# Precedex



## Farmer2DO (Oct 27, 2011)

Anyone have any experience with Precedex (dexmedetomidine) in the mechanically vented, critical care patient?

I do a lot of critical care transport, but most of it is from the smaller hospitals to the tertiary care medical centers.  I recently did a job from one major hospital to another (70 miles apart; receiving hospital is a heart transplant center) and this was being used in conjunction with fentanyl.  The sending hospital said that they use it on all their open hearts; it was the first time I've seen it.

I'm having a hard time finding information comparing it to the standards:  midazolam, fentanyl, and propofol, particularly regarding hemodynamic effects and duration of action.  This patient was paralyzed, and as he had ECMO, balloon pump and his chest was still open, there was no way in hell we were going to let the paralysis wear off so that we could evaluate his sedation.  So, I had no idea how well he was sedated under the paralysis.

Any thoughts?


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## EnviroMed (Dec 22, 2011)

Farmer2DO said:


> Anyone have any experience with Precedex (dexmedetomidine) in the mechanically vented, critical care patient?
> 
> I do a lot of critical care transport, but most of it is from the smaller hospitals to the tertiary care medical centers.  I recently did a job from one major hospital to another (70 miles apart; receiving hospital is a heart transplant center) and this was being used in conjunction with fentanyl.  The sending hospital said that they use it on all their open hearts; it was the first time I've seen it.
> 
> ...



hey dude, that drug is super expensive, its like propofol minus the respiratory depression (for the most part). if you see a propofol transport long distances, and its a volume resuscitated patient or a cardiac patient DEMAND reevaluation of the propofol (it is a potent respiratory - via direct alpha 2 stimulation and cardiac depressant - infact it acts as an intrinsic beta blocker, also lower BMR, CO, HR, vasodilation, causes bradycardia). very tricky situation with the ecmo. but precedex has been used for longer durations with seemingly fewer side effects. since the patient was ECMO I guess it didn't matter if he was on another respriatory depressant (fentanyl), though better fentanyl than morphine (less vasodilation secondary to histamine release). Did you find how how the patient did?


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## usalsfyre (Dec 22, 2011)

Supposedly no respiratory depression and "less" hemodynamic effect than propofol, although I haven't run across the stuff because as noted above, it's still under patent and godawfully expensive.


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## Farmer2DO (Dec 22, 2011)

EnviroMed said:


> Did you find how how the patient did?




I did.  He was bleeding from his open chest.  Bad.  We did massive transfusion; I think we ran 20 units of blood products while enroute (cryo, FFP, platelets and PRBCs).  He ended up getting an RVAD, and didn't do well.  The family withdrew care.  It was too bad, b/c the guy took time off from his job to go in for an elective procedure: CABG and aortic valve repair.  Walked in under his own power.  

Nice family and productive member of society: poor prognostic indicators.


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## Dwindlin (Dec 22, 2011)

I haven't seen it specifically for sedation, but we use it all the time in the unit for alcohol withdrawal.  Works great, especially for avoiding having to tube someone due to the high amounts of benzos that sometimes get used for withdrawal.


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## bigbaldguy (Dec 22, 2011)

Dwindlin said:


> I haven't seen it specifically for sedation, but we use it all the time in the unit for alcohol withdrawal.  Works great, especially for avoiding having to tube someone due to the high amounts of benzos that sometimes get used for withdrawal.



That's very interesting. I haven't come across this method of getting people through severe alcohol withdrawal in my online research.


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## Dwindlin (Dec 22, 2011)

bigbaldguy said:


> That's very interesting. I haven't come across this method of getting people through severe alcohol withdrawal in my online research.



Below is link to an article on alpha-2 agonists in the treatment of alcohol withdrawal (Precedex is an alpha-2 agonist).

http://www.medscape.com/viewarticle/742191


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## EnviroMed (Dec 25, 2011)

Farmer2DO said:


> Nice family and productive member of society: poor prognostic indicators.



what do you mean by this? poor guy. RIP. May God Bless his soul.


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## Dwindlin (Dec 25, 2011)

EnviroMed said:


> what do you mean by this? poor guy. RIP. May God Bless his soul.



He means it's the nice people who have the bad outcomes. Had this person been a drug dealer (or the like) he would have pulled through and proceeded to live forever.


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## Melclin (Dec 26, 2011)

Why on earth were they transporting a guy this crook?

Were you part of a retrieval team? Not to be nasty, I'm sure you're perfectly capable, but I wouldn't even look at a patient like that without a small army of retrieval doctors present.


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## Dwindlin (Dec 26, 2011)

Melclin said:


> Why on earth were they transporting a guy this crook?
> 
> Were you part of a retrieval team? Not to be nasty, I'm sure you're perfectly capable, but I wouldn't even look at a patient like that without a small army of retrieval doctors present.



Docs doing transports is somewhat a rarity here in the states.  In this area you see residents on HEMS units but that is it.


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## usalsfyre (Dec 26, 2011)

While I can't speak for the OP, I'd be EXTREMELY surprised if there wasn't at least a perfusionist on board with a patient on IABP and ECMO.


