Precedex for labor epidurals and spinals

[pmichaelmd]

Our group is just starting to toy with the idea of using Precedex for these purposes and I am wondering what the experience has been in other practices doing the same? 5 mcg in spinals and 25 mcg in labor epidurals with 0.2% ropi/ fentanyl 2 mcg per in the infusion. The limited exposure we have had had shown some benefit in terms of duration and consistency of block level even with switching labor positions.
If you use it for either or both, what doses and pitfalls have you run across?

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[ProwlerturnGas]

Purely anecdotal. I’ve only been adding 25 mcg precedex to epidural top offs. Never use for spinals. The times I have added to my top offs, it greatly reduces the calls from the labor nurses. It seems to me that it helps with maybe marginal epidurals. Again, just my observation.

 

[OptionOffense]

Want to help not get calls? give a bolus of fentanyl when activating the epidural. and make sure the epidural catheter is in the correct place to begin with. If you are not sure, make sure.

 

[pmichaelmd]

Want to help not get calls? give a bolus of fentanyl when activating the epidural. and make sure the epidural catheter is in the correct place to begin with. If you are not sure, make sure.

Lol, I do well with the bolus of 0.2% ropi and then the infusion, but don’t want to be the old fogie who is against progress and modernisation of our practice. Thus I am open to trying Precedex if it seems to have benefits. So far no untoward bradycardia or prolongation of motor blockade to report, but our sample size is still limited. Seems to help in c-sections with discomfort experienced with exteriorisation of the uterus.

 

[IMGASMD]

I think this has been discussed partly before. Whatever additives and/or benefit. May need to do a quick search.

I’ve subscribed to one of the members method for a bit. One solution method…. If there’s some local in the kit, use that for local wheal. Draw from the bag. Use that for LOR. I think some suggested even just use epidural solution for local. For a while, we had a few dry kits, somewhat beneficial.

 

[ProwlerturnGas]

Want to help not get calls? give a bolus of fentanyl when activating the epidural. and make sure the epidural catheter is in the correct place to begin with. If you are not sure, make sure.

Incredibly insightful. I’ll make sure it’s in the correct place when I “activate “ it. 🤪

 

[Katheudontas parateroumen]

Are you saying your epidural solution is 0.2 ropi/2mcg fent/5mcg precedex? Or are these just one time doses of precdex?

 

[pmichaelmd]

Are you saying your epidural solution is 0.2 ropi/2mcg fent/5mcg precedex? Or are these just one time doses of precdex?

The epidural solution is 0.2% ropi/2 mcg per ml fent. The 25 mcg is an epidural bolus dose of Precedex up front.
For spinals 5 mcg of Precedex is added to the heavy marcaine.

 

[BLADEMDA]

The efficacy and safety of intrathecal dexmedetomidine for parturients undergoing cesarean section: a double-blind randomized controlled trial - BMC Anesthesiology

Background The efficacy and safety of spinal anesthesia by intrathecal dexmedetomidine (DEX) for parturients undergoing cesarean section are still lack of evidence. This aim of our study was to evaluate the efficacy and safety of intrathecal DEX for parturients undergoing cesarean section to...

bmcanesthesiol.biomedcentral.com

In our study, compared with intrathecal 9 mg of bupivacaine alone, the onset time of sensory and motor block of parturients in combination of 9 mg of intrathecal bupivacaine with 5 μg of DEX was significantly shortened, and the duration of sensory block was significantly prolonged by 40 min, which is consistent with the research results of Suthar’s [20] and Sushruta’s [10]. The mechanism may be as follows: DEX can activate the α-2 adrenergic receptor in the dorsal horn neurons, activate the spinal cord intermediate neurons by reducing the neurotransmitter released by the primary afferent end and G-protein-mediated potassium channel, and make the spinal cord intermediate neurons hyperpolarized, thus reducing the pain transmission. In addition, DEX can also block the internal flow of Na + and enhance the blocking effect of local anesthetics on the sodium channel of the cell membrane [21, 22]. However, consisted with the results of a meta-analysis [23] that included 9 RCTs, our study found that motor block duration of paturients with intrathecal DEX was also prolonged, which suggest that combination with DEX may increase the fall risk and delay the early rehabilitation of parturients.

