Case Report
25 days old, 3.75 Kg male baby underwent lid surgery (adhesiolysis for symblepharon). He was given Ketamine 4.0mg and glycopyrrolate 0.1 mg (recommended dose: 4-8 mcg/kg) as pre-anaesthetic medication for antisialogogic action. Baby immediately had a tonic clonic convulsion, which responded on giving Inj. Midazolam(0.1mg/kg, IV). Heart rate was more than 200/min. Pulses were feeble, thready, and skin was mottled. Blood pressure was not recordable by non invasive BP monitor. Pupils were dilated and baby was crying excessively, irritable and febrile (temp 390C). Bladder was palpable till umbilicus. Surgery was deferred in view of above condition.
Baby was immediately given normal saline boluses, followed by Dobutamine infusion. HR increased to 250/min. ECG showed sinus tachycardia. After giving digoxin and hydrotherapy, HR decreased to 200/min. Dobutamine was tapered and stopped in 1 hour and neonate shifted to Neonatal ICU for observation. Feeds were gradually restarted. Tachycardia resolved over next three days. Patient was discharged after 4 days of hospital stay.
Introduction
Medication errors are common but under recognized, in primary care settings where neonatal surgeries are not commonly performed.
Table 1
|
Medication |
Dosage |
Onset of Action |
Duration of Action |
Common Adverse Effects 1 |
|
Atropine |
10-20 mcg/kg |
1-2 min |
30-120 min |
Tachycardia, dry hot skin |
|
Glycopyrrolate |
5 mcg/kg |
1-10 min |
360 min |
Tachycardia, arrhythmias, Bronchospasm |
Neonatal anesthesia
Sometime ago, few scientists and healthcare providers believed that infants and young children were unable to localize and/or perceive painful stimuli. Today we know well that newborn can localize and perceive pain from 26-28 weeks of gestation. Now infants routinely receive analgesia and sedation for surgical procedures in the operating room, but the extent to which infants routinely receive medication for other painful procedures varies. In 2016, the American Academy of Pediatrics (AAP) recommended that premedication be used for all intubations in neonates, except in the case of emergent intubation during resuscitation.2 The goal of premedication is to eliminate pain, discomfort, traumatic injury to the airway, and physiologic instability (e.g., bradycardia, hypotension/hypertension, decreased oxygen saturation) associated with endotracheal intubation procedure. Vagolytic agents help prevent reflex bradycardia during intubation because of an exaggerated vagal response and decrease oral and bronchial secretions. Atropine and glycopyrrolate are the most commonly administered vagolytic agents.3
Glycopyrrolate: Indications and usage
Glycopyrrolate is indicated for use as a preoperative antimuscarinic to reduce salivary, tracheobronchial, and pharyngeal secretions; to reduce the volume and free acidity of gastric secretions; and to block cardiac vagal inhibitory reflexes during induction of anesthesia and intubation. It may be used intraoperatively to counteract surgically or drug-induced or vagal reflexes associated arrhythmias.
Dosage and administration
Glycopyrrolate Injection may be administered intramuscularly, or intravenously.
Pediatric dose is 0.004 mg/kg intravenously, maximum 0.1 mg in a single dose which may be repeated, at intervals of 2 to 3 minutes. The another safe alternative is atropine in children.1 (Table 1)
Overdosage
CNS symptoms - excitement, restlessness, psychosis, ataxia, hallucinations, convulsion, coma
Neuromuscular blockade leading to muscular weakness and possible paralysis. Respiratory muscle paralysis can also occur.
Dryness of the skin and mouth, dermal flushing,
Fever, abdominal distention,
Urinary retention, feeding intolerance,
Tachycardia with normal blood pressure, arrhythmia, hypotension
Management of toxicity
Mainly symptomatic.
Specific antidote is Physostigmine.4
Physostigmine infusion with a dose of 0.02 mg/kg (maximum of 0.5mg/dose) over 3 minutes is recommended in infants/children (before infusion, conduction abnormalities e.g., PR, QRS, or QTc interval prolongation should be checked).
Conclusion
Neonatal Dhatura (atropine–like) poisoning needs to be suspected in babies who show postoperative or per operative deterioration in case premedication with atropine or glycopyrrolate is done. The possibility of central anticholinergic syndrome (CAS) should be considered with post-operative flushing, mydriasis, dry skin and mucous membranes, altered mental status or fever.
The American Academy of Pediatrics (AAP) suggests that when choosing premedication, medications with rapid onset and a short duration of action are preferred. Thus, the AAP-preferred vagolytic agent is atropine because of the rapid onset and shorter duration of action compared to glycopyrrolate.
Physostigmine, a tertiary amine, should be available in the operating room for treatment of central anticholinergic syndrome (CAS).