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## CANMAN (Dec 26, 2011)

I have transported almost identical patients as the OP posted, pump, two VADS, open chest, bilat chest tubes, etc.. without a MD and was more then comfortable doing so. As USAF said we used to run perfusionist, RN, medic on those calls and while they are a logistical nightmare then all went well. What would you want a physician for on that transport?


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## Melclin (Dec 27, 2011)

CANMAN13 said:


> I have transported almost identical patients as the OP posted, pump, two VADS, open chest, bilat chest tubes, etc.. without a MD and was more then comfortable doing so. As USAF said we used to run perfusionist, RN, medic on those calls and while they are a logistical nightmare then all went well. What would you want a physician for on that transport?



Because I'm not intimately familiar with the theory of, nor do I have experience with: 
-surgical intensive care pts 
-balloon pumps
-ECMO machines
-The common complications (how to identify them & how to treat them) of all three of the above. 

This isn't really a matter of paramedic scope, its a matter of speciality. I'd be surprised if a pt like this was moved at all here, but it may happen sometimes. If it did I'd be surprised if anybody but the specialist docs involved in their care did the transport. I'd be surprised if an emergency doctors would facilitate transfers like this. 

I mean, even for average ICU to ICU transports here retrieval docs are preferred. They have constant access to seniors registrars or consultants in hospital, why shouldn't they have the same in the back of the truck.


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## rambc (Dec 27, 2011)

*Not so much experience*

Anyone have any experience with Precedex (dexmedetomidine) in the mechanically vented, critical care patient?


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## Farmer2DO (Dec 27, 2011)

Melclin said:


> Why on earth were they transporting a guy this crook?
> 
> Were you part of a retrieval team? Not to be nasty, I'm sure you're perfectly capable, but I wouldn't even look at a patient like that without a small army of retrieval doctors present.



We were not part of a retrieval team.  This is the only hospital in upstate NY that places VADs and does heart transplants.  This was his only chance.  



Dwindlin said:


> Docs doing transports is somewhat a rarity here in the states.  In this area you see residents on HEMS units but that is it.



The only time I've ever done transfers with physicians, they are usually residents there for the ride.  The few attendings I've taken were on neonatal runs long distances away from preemie multiples.



usalsfyre said:


> While I can't speak for the OP, I'd be EXTREMELY surprised if there wasn't at least a perfusionist on board with a patient on IABP and ECMO.



Our crew was myself and another paramedic (critical care intern), an RN and an RN intern, an RT and a perfusionist.



CANMAN13 said:


> I have transported almost identical patients as the OP posted, pump, two VADS, open chest, bilat chest tubes, etc.. without a MD and was more then comfortable doing so. As USAF said we used to run perfusionist, RN, medic on those calls and while they are a logistical nightmare then all went well. What would you want a physician for on that transport?



Yes, they are a logistical challenge.  Anytime we have a VAD, a balloon, or ECMO, we use a perfusionist, unless they aren't intubated and are stable, we may use just the nurse.  But it's always RN/paramedic, if intubated an RT.  



Melclin said:


> Because I'm not intimately familiar with the theory of, nor do I have experience with:
> -surgical intensive care pts
> -balloon pumps
> -ECMO machines
> ...



Here, paramedics do the average ICU to ICU transports all the time.  I routinely take intubated patients on multiple drips by myself.  But you're right, it's less about scope and more about specialty.  The major hospital here only has 1 cardiac ICU (CVICU) and they do all the cardiac work, including CABG, intubated CHF, post arrest, unstable MI, VADs, balloon pumps, and all cardiac surgery and heart transplants.  They are a high volume, high acuity unit, and their nurses are pretty damn good at what they do.  On these jobs, we all have our own "niche" of what we do.  I don't pretend I'm any expert on ECMO, VADs and balloons, and having an RT means one less thing for me to worry about.  We actually all work pretty well together.  We don't do many of these, but when we do, they usually go pretty well.


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## CANMAN (Dec 27, 2011)

Farmer2DO said:


> Our crew was myself and another paramedic (critical care intern), an RN and an RN intern, an RT and a perfusionist.
> 
> 
> 
> ...


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## Farmer2DO (Dec 28, 2011)

> Holy clown car of people batman.... 6 people plus a drive on one transport, do you even have that many seatbelts?



Actually, we have a very large truck on a Freightliner chassis.  6 providers can fit comfortably in the back.



> I can understand a perfusionist on some VAD transports and certainly ECMO but you run one on all Balloon Pump patients?



Like I said, sometimes we do just the RN paramedic configuration, like when we have a balloon pump in a stable, concious, un-intubated patient.  But if they are intubated, then they send a perfusionist and RT.  Also, the hospital insists on sending an RN if they have a PA line.



> I guess having the additional resources is nice at times, I have always been used to and comfortable with RN/Paramedic team for 99.9 percent of my transports in my career and am more of a minimalist with number of people on transport. In my time doing transport the more people you add the more chaos insues typically.



We don't do a lot of these jobs; the ones we do are truly sick people that need a multidisciplinary approach.  On these trainwrecks, just a nurse and a paramedic wouldn't be enough to appropriately manage these people.

We also do the routine VAD jobs by ourselves (just paramedic) when the patient already has a VAD and is discharged into the community.  They often end up in their local ED with issues like sepsis, and we go get them and pick them up.


