et al. Fecal microbiota transplant for treatment of Clostridium difficile infection in immunocompromised patients. Am J Gastroenterol. 2014; 109:1065–71. DOI: 10.1038/ajg.2014.133. PMID: 24890442. PMCID: PMC5537742.

15. Engelhardt T, Webster NR. Pulmonary aspiration of gastric contents in anaesthesia. Br J Anaesth. 1999; 83:453–60. DOI: 10.1093/bja/83.3.453. PMID: 10655918.