 

[pmichaelmd]

The efficacy and safety of intrathecal dexmedetomidine for parturients undergoing cesarean section: a double-blind randomized controlled trial - BMC Anesthesiology

Background The efficacy and safety of spinal anesthesia by intrathecal dexmedetomidine (DEX) for parturients undergoing cesarean section are still lack of evidence. This aim of our study was to evaluate the efficacy and safety of intrathecal DEX for parturients undergoing cesarean section to...

bmcanesthesiol.biomedcentral.com

In our study, compared with intrathecal 9 mg of bupivacaine alone, the onset time of sensory and motor block of parturients in combination of 9 mg of intrathecal bupivacaine with 5 μg of DEX was significantly shortened, and the duration of sensory block was significantly prolonged by 40 min, which is consistent with the research results of Suthar’s [20] and Sushruta’s [10]. The mechanism may be as follows: DEX can activate the α-2 adrenergic receptor in the dorsal horn neurons, activate the spinal cord intermediate neurons by reducing the neurotransmitter released by the primary afferent end and G-protein-mediated potassium channel, and make the spinal cord intermediate neurons hyperpolarized, thus reducing the pain transmission. In addition, DEX can also block the internal flow of Na + and enhance the blocking effect of local anesthetics on the sodium channel of the cell membrane [21, 22]. However, consisted with the results of a meta-analysis [23] that included 9 RCTs, our study found that motor block duration of paturients with intrathecal DEX was also prolonged, which suggest that combination with DEX may increase the fall risk and delay the early rehabilitation of parturients.

Thank you, prolongation of motor blockade is a definite concern in terms of fall risk. Right now we are only using it in parturients. Any experience with labor epidural use?

 

[BLADEMDA]

Comparison of dexmedetomidine and sufentanil as adjuvants to local anesthetic for epidural labor analgesia: a randomized controlled trial

The epidural dexmedetomidine combined with ropivacaine has been successfully used for labor analgesia. We compared the effects of dexmedetomidine and sufentanil as adjuvants to local anesthetic for epidural labor analgesia.Eighty nulliparous women were ...

www.ncbi.nlm.nih.gov

There was no significant difference with regard to SpO2 and motor block during labor. SpO2 values were >90% in group D, suggesting that epidural dexmedetomidine did not result in respiratory depression. RSS values were 1–3 in both groups during labor. There was a significant difference in RSS between the groups, but no excessive sedation was observed in this study. We found RSS values increased obviously in the dexmedetomidine group because dexmedetomidine produced sedative and analgesic effects by acting on α2-adrenergic receptors. Many studies have shown that RSS values with addition of dexmedetomidine to local anesthetic are greater compared to addition of fentanyl,11,12,14 and these findings are in good agreement with our results. Opioids are well known to cause side effects such as, pruritus, nausea, vomiting, and respiratory depression. Compared with opioids, dexmedetomidine did not cause pruritus and had fewer complications of nausea and vomiting during analgesia.15 Dexmedetomidine can be used safely for epidural labor analgesia.

 

[pmichaelmd]

Comparison of dexmedetomidine and sufentanil as adjuvants to local anesthetic for epidural labor analgesia: a randomized controlled trial

The epidural dexmedetomidine combined with ropivacaine has been successfully used for labor analgesia. We compared the effects of dexmedetomidine and sufentanil as adjuvants to local anesthetic for epidural labor analgesia.Eighty nulliparous women were ...

www.ncbi.nlm.nih.gov

Right, read that one also and am intrigued. I am just wondering if you have used it personally and to what effect? Are you using 25mcg instead of the 0.5 mcg/kg? I am trying to find the best risk/benefit balance and lowest effective dose.