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## coolidge (Aug 22, 2012)

*Clonidine and dexmedetomidine - Alcohol dependence represents approximately 20% of ho*

http://www.medscape.com/viewarticle/742191_print

Above is a link to an article I saved.

Side bar issue.....but good information.

Bob Coolidge, RPh EMT-I CFF

Role of α2-agonists in the Treatment of Acute Alcohol Withdrawal

Clonidine and dexmedetomidine may provide additional benefit in managing alcohol withdrawal by offering a different mechanism of action for targeting withdrawal symptoms. Based on literature reviewed here, the primary role for clonidine and dexmedetomidine is as adjunctive treatment to benzodiazepines, the standard of care in alcohol withdrawal.


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## usalsfyre (Aug 22, 2012)

Since we're reviving dead threads....I've run into dex a couple of times since I posted. My very limited anecdotal experience seems to indicate its even less suited to transport than propofol.


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## FLdoc2011 (Aug 22, 2012)

rambc said:


> Anyone have any experience with Precedex (dexmedetomidine) in the mechanically vented, critical care patient?



At least where I'm at it's main use here is when we have a difficult wean from the vent.  Allows us to do a sort of "awake/sedated" wean and extubate.  Definitely not used that much at all here, but have had to use it a few times on pts that can come off the vent but just need a little more sedation than normal.  We'll transition over to a preceded drip when ready to wean and then turn it off just after extubation.    

In setting of alcohol withdrawal it's like clonidine, just an adjunct to benzos, not meant to replace benzos.    I've personally never seen it used in that setting.   Usually if we have have an ETOH withdrawal that can't be controlled with scheduled PO or IV benzos then they're getting heavily sedated and intubated.


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## Doczilla (Aug 23, 2012)

With limited resources , I've had good results with an "anesthesia bag" consisting of ketamine, (go figure) vecuronium, and versed, hung at a weight-specific rate. Had propofol, but no I.V pump  

I've never even HEARD of the drug in discussion. Then again, Army and expensive isn't even in the same lexicon when it comes to medical stuff.


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## WTEngel (Aug 23, 2012)

As far as having 6 providers along for the ride on a call like this...you practically need 6 providers to lift the transport ECMO circuit and carry all the crap that goes along with it!

It seems like calls like this always have more people, because you try to get the residents and nursing students involved...with complex cases like this it is nice to give the greenhorns a little of exposure.

I am not a fan of propofol on transport, and have limited experience with precedex. What I do know is that most of our referrals that were considering initiating it were told not to do so by our intensivists. My understanding was that, as the good doctor pointed out earlier, it was a nightmare to get them off the vent and they saw higher incidence of ARDS with precedex. 

I think the administration limit on this med is something like 24 or 48 hours before they need to be switched to another sedation package...I could be making that up though...I don't remember specifically.


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## jwk (Aug 25, 2012)

Melclin said:


> Why on earth were they transporting a guy this crook?
> 
> Were you part of a retrieval team? Not to be nasty, I'm sure you're perfectly capable, but I wouldn't even look at a patient like that without a small army of retrieval doctors present.



Because not all hospitals that do open heart surgery do heart transplants.


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## JakeEMTP (Aug 25, 2012)

Farmer2DO said:


> Anyone have any experience with Precedex (dexmedetomidine) in the mechanically vented, critical care patient?
> 
> I do a lot of critical care transport, but most of it is from the smaller hospitals to the tertiary care medical centers.  I recently did a job from one major hospital to another (70 miles apart; receiving hospital is a heart transplant center) and this was being used in conjunction with fentanyl.  The sending hospital said that they use it on all their open hearts; it was the first time I've seen it.
> 
> ...



If you are accepting a patient with a medication you are not familiar with, you need to ask this question when receiving the patient to those in charge of his care like a doctor or the nurse. Later on an anonymous forum is not the time.


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## JakeEMTP (Aug 25, 2012)

WTEngel said:


> As far as having 6 providers along for the ride on a call like this...you practically need 6 providers to lift the transport ECMO circuit and carry all the crap that goes along with it!
> 
> It seems like calls like this always have more people, because you try to get the residents and nursing students involved...with complex cases like this it is nice to give the greenhorns a little of exposure.



Portable ECMO machines do not take 6 people to lift. 

It does take a well organized team to stay in control of all of the devices and make whatever adjustments. This is not a transport for babysitters who do not know the meds or the equipment.

Nursing students have no place on a transport like this due to the limited space. Only experienced licensed caregivers who have many hours of bedside experience with these types of patients should be the primaries with direct patient contact.  The less confusion about who is in charge or doing what is best which is why the bedside team trained in transport with portable vents, IABP, ECMO and VADs are the ideal choice for the team. 

There is nothing wrong with having a doctor on a call like this. Egos should be left behind since anything can go very bad very fast with a patient like this. A Paramedic is limited by scope of practice. A doctor is not.

*Farmer2DO*


> Here, paramedics do the average ICU to ICU transports all the time. I routinely take intubated patients on multiple drips by myself.



That depends on what you consider average.  Average neuro with an EVD and hypothermia? Average MI with hypothermia and multiple drips?  Are you able to make changes to any of the drips?

