Share this article on:

Polyuria Related to Dexmedetomidine

Pratt, Alexandra MD*; Aboudara, Matthew MD; Lung, Linn BA

doi: 10.1213/ANE.0b013e3182917c86
Critical Care, Trauma, and Resuscitation: Case Report

Dexmedetomidine has become a popular sedative in the intensive care unit for patients undergoing mechanical ventilation because of its highly selective α-2 agonism, which exerts a combination of anesthetic, analgesic, and anxiolytic effects. Bradycardia and hypotension have been reported as the most common side effects of its use in large studies. Dexmedetomidine has been reported to induce polyuria by suppressing vasopressin secretion and increasing permeability of the collecting ducts in a dose-dependent fashion. We report a case of dexmedetomidine-related polyuria that occurred with a high-dose continuous infusion and subsequently resolved with discontinuation of the drug.

Published ahead of print April 30, 2013 Supplemental Digital Content is available in the text.

From the *Department of Surgical Critical Care, Washington Hospital Center, Washington, District of Columbia; Department of Pulmonary and Critical Care, Walter Reed National Military Medical Center, Bethesda, Maryland; and Georgetown University School of Medicine, Washington, District of Columbia.

Matthew Aboudara, MD, is currently affiliated with Pulmonary Clinic, Tripler Army Medical Center, Honolulu, Hawaii.

Linn Lung, MD, resident in training, is currently affiliated with the Department of Emergency Medicine, NYU/Bellevue Hospital, New York, NY.

Accepted for publication March 4, 2013.

Published ahead of print April 30, 2013

Funding: None.

The authors declare no conflicts of interest.

The views expressed in this article are those of the authors and do not reflect the official policy of the Department of Army, Department of Defense, or US government.

Reprints will not be available from the authors.

Address correspondence to Matthew Aboudara, MD, 1 Jarrett White Rd., MCHK-DM-P, Pulmonary Clinic, Tripler Army Medical Center, Honolulu, HI 96859. Address e-mail to maboudara23@gmail.com.

Dexmedetomidine is a sedative with highly selective α-2 agonism resulting in sympatholytic, analgesic, and anxiolytic effects. Common uses include sedation in critically ill patients, as an adjunct in general or epidural anesthesia, and management of alcohol withdrawal delirium.1,2 We report a case of dose-dependent dexmedetomidine-related polyuric syndrome in an intensive care unit (ICU) patient with agitated delirium due to alcohol withdrawal. IRB approval was obtained.

Back to Top | Article Outline

CASE DESCRIPTION

A 50-year-old man with history of alcohol abuse presented to our hospital after a witnessed seizure and fall down a number of steps. There was no relevant medical history. He was tracheally intubated on arrival with a Glasgow Coma Scale of 3, which was believed to be due to a combination of alcohol intoxication, potential postictal state, and a concussion secondary to his fall. Physical examination was notable for only minor facial lacerations and no hemodynamic derangements. Computed tomography of the chest, abdomen, and pelvis showed bilateral lower lobe infiltrates, but no other organ injury or fractures. Computed tomography of the head showed no intracranial pathology. His pertinent admission laboratory values are shown in Table 1. The patient was admitted to the ICU.

Table 1

Table 1

On hospital day 1, the patient’s level of alertness improved but required treatment for hyperactive delirium. On hospital day 2, he was transitioned from propofol to continuous infusion of dexmedetomidine (0.8–1 μg/kg/h) with as-needed doses of lorazepam to minimize respiratory depression in anticipation of tracheal extubation. An initial loading dose of dexmedetomidine was not administered. Despite successful extubation on hospital day 3, his agitation was difficult to control. As a result, dexmedetomidine infusion was increased from 1 to 2 μg/kg/h, and a midazolam infusion was started. Two hours later, the patient’s urine output began to increase from a mean baseline of 95 mL/h (range 60–275 mL/h) to a mean of 455 mL/h (range 500–700 mL/h, see Fig. 1). There was no change in the patient’s hourly fluid intake, serum glucose, or calcium over this time. The infusion was continued at 2 μg/kg/h overnight for a total 18 hours. No adverse hemodynamic consequences occurred. On hospital day 4, dexmedetomidine was tapered off over 3 hours, and he was transitioned to scheduled and as-needed benzodiazepines for ongoing hyperactive delirium. As dexmedetomidine was discontinued, the patient’s urine output returned to 45 to 275 mL/h. There was no significant change in serum sodium over this time period. There was a transient decrease in urine-specific gravity that returned to baseline while the dexmedetomidine was at its maximum dose (Table 1). The patient’s blood glucose did not exceed 172 mg/dL during his ICU stay. His medications are listed in Table 2.

