Precedex

[FLdoc2011]

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.

 

[Doczilla]

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.

 

[WTEngel]

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.

 

[jwk]

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.

 

[JakeEMTP]

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?

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.

 

[JakeEMTP]

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?

 

[NomadicMedic]

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.

 

[JakeEMTP]

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

 

[jwk]

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.

 

[Doczilla]

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

 

[jwk]

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.

 

[terra incognita]

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.

 

[VFlutter]

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.

 

[STXmedic]

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).

 

[coolidge]

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

 

[STXmedic]

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.

 

[Nova1300]

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.

 

[Dwindlin]

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. . .

 

[Carlos Danger]

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.

 

[Nova1300]

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

I'm not quite so sure about that