*Farmer2DO*


> Also, the hospital insists on sending an RN if they have a PA line.


Do you know why the PA line is in the patient?  What monitoring was being done and drips adjusted accordingly?  How often do you routinely care for a patient with a PA line and utilize all the ports?


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## NomadicMedic (Aug 25, 2012)

Farmer2DO said:


> Anyone have any experience with Precedex (dexmedetomidine) in the mechanically vented, critical care patient?



My fiancé was surprised when I shared this post with her. She was surprised that its used on humans. The animal version of this drug, DexDomitor, can cause severe bradycardia and peripheral vasoconstriction. She uses it often, but in much smaller doses than the recommended dose, coupled with opiates, to achieve sedation in pets.


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## JakeEMTP (Aug 25, 2012)

I am not surprised most in EMS have not heard of this drug.  Patients who are normally on Precedex are usually already at a hospital for higher care or the patient is transported by a specialty team who normally work in the CVICUs every day.

This is a nursing forum and a thread discussing Precedex from 7 years ago. 

http://allnurses.com/ccu-nursing-coronary/precedex-99225.html


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## jwk (Aug 25, 2012)

n7lxi said:


> My fiancé was surprised when I shared this post with her. She was surprised that its used on humans. The animal version of this drug, DexDomitor, can cause severe bradycardia and peripheral vasoconstriction. She uses it often, but in much smaller doses than the recommended dose, coupled with opiates, to achieve sedation in pets.



It's been around for a number of years.  The main drawbacks to most is the cost.  Propofol is far cheaper (and it's not exactly cheap) and most of our ventilated patients in the unit seem to be on that.


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## Doczilla (Aug 25, 2012)

Does prexedex share the same anti-convulsant properties as propofol?


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## jwk (Aug 25, 2012)

Doczilla said:


> Does prexedex share the same anti-convulsant properties as propofol?



It's not really thought of as an anti-convulsant drug like barbiturates or some benzos, but it does have anti-convulsant activity simply because it's a CNS depressant.


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## terra incognita (Aug 26, 2012)

We used precedex at times in the trauma unit and I personally wasn't that jazzed bout it. Some attendings just swore by it and I always got the "it makes weaning from the ventilator easier and the patients aren't as restless" response when I asked why.  Our dosing was 0.1-1.4 mcg/kg/hr with caution for bradycardia and hypotension at the higher doses. Also, it was only good for 24 hrs. I think the loading dose was effective but sedation after that was sooooo labile among patients and when you can't titrate the precedex anymore things can get frustrating trying to keep your pt in a lower RASS without being more liberal with the fentanyl drip. I digress. I haven't had great success with it.


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## VFlutter (Aug 26, 2012)

From my pharm textbook. Pretty much the same information you can find online

Actions and Therapeutic Use.

Dexmedetomidine [Precedex], like clonidine, is a selective alpha2-adrenergic agonist. The drug acts in the CNS to cause sedation and analgesia. At this time dexmedetomidine is approved only for short-term sedation in critically ill patients who are initially intubated and undergoing mechanical ventilation. However, in addition to this approved use, the drug has a variety of off-label uses, including enhancement of sedation and analgesia in patients undergoing general anesthesia. In contrast to clonidine, which is administered by epidural infusion, dexmedetomidine is administered by IV infusion.

Pharmacokinetics.

With IV infusion, dexmedetomidine undergoes wide distribution to tissues. In the blood, the drug is 94% protein bound. Dexmedetomidine undergoes rapid and complete hepatic metabolism, followed by excretion in the urine. The elimination half-life is 2 hours.

Adverse Effects.

The most common adverse effects are hypotension and bradycardia. The mechanism is activation of alpha2-adrenergic receptors in the CNS and periphery, which results in decreased release of norepinephrine from sympathetic neurons innervating the heart and blood vessels. If these cardiovascular effects are too intense, they can managed in several ways, including (1) decreasing or stopping the infusion, (2) infusing fluid, (3) and elevating the lower extremities. Giving a muscarinic antagonist (eg, atropine) can increase heart rate.

Additional adverse effects include nausea, dry mouth, and transient hypertension. Importantly, dexmedetomidine does not cause respiratory depression.


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## STXmedic (Mar 16, 2013)

Reviving this thread once again.

Just ran across Dex recently and was curious about something; purely academic wonder. 

So dexmetetomidine is similar to clonidine (and partially oxymetazoline) in that they are Alpha 2 agonists. 

Both clonidine and oxymetazoline have shown to be at least partially reversible in overdose with naloxone.

Is there any evidence that naloxone would be able to reverse any of the effects of dex? Considering the patients Dex is commonly used on, I don't really see too much of a need, but I'd still be curious if it would work. I did a quick google search on my phone that didn't come up with much (that I had access to at least).