Table 2

Table 2

Figure 1

Figure 1

Back to Top | Article Outline

DISCUSSION

Our search of the literature reveals 1 previous case report of polyuric syndrome in a patient receiving dexmedetomidine.3 In that case, the patient received dexmedetomidine as part of an intraoperative anesthesia regimen at a dose of 0.5 μg/kg/h without a bolus. Elevated serum osmolality and sodium levels resolved within 24 hours of stopping the infusion. In contrast, our patient did not exhibit signs of polyuria until the dose was increased above an infusion rate of 1 μg/kg/h. It is surprising that our patient did not develop hypernatremia despite a urine output in excess of 8 L over 18 hours. Particularly, (as outlined subsequently), dexmedetomidine has been documented to attenuate antidiuretic hormone (ADH) secretion and essentially cause a drug-induced central diabetes insipidus. However, our patient’s urine was not dilute as one would expect if ADH secretion had been suppressed or significantly reduced. In addition, his urine sodium was elevated (Table 1). We feel that the expected reduction in urine osmolality that would be seen with attenuation in ADH secretion was offset by the concomitant infusion of half-normal saline with 5% dextrose that was given during this period, preventing an increase in serum sodium, serum osmolality, or decrease in urine-specific gravity. Other etiologies of polyuria, such as central and nephrogenic diabetes insipidus, primary polydipsia, diuretic administration, and postobstructive diuresis were all unlikely in our case. Our patient had no evidence of intracranial injury affecting the pituitary gland, was not consuming oral fluids, received no diuretics, and had a foley catheter in place. None of the other prescribed medications have been implicated in polyuria (Table 2). Ethanol does have effects on renal function, principally by causing a diuresis of dilute urine via suppression of ADH secretion. However, our patient developed polyuria at a minimum of 72 hours after admission, at which time one would anticipate the ethanol to have been metabolized and the diuretic effect to be negligible. Fortunately, our patient did not develop further renal complications related to alcohol withdrawal such as hypokalemia from renal potassium wasting or acute kidney injury. While we cannot exclude that another undetected phenomenon was responsible for the polyuria, the temporal relationship between the infusion of dexmedetomidine and the dramatic changes in urine output suggests a strong causality.

Dexmedetomidine is an α-2 receptor agonist with 8 times greater affinity for the α-2 adrenoreceptor than clonidine.4 Dexmedetomidine mediates its sedative effects via α-2 receptors in the locus coeruleus.5 Side effects are mediated by central and peripheral actions, and some mechanisms have not been described.6 Multiple animal studies have demonstrated that dexmedetomidine induces polyuria by suppressing vasopressin secretion and increasing permeability of the collecting ducts in a dose-dependent fashion.7–9 Yet, evidence of a similar clinical effect in humans has been rarely reported. Among healthy volunteers, single, high doses of dexmedetomidine decreased norepinephrine and renin levels, but there was no significant change in plasma vasopressin levels.10 We feel that in our case, suppression of vasopressin secretion is the most reasonable explanation for the observed polyuria.

Effects on renal function have not been reported in most studies of dexmedetomidine.11–14 However, in a study of patients undergoing coronary artery bypass grafting, Kulka et al.15 reported preservation of creatinine clearance in patients given clonidine versus placebo. Patients receiving dexmedetomidine as compared with propofol sedation after coronary artery bypass grafting had lower urea and creatinine levels and required less diuretic.16 In another study by Frumento et al.17, thoracic surgery patients receiving adjunctive dexmedetomidine had greater urine output, less diuretic use, and preserved renal function. In contrast, a study of 20 mechanically ventilated ICU patients found no difference in blood urea nitrogen or creatinine levels, or urine output in patients receiving dexmedetomidine compared with propofol.18 In aggregate, these studies suggest no renal harm, and potentially some benefit, with dexmedetomidine.

The dose of dexmedetomidine used was higher than recommended by the United States Food and Drug Administration. Dexmedetomidine has been used with success in patients with alcohol withdrawal,2 and this dose was chosen because our patient had uncontrolled hyperactive alcohol-related delirium on conventional medical therapy. Because there were no adverse hemodynamic or respiratory effects at the time, the dose was titrated in attempts to control his symptoms. Although he developed polyuria, no untoward renal injury occurred, seemingly consistent with the renal outcomes in the study by Frumento et al.17 outlined earlier. It is interesting to note that no adverse hemodynamic effects occurred at this high dose.

In summary, clinicians should be aware that dexmedetomidine has been associated with severe polyuria. The exact mechanism remains to be elucidated, but dexmedetomidine may attenuate the actions of vasopressin. Careful monitoring of urine output and serum sodium levels should be considered in patients receiving dexmedetomidine.

Back to Top | Article Outline

DISCLOSURES

Name: Alexandra Pratt, MD.

Contribution: This author helped analyze the data and write the manuscript.

