Precedex

[Farmer2DO]

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?

 

[EnviroMed]

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?

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?

 

[usalsfyre]

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.

 

[Farmer2DO]

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.

 

[Dwindlin]

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.

 

[bigbaldguy]

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.

 

[Dwindlin]

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

 

[EnviroMed]

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

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

 

[Dwindlin]

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.

 

[Melclin]

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.

 

[Dwindlin]

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.

 

[usalsfyre]

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.

 

[CANMAN]

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?

 

[Melclin]

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.

 

[rambc]

Not so much experience

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

 

[Farmer2DO]

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.

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.

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.

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.

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.

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.

 

[CANMAN]

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



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.



QUOTE]

Holy clown car of people batman.... 6 people plus a drive on one transport, do you even have that many seatbelts? I can understand a perfusionist on some VAD transports and certainly ECMO but you run one on all Balloon Pump patients?

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.

 

[Farmer2DO]

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.

 

[coolidge]

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.

 

[usalsfyre]

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.