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## coolidge (Mar 16, 2013)

From wiki 
Dexmedetomidine (trade names Precedex, Dexdor) is a sedative medication used by intensive care units and anesthetists. It is relatively unusual in its ability to provide sedation without causing respiratory depression. Like clonidine, it is an agonist of α2-adrenergic receptors in certain parts of the brain.
without resp depres
wears off fairly quickly


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## STXmedic (Mar 17, 2013)

coolidge said:


> From wiki
> Dexmedetomidine (trade names Precedex, Dexdor) is a sedative medication used by intensive care units and anesthetists. It is relatively unusual in its ability to provide sedation without causing respiratory depression. Like clonidine, it is an agonist of α2-adrenergic receptors in certain parts of the brain.
> without resp depres
> wears off fairly quickly



Yeah, I'm quite aware of how it works and it's effects. I'm also aware that it's not likely to be needed to be reversed in the setting it's used. Merely curious if naloxone would be effective with it. Again, purely academic curiosity. Thanks, though.


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## Nova1300 (Mar 17, 2013)

I don't know that anyone has studied it.  Narcan is a weird and dangerous drug.  The workings of the endogenous opioid systems are complex and intertwined with multiple other systems in the body, as you likely know.  And I think narcan's pharmacodynamics are varied from person to person, depending on the genetics of the individual.  If there is a reversal effect, it is likely due to narcan screwing with the endogenous opioid system, thereby increasing the catecholamine release that the precedex had initially blocked.  


But, that is only my opinion.  I have not seen the studies you were speaking of.


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## Dwindlin (Mar 17, 2013)

Nova1300 said:


> I don't know that anyone has studied it.  *Narcan is a weird and dangerous drug.*  The workings of the endogenous opioid systems are complex and intertwined with multiple other systems in the body, as you likely know.  And I think narcan's pharmacodynamics are varied from person to person, depending on the genetics of the individual.  If there is a reversal effect, it is likely due to narcan screwing with the endogenous opioid system, thereby increasing the catecholamine release that the precedex had initially blocked.
> 
> 
> But, that is only my opinion.  I have not seen the studies you were speaking of.



Eh?  Narcan is one of the safer drugs out there. . .


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## Carlos Danger (Mar 17, 2013)

usalsfyre said:


> Since we're reviving dead threads....I've run into dex a couple of times since I posted. My very limited anecdotal experience seems to indicate its even less suited to transport than propofol.



Propofol is great drug for transport....Dex, I would agree, not so much.

I have used Dex a handful of times in the ICU, and a few times in transport. And I've studied it a fair amount in school. 

Dex seems to be growing in popularity for both ICU and anesthesia applications. As it has both "sedative" and analgesic properties but when dosed properly, allows the patient to be alert and cooperative and breathe on their own. It has minimal impact on hemodynamics.

It is being used for ventilator sedation and post-operatively. It is being used for "awake" intubations in known difficult airways and also as part of a total IV anesthesia technique. 

I do not see it as an appropriate drug for transport of intubated patients. As anyone who does HEMS can tell you, the dose of sedative and analgesic that you find you patient comfortably on in the referring ICU often needs to be substantially increased to keep them comfortable during transport. Versed, propofol, fentanyl, etc lend themselves well to this. Precedex, however, at a dose range of 0.2-1 mcg/kg/hr is not a highly titratable drug. It is not intended for patients who need deep sedation, and in my experience doesn't fit that role well.

In my (albeit limited) experience with it in transport, it is not uncommon to need to provide additional analgesia or sedation. At which point you've likely defeated the purpose of using Dex in the first place.

If the patient is not intubated and can interact with you, then Dex might work OK during transport.


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## Nova1300 (Mar 17, 2013)

Dwindlin said:


> Eh?  Narcan is one of the safer drugs out there. . .



I'm not quite so sure about that


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## Dwindlin (Mar 17, 2013)

Nova1300 said:


> I'm not quite so sure about that



Yeah, your going to have come with more than that, Narcan (used properly) is an incredibly safe drug, and hell used incorrectly is still safer than most drugs out there. 

What makes you think it isn't safe?


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## Nova1300 (Mar 17, 2013)

I guess it depends on your definition of 'used correctly.' Narcan given in 40 mcg boluses q3 min titrated to a decent resp rate is probably very safe.  Note, that is the 0.4 mg/ml diluted in 10 cc.  A 0.4 mg bolus of narcan can off somebody.  

When I was in paramedic school I was preached the doctrine of narcan's benign nature.  Well, it's untrue.  Narcan is a very potent antagonist and anytime you rapidly antagonize such a widespread system in the body, there are bound to be repercussions.  You give a patient with valvular heart disease or coronary artery disease too much narcan, and you can put them into florid heart failure easily.  There is a sympathetic discharge that comes with opiate reversal (especially rapid and potent antagpnism) that markedly increases myocardial oxygen demand and CO2 production and acutely increases afterload.  

I was that medic.  My protocols called for 0.4 mg narcan IVP for opiate reversal and I gave it like adenosine.  I loved to teach the addicts a lesson.  But that bolus has effects beyond what you may see in the prehospital world, I promise.  

Slow and steady wins the race.  And you don't need a patient awake enough to do calculus.  You need them protecting their airway, nothing more.


