Abstract

A 90-year-old female with dementia required an open reduction with internal versus external fixation of the tibia, fibula, and talus bones. General anesthesia was to be avoided if possible, and a spinal anesthetic was contraindicated due to chronic dual antiplatelet therapy. A regional nerve block was to be attempted to allow the use of monitored anesthetic care during the surgical procedure. Due to the patient's age and dementia, the administration of midazolam for procedural sedation was avoided. She received fentanyl 100 mcg intravenously, providing minimal sedative effects and requiring the assistance of 2 staff members to minimize patient movement. During the nerve block placement, the patient's movement resulted in inadvertent intravenous access, which was identified by aspiration and rectified before further local anesthetic administration. After successful regional nerve block placement, the patient underwent the surgical intervention with a propofol infusion for sedation with no additional narcotics required during recovery.

This led to the clinical question, for geriatric patients with diagnosed dementia, can dexmedetomidine be safely used for procedural sedation during regional nerve block administration? A growing body of research concludes that dexmedetomidine is safe in this patient population and that it has neuroprotective qualities, particularly in patients with Alzheimer's disease. While its impact on postoperative cognitive dysfunction is unclear, dexmedetomidine would be an appropriate medication choice as it could provide enough sedation to facilitate the placement of a peripheral nerve block while not increasing the risk for postoperative cognitive dysfunction. Use of dexmedetomidine in the preoperative setting for procedural sedation would be ideally guided by a protocol that would identify specific patient criteria where the use of dexmedetomidine would be more appropriate than a benzodiazepine such as patients older than 65 years and patients diagnosed with dementia or other cognitive dysfunction.

Matthew Walker

Author Details

Matthew Walker anticipates completion of the nurse anesthesia track of the Doctor of Nursing Practice (DNP) program at Samford University on April 29, 2023. His DNP project was: Dexmedetomidine for Procedural Sedation in Patients with Dementia. He plans to start clinical practice this summer at Baptist Medical Center East in Montgomery, Alabama. His primary areas of interest are obstetric and pediatric anesthesia, pharmacology, crisis resource management, and patient safety issues. Prior to starting the program, his critical care experience focused on medical intensive care patients, working in the MICU at UAB Medical Center in Birmingham, Alabama. He holds a Bachelor of Science in Nursing from the University of Alabama at Birmingham and a Bachelor of Science in Finance from the University of Alabama.

Sigma Membership

Non-member

Lead Author Affiliation

Samford University, Birmingham, Alabama, USA

Type

DNP Capstone Project

Format Type

Text-based Document

Study Design/Type

Case Study/Series

Research Approach

N/A

Keywords:

Dexmedetomidine, Dementia, Postoperative Cognitive Dysfunction, Procedural Sedation

Advisor

Herbinger, Lisa

Degree

Doctoral-Other

Degree Grantor

Samford University

Degree Year

2023

Rights Holder

All rights reserved by the author(s) and/or publisher(s) listed in this item record unless relinquished in whole or part by a rights notation or a Creative Commons License present in this item record.

All permission requests should be directed accordingly and not to the Sigma Repository.

All submitting authors or publishers have affirmed that when using material in their work where they do not own copyright, they have obtained permission of the copyright holder prior to submission and the rights holder has been acknowledged as necessary.

Review Type

None: Degree-based Submission

Acquisition

Self-submission

Date of Issue

2023-02-01

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