Effect of Oral Clonidine as premedication in attenuating Hemodynamic Responses

1. Presentation by Dr S.N.Bhagirath
Professor Hemalatha
Professor and HoD –Dr P.N.Vishwanathan

2. Overview
 Laparoscopic surgeries-increasingly used in varied fields of
surgery.
 Prerequisites for laparoscopic surgery- working cavity,
positional changes
 Working cavity (pneumoperitoneum and its associated side effects)
– hemodynamic effects in terms of SBP, DBP, MAP
 Clonidine oral premedication-
1. Attenuation of these hemodynamic variations
2. Extended post operative analgesia
3. Reduced nausea, vomiting and shivering

3. Pneumoperitoneum
Increased IAP
>15 mm of Hg
Increased
absorption of
CO2
Decreased
exsufflation of
CO2
Hypercarbia
50 – 70 mm of Hg
Acidosis
Trendelenburg’s
position

4. • decreased cardiac
contractility
• sensitization of
myocardium to
arrythmogenic effects of
catecholamines
• systemic vasodilatation
• centrally mediated
sympathetic stimulation
•Decreased CO
•Decreased SV
•Decreased pH
•Increased HR
•Increased BP
•Increased CVP
•Increased Epinephrine
•Increased
Nor Epinephrine
Hypercarbia, Acidosis
Clonidine

5. Patients, material & methods
100 Adult ASA physical status I & II (aged 18 years – 50 years)
Group C (Clonidine) Group P (Placebo)
• 50 patients
• Tab. Clonidine 150 μg as
premedication -90 mins before
• 50 patients
• Tab. Ranitidine 150 mg as
premedication -90 mins before
• Obese patients, patients on antihypertensives and patients with
severe CVS abnormalities excluded from either group
• SBP, DBP, MAP, HR, SpO2, EtCO2, ECG were recorded prior
to induction, before pnp, 3, 15 and 30 mins after pnp, 5 mins
after release of CO2 and 5 mins after extubation.

6. Anaesthesia
 Monitors- SpO2, HR (pulseox), NBP, ECG, EtCO2
 Induction-Thiopentone 5 mg Kg-1
 Muscle relaxant for intubation-Suxamethonium 1.5 mg Kg-1
 Maintained with 33 % O2 in N2O + 0.4 % Halothane
 Relaxant-Vecuronium bromide 0.1 mg Kg-1
 Analgesia-Fentanyl Citrate 1.5 μg Kg-1
 EtCO2 maintained between 35-45 mm of Hg
 Table position-reverse trendelenburg position
 SBP, DBP, MAP, EtCO2, SpO2, ECG were recorded
 Reversal with Neostigmine – 0.05 mg Kg-1 and
Glycopyrrolate 0.01 mg Kg-1
 Degree of pain & sedation assessed with VAS & sedation score.

7. Observations
 Changes in pulse pressure in two groups

8. Observations
 Changes in systolic pressure in two groups

9. Observations
 Changes in mean arterial pressure in two groups

10. Observations
 Changes in diastolic blood pressure in two groups

11. Observations
 VAS Score

12. Discussion
 Hemodynamic changes assoc with pnp-first seen in 1947
 Other drugs tried at attenuating hemodynamic response
1. Esmolol 2. Labetalol 3. Nifedipine
 Aho et al: 4.5μg/kg of Clonidine-decreased MAP
 Joris et al: 8μg/kg of Clonidine-decreased catecholamine levels
 Malek et al: 150μg of Clonidine-hemodynamic stability-pnp
 Sung et al: 150μg of Clonidine-hemodynamic stability-pnp
 Yu et al: 150μg of Clonidine-hemodynamic stability-pnp
 Ishizaki et al: Safe IAP in laparoscopic surgery (<14 mm of Hg)

13. Clonidine
 Imidazoline derivative
 Centrally acting selective
partial α-2 agonist
α-2
Clonidine
Creates a false perception
of high circulating levels
of catecholamines
Reduced
signal to
adrenals
Decreased secretion
of catecholamines
•Decreased HR
• Decreased
blood pressure

14. Conclusion
 Clonidine provides stable hemodynamics during pnp.
 Protects against stress response due to pneumoperitoneum
 Reduced post operative pain.
 Reduced nausea, vomiting and shivering.

15. References
 Booker WM, French DM, Molano PA. Further studies on the acute effects of intra
abdominal pressure. Am J Physiol 1947; 149: 292-8.
 Aho M, Scheinin M, Lehtinen AM, et al. Intramuscularly administered
dexmedetomidine attenuates haemodynamic and stress responses to
gynaecologic laparoscopy. Anesth Analg 1992; 75: 932-9.
 Joris J.L., J.D. Cliche, J.L.M. Canivet, N.J. Jacquet, J.J.Y. Legros and M.L. Lamy.
Hemodynamic Changes Induced by Laparoscopy and Their Endocrine Correlates:
Effects of Clonidine. JACC Vol. 32, No. 5 November 1, 1998:1389-96
 Malek KJ, Knor J, Kurzova A, Lopourova M. Adverse haemodynamic changes
during laparoscopic cholecystectomy and their possible suppression with clonidine
premedication. Comparison with intravenous and intramuscular premedication.
Rozhl Chir 1999; 78: 286-91.
 Ishizaki Y, Bandae Y, Shimomura K, Abe H, Ohtomo Y, Idezuki Y. Safe intra
abdominal pressure of carbon dioxide pneumoperitoneum during laparoscopic
surgery. Surgery 1993; 114: 549-54.

16. Warm thanks to one and all..
Wish you all a happy year ahead..