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## rwik123 (Mar 17, 2013)

Nova1300 said:


> I guess it depends on your definition of 'used correctly.' Narcan given in 40 mcg boluses q3 min titrated to a decent resp rate is probably very safe.  Note, that is the 0.4 mg/ml diluted in 10 cc.  A 0.4 mg bolus of narcan can off somebody.
> 
> When I was in paramedic school I was preached the doctrine of narcan's benign nature.  Well, it's untrue.  Narcan is a very potent antagonist and anytime you rapidly antagonize such a widespread system in the body, there are bound to be repercussions.  You give a patient with valvular heart disease or coronary artery disease too much narcan, and you can put them into florid heart failure easily.  There is a sympathetic discharge that comes with opiate reversal (especially rapid and potent antagpnism) that markedly increases myocardial oxygen demand and CO2 production and acutely increases afterload.
> 
> ...



Care to cite any literature? 

I agree with not slamming the patients back to full consciousness but narcan is fairly benign when used properly. I don't know if I'm buying all the later down the road consequences you're claiming.


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## Dwindlin (Mar 17, 2013)

Nova1300 said:


> I guess it depends on your definition of 'used correctly.' Narcan given in 40 mcg boluses q3 min titrated to a decent resp rate is probably very safe.  Note, that is the 0.4 mg/ml diluted in 10 cc.  A 0.4 mg bolus of narcan can off somebody.
> 
> When I was in paramedic school I was preached the doctrine of narcan's benign nature.  Well, it's untrue.  Narcan is a very potent antagonist and anytime you rapidly antagonize such a widespread system in the body, there are bound to be repercussions.  You give a patient with valvular heart disease or coronary artery disease too much narcan, and you can put them into florid heart failure easily.  There is a sympathetic discharge that comes with opiate reversal (especially rapid and potent antagpnism) that markedly increases myocardial oxygen demand and CO2 production and acutely increases afterload.
> 
> ...



Theoretical.  Only a handful of cases in the literature and even those cases it is unclear if it was actually the Narcan that caused it.  And I work in the in non-prehospital realm, so I am well aware of what goes on after the patient is transferred (both in the ED and beyond. . .)


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## Nova1300 (Mar 17, 2013)

Will you accept a textbook citation?  I hope this is enough without making me go to pubmed, cuz I'm kinda tired.  This is cut and paste from Barash "Clinical Anesthesia" 




In clinical anesthesia practice, naloxone is administered to antagonize opioid-induced respiratory depression and sedation. Because opioid antagonists will reverse all opioid effects, including analgesia, naloxone should be carefully titrated to avoid producing sudden, severe pain in postoperative patients. Sudden, complete antagonism of opioid effects with naloxone has been reported to cause severe hypertension, tachycardia, ventricular dysrhythmias, and acute, sometimes fatal, pulmonary edema.288 Naloxone-induced pulmonary edema can occur even in healthy young patients who have received relatively small doses (80 to 500 μg) of naloxone.289,290 The mechanism for this phenomenon is thought to be centrally mediated catecholamine release, which causes acute pulmonary hypertension. Because most patients with opioid-induced respiratory depression will often breathe on command, it is important to stimulate them in addition to administering carefully titrated naloxone doses in the immediate postoperative period. It is also essential to monitor vital signs and oxygenation closely after naloxone is administered to detect occurrence of any of these potentially serious complications.
Naloxone will precipitate opioid withdrawal symptoms in opioid-dependent individuals. Clinicians tend to be aware of this risk when treating patients with known opioid addiction, but it is important to consider the potential for opioid withdrawal syndrome when treating nonaddicts who use opioids chronically, such as cancer patients and severe burn and trauma patients with protracted recovery courses.
Naloxone has a very fast onset of action, and thus is easily titrated. Peak effects occur within 1 to 2 minutes, and duration is dose-dependent, but total doses of 0.4 to 0.8 mg generally last 1 to 4 hours.1 Suggested incremental doses for IV titration are 20 to 40 μg given every few minutes until the patient's ventilation improves, but analgesia is not completely reversed. Because naloxone has a short duration of action, respiratory depression may recur if large doses and/or long-acting opioid agonists have been administered. When prolonged ventilatory depression is anticipated, an initial loading dose followed by a naloxone infusion can be used. Infusion rates between 3 and 10 μg/hr have been effective in antagonizing respiratory depression from systemic as well as epidural opioids.291


Not theoretical. I have watched a patient have an NSTEMI after a slug of narcan.  Or you can just look in the PDR or epocrqtes under adverse reactions.


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## Carlos Danger (Mar 17, 2013)

Nova1300 said:


> Not theoretical. I have watched a patient have an NSTEMI after a slug of narcan.  Or you can just look in the PDR or epocrqtes under adverse reactions.



Serious side effects from nalaxone are not theoretical, but they are also not common. 

I do not have a lot of experience with nalaxone. I've given it a few times, watched it given a few more times, and read a fair amount about it. Aside from the common sense "if you give too much or give it too fast it can cause problems, especially in addicts", and "try to only give enough to get them breathing" warning, I've never thought of nalaxone as an especially hazardous drug.

Then, as of late, it seems there has been a lot of talk about nalaxone on the EMS sites and blogs, mostly by those saying we shouldn't use it, because it is so dangerous. However, no one has really given a good explanation or cited any new or damning literature, that I've seen.


