NM-282
Clonidine Caudal Combined with Dexmedetomidine IV for Awake Incision and Drainage of Septic Knee in 1 Month Old
Deygoo J, Bebic Z, Barnett N, DiMauro J, Kars M, Hagen J
Hofstra Northwell Health System, New Hyde Park, NY, USA
An infant undergoing invasive lower extremity orthopedic procedures is most often managed with a balanced general anesthetic with opiates and/or regional anesthesia; anesthetic techniques reducing the need for postoperative opiates are preferred. Furthermore, recent concern amongst parents, as well as medical practitioners, regarding the potential detrimental effects of certain anesthetics on developing brains has prompted the increased interest in techniques which reduce the need for general endotracheal anesthesia.
We present a full term, one month old female weighing 4.55 kg with no significant past medical history who presented to the emergency department with right leg pain. The patient was found to have osteomyelitis of the right femur and septic arthritis of the right knee. She was started on ampicillin and taken to the OR on hospital day 2 for irrigation and debridement of the right thigh and knee. The patient underwent an uncomplicated general anesthetic for the procedure. On hospital day 3, pus was noted to be draining from the wound. Incision and drainage of the right knee was planned for day 4. The parents were opposed to repeated general anesthesia for this procedure given the recent exposure. The heightened anxiety stemmed from an online search revealing possible detrimental effects of a general. The parents wanted their baby to remain awake for the procedure. An extensive preoperative discussion amongst the attending anesthesiologist, surgeon and multiple family members commenced and the final decision was to attempt regional neuraxial anesthesia with sedation with general anesthesia as backup. An awake caudal with 4.5mL of bupivacaine with epinephrine and 4mcg of clonidine was performed. The patient received a total of 5 micrograms of dexmedetomidine intravenously and a pacifier with sweeties for sedation. Throughout the procedure, the patient remained awake and comfortable, and all vital signs remained stable. The patient recovered in the pediatric PACU and was transferred to the PICU for postoperative monitoring. She did not require any opiates postoperatively and received a single dose 70mg of tylenol the next day for analgesia. FLACC scale was used to assess for pain.
This case highlights the utility of a regional neuraxial anesthetic with sedation in infants as young as 1 month. Furthermore, it demonstrates the probable safety and efficacy of combining clonidine and dexmedetomidine via different routes for both prolongation of caudal analgesia and intraoperative sedation. We preemptively monitored the patient’s hemodynamics and level of sedation in both the PACU and the PICU given the possible heightened effects with this combination of alpha agonists. Further studies are certainly warranted for the safety profile of the combination of neuraxial clonidine in combination with intravenous dexmedetomidine. We believe this technique of an awake caudal with intravenous sedation should be considered in those patients for whom endotracheal anesthesia or opiates should be avoided.​
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