Attestation: Alexandra Pratt approved the final manuscript.

Name: Matthew Aboudara, MD.

Contribution: This author helped analyze the data and write the manuscript.

Attestation: Matthew Aboudara approved the final manuscript.

Name: Linn Lung, BA.

Contribution: This author helped analyze the data and write the manuscript.

Attestation: Linn Lung approved the final manuscript.

This manuscript was handled by: Michael J. Murray, MD, PhD.

Back to Top | Article Outline

REFERENCES

1. Muzyk AJ, Fowler JA, Norwood DK, Chilipko A. Role of α2-agonists in the treatment of acute alcohol withdrawal. Ann Pharmacother. 2011;45:649–57
2. DeMuro JP, Botros DG, Wirkowski E, Hanna AF. Use of dexmedetomidine for the treatment of alcohol withdrawal syndrome in critically ill patients: a retrospective case series. J Anesth. 2012;26:601–5
3. Greening A, Mathews L, Blair J. Apparent dexmedetomidine-induced polyuric syndrome in an achondroplastic patient undergoing posterior spinal fusion. Anesth Analg. 2011;113:1381–3
4. Bhana N, Goa KL, McClellan KJ. Dexmedetomidine. Drugs. 2000;59:263–8
5. Coursin DB, Coursin DB, Maccioli GA. Dexmedetomidine. Curr Opin Crit Care. 2001;7:221–6
6. Kamibayashi T, Maze M. Clinical uses of alpha2-adrenergic agonists. Anesthesiology. 2000;93:1345–9
7. Kudo LH, Hébert CA, Rouch AJ. Inhibition of water permeability in the rat collecting duct: effect of imidazoline and alpha-2 compounds. Proc Soc Exp Biol Med. 1999;221:136–46
8. Rouch AJ, Kudo LH. Alpha 2-adrenergic-mediated inhibition of water and urea permeability in the rat IMCD. Am J Physiol. 1996;271:F150–7
9. Villela NR, do Nascimento Júnior P, de Carvalho LR, Teixeira A. Effects of dexmedetomidine on renal system and on vasopressin plasma levels. Experimental study in dogs. Rev Bras Anestesiol. 2005;55:429–40
10. Kallio A, Scheinin M, Koulu M, Ponkilainen R, Ruskoaho H, Viinamäki O, Scheinin H. Effects of dexmedetomidine, a selective alpha 2-adrenoceptor agonist, on hemodynamic control mechanisms. Clin Pharmacol Ther. 1989;46:33–42
11. Jakob SM, Ruokonen E, Grounds RM, Sarapohja T, Garratt C, Pocock SJ, Bratty JR, Takala JDexmedetomidine for Long-Term Sedation Investigators. . Dexmedetomidine vs midazolam or propofol for sedation during prolonged mechanical ventilation: two randomized controlled trials. JAMA. 2012;307:1151–60
12. Pandharipande PP, Pun BT, Herr DL, Maze M, Girard TD, Miller RR, Shintani AK, Thompson JL, Jackson JC, Deppen SA, Stiles RA, Dittus RS, Bernard GR, Ely EW. Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial. JAMA. 2007;298:2644–53
13. Riker RR, Shehabi Y, Bokesch PM, Ceraso D, Wisemandle W, Koura F, Whitten P, Margolis BD, Byrne DW, Ely EW, Rocha MGSEDCOM (Safety and Efficacy of Dexmedetomidine Compared With Midazolam) Study Group. . Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial. JAMA. 2009;301:489–99
14. Ruokonen E, Parviainen I, Jakob SM, Nunes S, Kaukonen M, Shepherd ST, Sarapohja T, Bratty JR, Takala J“Dexmedetomidine for Continuous Sedation” Investigators. . Dexmedetomidine versus propofol/midazolam for long-term sedation during mechanical ventilation. Intensive Care Med. 2009;35:282–90
15. Kulka PJ, Tryba M, Zenz M. Dose-response effects of intravenous clonidine on stress response during induction of anesthesia in coronary artery bypass graft patients. Anesth Analg. 1995;80:263–8
16. Herr DL, Sum-Ping ST, England M. ICU sedation after coronary artery bypass graft surgery: dexmedetomidine-based versus propofol-based sedation regimens. J Cardiothorac Vasc Anesth. 2003;17:576–84
17. Frumento RJ, Logginidou HG, Wahlander S, Wagener G, Playford HR, Sladen RN. Dexmedetomidine infusion is associated with enhanced renal function after thoracic surgery. J Clin Anesth. 2006;18:422–6
18. Venn M, Newman J, Grounds M. A phase II study to evaluate the efficacy of dexmedetomidine for sedation in the medical intensive care unit. Intensive Care Med. 2003;29:201–7
© 2013 International Anesthesia Research Society