Here's how I see it:

Serious side effects from any medication are possible, especially in large doses or rapid administration. I don't hear people saying that we should not use fentanyl or versed or propofol, even those meds are probably responsible for more problems than nalaxone.

The alternative to using nalaxone in a severely narcotized patient is intubation. Intubation will commonly require exposing the patient to other drugs that also have potentially serious side effects. Not to mention that prehospital intubation is probably associated with more problems than is nalaxone administration.


Anyway, because I was curious about this and because I was not able to find much info on the hazards of nalaxone, I spent about that past 60 minutes consulting the following textbooks:

Clinical Anesthesia (Barash)
Miller's Anesthesia
Clinical Anesthesiology (Morgan & Mikhail)
Essential Clinical Anesthesia (Vacanti)
Manual of Clinical Anesthesiology (Chu & Fuller)
Nurse Anesthesia (Nagelhout)
Pharmacology & Physiology in Anesthetic Practice (Stoelting)
Principles of Pharmacology (Golan)
Lippincott's Pharmacology Review's (Harvey)
Anesthetic Pharmacology (Evers)
Goodman & Gillman's Manual of Pharmacology & Therapeutics

Not one of those texts described nalaxone as especially hazardous. Every one of them did refer to problems that can potentially result from sudden sympathetic overstimulation secondary to opiate antagonism. Most of them state that side effects of nalaxone are dose-dependent. 

The description that I found most helpful came from Nagelhout:  

_"The effects of naloxone use range from discomfort to pulmonary edema to sudden death. Pulmonary edema after naloxone administration has been observed in patients with a documented history of cardiovascular disease. Prough and co-workers reported two cases of acute onset of pulmonary edema in young male patients who received either 100 or 200 mcg of naloxone. The report discusses the ability of naloxone to inhibit endogenous pain suppression pathways and to allow unopposed noradrenergic transmission from medullary centers that can produce neurogenic pulmonary edema. Neurogenic pulmonary edema results from an increase in catecholamine levels in healthy patients, as well as in patients with a history of cardiovascular disease. Cautious titration of naloxone is of paramount importance in both cardiovascular patients and healthy patients." _

Granted, these texts are all a few years old so maybe there's some newer info out there. But I have yet to see a compelling reason why nalaxone shouldn't be used when indicated - with caution, like any other medication.


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## Nova1300 (Mar 17, 2013)

Yes, that is certainly a balanced view.  But keep this in mind--  with the availability and use of oral opiates these days, it is not just the addicts we are seeing anymore.  A lot of my elderly patients are on chronic opiates and some on multiples from different doctors without realizing it.  There is a big difference in the tachycardia and hypertension from narcan in a 28 yo addict vs. reversing grandma with aortic stenosis, cad, or pulmonary hypertension.  

When you are reversing opiates, you should view narcan as a vasoactive substance and all of the implications thereof should be taken into account.  


My point - it is not the benign drug I was led to believe it was in paramedic class.  And I do my best to make sure my paramedic friends understand that too.  

Sorry for the soapbox.


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## Carlos Danger (Mar 17, 2013)

Nova1300 said:


> My point - it is not the benign drug I was led to believe it was in paramedic class.  And I do my best to make sure my paramedic friends understand that too.



I think that is a good point.


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## Akulahawk (Mar 17, 2013)

Nova1300 said:


> When you are reversing opiates, you should view narcan as a vasoactive substance and all of the implications thereof should be taken into account.
> 
> 
> My point - it is not the benign drug I was led to believe it was in paramedic class. And I do my best to make sure my paramedic friends understand that too.
> ...


 Don't be sorry for the soapbox that you are on!

While I tend to think of Narcan as basically benign, I am also quite aware of the dangers of using it incorrectly - such as slamming the dose in. While the Narcan itself doesn't cause the effects, it allows an unchecked "stomping of the gas" on the patient, which the opiate was kindly keeping the brakes on. I might consider doing a 0.2-0.3mg IM injection and the balance of a 0.4mg dose would be given slow IVP. Why? Start the process of increasing their respiratory drive and allow the IM injection the time to slowly bring the patient up to consciousness. 

Simply put though, I'm not going to, nor have I ever, slammed in the 0.4mg Narcan dose just because I can or I feel like punishing my opiate OD patient, nor am I going to give it right before delivery to the ED. Why? I much prefer a sedated patient that's not going to cause me problems that all I have to deal with is just keeping a close watch on their respiratory status. No sense in fighting someone that hates my guts completely because I wrecked their high.


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## 18G (Mar 18, 2013)

I transported one patient on Precedex from a V.A Hospital and this was the first time that I had ever heard of it. It was a ventilated patient and it was being used for sedation. It wasn't doing the job very well and the doctor was insistent on leaving it run and not change to something else for transport. As usual, we got bolus dose order for Ativan.

Needless to say, soon as we got down to the unit the RN with us gave like 10mg of Ativan and the patient was great for the transfer.


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## usalsfyre (Mar 18, 2013)

18G said:


> I transported one patient on Precedex from a V.A Hospital and this was the first time that I had ever heard of it. It was a ventilated patient and it was being used for sedation. It wasn't doing the job very well and the doctor was insistent on leaving it run and not change to something else for transport. As usual, we got bolus dose order for Ativan.


