Successful management of dexmedetomidine for postoperative intensive care sedation in a patient with anti-NMDA receptor encephalitis: a case report and animal experiment

Abstract

Background: Anti-N-methyl-d-aspartate receptor (NMDA-R) encephalitis is a recently identified but increasingly recognized autoimmune paraneoplastic disease. Because these patients present complex neuropsychiatric symptoms due to NMDA-R dysfunction, the optimal methods of sedation/anesthesia remain controversial. Here, we present animal experiment data, along with a related case report, implying the safe and effective use of dexmedetomidine in patients with anti-NMDA-R encephalitis. Findings:(1) Animal experiment: in order to investigate whether dexmedetomidine may interfere with NMDA-R activity, an NMDA antagonist (MK-801) model in rats was used to simulate anti-NMDA-R encephalitis. Administration of MK-801 produced well-characterized schizophrenia-like behaviors, i.e. hyperlocomotion and stereotyped sniffing. Ketamine, an NMDA receptor-dependent anesthetic, exaggerated both behaviors, even at sub-anesthetic doses. On the other hand, dexmedetomidine did not show any exacerbation, suggesting that dexmedetomidine has no clinically relevant interaction with the NMDA-R in vivo. (2) Case report: our patient, a 27-year-old female, was diagnosed with anti-NMDA-R encephalitis secondary to ovarian teratoma. She underwent laparoscopic ovariectomy under general anesthesia using thiopental, sevoflurane, and remifentanil, which were well tolerated. After transfer to the intensive care unit, she became increasingly agitated despite repeated boluses of intravenous fentanyl. Infusion of dexmedetomidine (0.5-1.0 μg/kg/h) was started, and an adequate level of sedation was achieved uneventfully. After discontinuation of dexmedetomidine, recovery from sedation was smooth and quick without any deterioration of neurological or psychological symptoms. Conclusions:Our experimental findings and the presented case suggest that dexmedetomidine may be safely used in patients with anti-NMDA-R encephalitis. Further clinical evaluation is warranted to validate this finding.

Safety and Efficacy of Ketamine Versus Ketamine-Fentanyl-Dexmedetomidine Combination for Anesthesia and Analgesia in Rats

“…The doses of each drug in the combination were modified from previous studies. [21][22][23][24] The anesthesia and analgesia responsiveness were evaluated by the absence or presence of righting reflex and toe pinch. The righting reflex was accessed by placing the rat in the supine position and observing whether it was able to turn prone.…”

“…We used the doses for each drug in combination based on previous studies, with modifications. [21][22][23][24]…”

An Enigma of Female Psychosis: Case Report and Literature Review of Therapeutic Strategies in Paraneoplastic Encephalitis Associated with Ovarian Teratoma

“…Our comprehensive review and experience can be summarized Author Sex/Age Outcome Sameshima et al [8] f/17 Complete recovery Massa et al [10] f/38 Partial remission with no consciousness with spontaneous eye opening Tachibana et al [11] f/21 Complete recovery Abdul-Rahman et al [12] f/25 Partial remission with memory impairment Wali et al [13] f/29 Partial remission with anterograde and retrograde amnesia Boeck et al [6] f/34 Partial remission with reduced cognitive function Imai et al [14] f/39 Complete recovery Braverman et al [15] f/12 Complete recovery Kleyensteuber et al [16] f/25 Partial remission with short term memory loss Naoura et al [17] f/27 Partial remission with attention deficits Kim et al [9] f/15 Complete recovery Frawley et al [18] f/11 Complete recovery Day et al [19] f/21 Patient expired ( cardiac arrest) Dulcey et al [20] f/20 Complete recovery Lo et al [7] f/21 Partial remission with dyskinesia, dysarthria, cognitive impairment Kawano et al [21] f/20 Complete recovery Yamanaka et al [22] f/27 Partial remission Johnson et al [23] f/35 Complete recovery Tanyi et al [24] f/34 Complete recovery f/24…”

Anesthesia for pediatric patients with anti‐NMDA receptor encephalitis: A retrospective case series

“…Volatile anesthetics, propofol, and midazolam have indirect action on the NMDA receptor. Propofol and inhalational agents (except nitrous oxide) were used successfully in these case reports 1,5,8,9,11,12,15,17 . Agents considered free of NMDA receptor activity are opioids, muscle relaxants, and dexmedetomidine 12 .…”