Adenosine-induced flow arrest to facilitate intracranial aneurysm clip ligation: dose-response data and safety profile.


BACKGROUND: Adenosine-induced transient flow arrest has been used to facilitate clip ligation of intracranial aneurysms. However, the starting dose that is most likely to produce an adequate duration of profound hypotension remains unclear. We reviewed our experience to determine the dose-response relationship and apparent perioperative safety profile of adenosine in intracranial aneurysm patients. METHODS: This case series describes 24 aneurysm clip ligation procedures performed under an anesthetic consisting of remifentanil, low-dose volatile anesthetic, and propofol in which adenosine was used. The report focuses on the doses administered; duration of systolic blood pressure <60 mm Hg (SBP(<60 mm Hg)); and any cardiovascular, neurologic, or pulmonary complications observed in the perioperative period. RESULTS: A median dose of 0.34 mg/kg ideal body weight (range: 0.29-0.44 mg/kg) resulted in a SBP(<60 mm Hg) for a median of 57 seconds (range: 26-105 seconds). There was a linear relationship between the log-transformed dose of adenosine and the duration of a SBP(<60 mm Hg) (R(2) = 0.38). Two patients developed transient, hemodynamically stable atrial fibrillation, 2 had postoperative troponin levels >0.03 ng/mL without any evidence of cardiac dysfunction, and 3 had postoperative neurologic changes. CONCLUSIONS: For intracranial aneurysms in which temporary occlusion is impractical or difficult, adenosine is capable of providing brief periods of profound systemic hypotension with low perioperative morbidity. On the basis of these data, a dose of 0.3 to 0.4 mg/kg ideal body weight may be the recommended starting dose to achieve approximately 45 seconds of profound systemic hypotension during a remifentanil/low-dose volatile anesthetic with propofol induced burst suppression.





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Bebawy, John F, Dhanesh K Gupta, Bernard R Bendok, Laura B Hemmer, Carine Zeeni, Michael J Avram, H Hunt Batjer, Antoun Koht, et al. (2010). Adenosine-induced flow arrest to facilitate intracranial aneurysm clip ligation: dose-response data and safety profile. Anesth Analg, 110(5). pp. 1406–1411. 10.1213/ANE.0b013e3181d65bf5 Retrieved from

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Dhanesh Kumar Gupta

Professor of Anesthesiology

The overall theme of my research is the application of clinical pharmacology tools to the individualization of the care of high-risk surgical patients, especially those undergoing neurosurgical procedures.  Current research focuses on creating pharmacokinetic-pharmacodynamic models to allow simulation of dose-concentration-effect relationships that will result in reduced toxicity while maximizing efficacy of intravenous opioids and hypnotics. The perioperative period is a time when patients are exposed to a multitude of drugs from a different classes, some of which may attenuate while others may augment the deleterious cascade of events that starts in the operating room and result in worse neuro-oncologic, neurovascular, or pain outcomes, even after the perioperative medication has been discontinued.  Analytical techniques for perioperative “big data” have not been combined with the clinical pharmacology toolbox to create dose-response models that can help optimize perioperative care. Through collaboration with pharmacometricians and informaticians, care paths can be developed in an iterative fashion to expose the innards of the perioperative black box.

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