Pretty much the issue for transport. Well, that and it's ungodly expensive compared to the standards (propofol or versed/fent). 



18G said:


> Needless to say, soon as we got down to the unit the RN with us gave like 10mg of Ativan and the patient was great for the transfer.


All at once?:unsure: You know there's this thing called titration....

One of the common complaints among physicians is the patient's level of sedation is titrated to nurse comfort rather than what's appropriate for the patient. While I'll be the first to say physicians have at times hard time understanding the transport environment, this would seem to be exactly what they're complaining about.


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## 18G (Mar 18, 2013)

usalsfyre said:


> Pretty much the issue for transport. Well, that and it's ungodly expensive compared to the standards (propofol or versed/fent).
> 
> 
> All at once?:unsure: You know there's this thing called titration....
> ...



I pushed for propofol for transport and made my case but physician wouldn't budge. 

I wouldn't have given the 10mg all at once personally as I think titration is best practice but the resp effect was irrelevant given the pt. was intubated. And pt. was on the hypertensive side to start. So I was like eh. It's all good.


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## usalsfyre (Mar 18, 2013)

18G said:


> the resp effect was irrelevant given the pt. was intubated.


Easy to think that, but one of the pluses of dex is the lack of effect on the respiratory drive. Meaning while you may not of seen it as a big deal, without knowing where they were in the weaning cycle this might have been a significant setback. Depending on the patient benzos can hang around a long time.


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## 18G (Mar 20, 2013)

usalsfyre said:


> Easy to think that, but one of the pluses of dex is the lack of effect on the respiratory drive. Meaning while you may not of seen it as a big deal, without knowing where they were in the weaning cycle this might have been a significant setback. Depending on the patient benzos can hang around a long time.



I understand. Our patient was having issues with delirium as well and just needed sedated for safe transport and to blunt the sympathetic response and do well on the vent. Trust me, with an Autovent 4000, you need an out cold patient.


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## 18G (Mar 11, 2014)

I've looked into Precedex a little more since this thread was originally active. Most of the studies I've seen reveal it as a decent drug in the quiet ICU for moderate sedation and not too bad of side effects. But the data pretty much says it doesn't offer any real advantages over a Versed drip or a propofol drip (those were being compared in the studies). Precedex cost a lot more too.


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## Handsome Robb (Mar 11, 2014)

I hate the phrase "just give them enough to keep them breathing."

No, you're stupid. Give them just enough to keep them breathing AND protecting their own airway, 

Does me no good to have to sit there and hold manual airway maneuvers, suction place adjuncts, whatever it may be when I can give another 100-200 mcg and bring them around enough that they'll breathe, not aspirated and stay super sleepy.


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## Nova1300 (Mar 12, 2014)

18G said:


> I've looked into Precedex a little more since this thread was originally active. Most of the studies I've seen reveal it as a decent drug in the quiet ICU for moderate sedation and not too bad of side effects. But the data pretty much says it doesn't offer any real advantages over a Versed drip or a propofol drip (those were being compared in the studies). Precedex cost a lot more too.



Benzodiazepines are now known to cause delirium in critically ill patients.    Propofol will as well, though to a lesser degree.  Delirium markedly increases both morbidity and mortality in ICU patients.  Neither benzos nor propofol offer any analgesia.  Precedex does have modest analgesic properties.   

You are probably looking at what are termed the ProDex and the MiDex studies.  These looked at time on the vent, hospital length of stay and ability to communicate pain scores. Patients on precedex got off the vent faster and were better able to communicate pain scores.  This study did not look at mortality.  

I sound like a precedex salesman, but in the critically ill population I think it is a great drug.  Even in the CCT truck, most patients don't need to be unconscious.  They need to be comfortable.


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## Brandon O (Mar 12, 2014)

One of the neat and maybe bad things about naloxone is its ability to antagonize endogenous opioid binding. There are probably users on this forum who wouldn't get the same rush from posting if they were on a narcan drip...


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## 18G (Mar 12, 2014)

Nova1300 said:


> Benzodiazepines are now known to cause delirium in critically ill patients.    Propofol will as well, though to a lesser degree.  Delirium markedly increases both morbidity and mortality in ICU patients.  Neither benzos nor propofol offer any analgesia.  Precedex does have modest analgesic properties.
> 
> You are probably looking at what are termed the ProDex and the MiDex studies.  These looked at time on the vent, hospital length of stay and ability to communicate pain scores. Patients on precedex got off the vent faster and were better able to communicate pain scores.  This study did not look at mortality.
> 
> I sound like a precedex salesman, but in the critically ill population I think it is a great drug.  Even in the CCT truck, most patients don't need to be unconscious.  They need to be comfortable.



I have heard about the benzos causing delirium as discussed on Emcrit.org. For IFT, our established goal in our acutely ill patients is to maintain a RASS score of at least -4 or -5. A paralytic is highly encouraged and our medical director is said to be implementing protocol for paralytic on our vent patients for transport. I personally like fentanyl followed by a low infusion dose of propofol in most patients. 

Precedex was not shown to be superior overall at least from what I have seen. I've only encountered the drug once in clinical practice and wasn't impressed but maybe further use will change my mind.


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