 

[BLADEMDA]

The motor block did not show any significant difference between the two groups, and it did not affect the mode of delivery. The use of low concentration of bupivacaine (0.125%) seems to provide satisfactory analgesia with a Bromage scale of a median value (Li et al. 2020; Rodríguez-Ramón et al. 2015). Adding low dose of dexmedetomidine (50 μg) does not appear to affect the motor block.

As the dexmedetomidine group reported better analgesic efficacy and better sedation score compared to the control group, it was reasonable to report a significant improvement in patient satisfaction with dexmedetomidine administration.

Regarding the labor progress and Apgar score, our results were in line with other studies (Jun et al. 2018; Zhao et al. 2017; Wangping and Ming 2017) that negated any significant difference between the two groups.

Effect of the use of dexmedetomidine as a local anesthetic adjuvant to bupivacaine 0.125% in epidural labor analgesia: randomized controlled study - Ain-Shams Journal of Anesthesiology

Background Multiple methods exist for the management of pain during normal labor. Epidural analgesia has been reported to be an effective method in that perspective. The current study was conducted to evaluate the efficacy of dexmedetomidine as an adjuvant to local anesthetics in epidural...

asja.springeropen.com

 

[BLADEMDA]

Right, read that one also and am intrigued. I am just wondering if you have used it personally and to what effect? Are you using 25mcg instead of the 0.5 mcg/kg? I am trying to find the best risk/benefit balance and lowest effective dose.

This is what you are looking for in terms of dosage. It seems just a small dose of Precedex via the epidural is sufficient to get the desired effect:

Dose-response relationship of epidural dexmedetomidine | DDDT

Determining the dose-response relationship of epidural dexmedetomidine (combined with ropivacaine) for labor analgesia

www.dovepress.com

Conclusion: The ED50 and ED95 values of dexmedetomidine for epidural labor analgesia was 0.085 and 0.357 μg/mL under the conditions of this study. Dexmedetomidine is a suitable adjuvant for epidural labor analgesia.

 

[pmichaelmd]

This is what you are looking for in terms of dosage. It seems just a small dose of Precedex via the epidural is sufficient to get the desired effect:

Dose-response relationship of epidural dexmedetomidine | DDDT

Determining the dose-response relationship of epidural dexmedetomidine (combined with ropivacaine) for labor analgesia

www.dovepress.com

Conclusion: The ED50 and ED95 values of dexmedetomidine for epidural labor analgesia was 0.085 and 0.357 μg/mL under the conditions of this study. Dexmedetomidine is a suitable adjuvant for epidural labor analgesia.

Seems promising. I know we use lots of things off-label (Exparel for example), and dexmedetomidine isn’t FDA approved for this use, but it seems to be a great adjuvant, especially in the lower doses we are discussing.
Thanks for the reply, reminds me of the good old days when JPP and UTSW were with us on this board.

 

[BLADEMDA]

Seems promising. I know we use lots of things off-label (Exparel for example), and dexmedetomidine isn’t FDA approved for this use, but it seems to be a great adjuvant, especially in the lower doses we are discussing.
Thanks for the reply, reminds me of the good old days when JPP and UTSW were with us on this board.

So, My hunch is you should be careful about giving more than 25 ug of Precedex as a bolus. Yes, it works quite well but as the dose climbs above 0.5 ug/kg the side-effects increase. I think 10-15 ug may be sufficient as a bolus rather than 25 ug. This is new territory and I don't have the answers so trial and error is needed along with more research.

Assessment the effect of fentanyl and dexmedetomidine as adjuvant to epidural bupivacaine in parturients undergoing normal labor

Introduction Epidural analgesia has been extensively used to provide pain relief during labor [1]. Labor pain and painful uterine contractions cause hyperventilation and high catecholamine levels, resulting in maternal and fetal hypoxemia [2]. Pain relief provides a comfort for the patients and...

www.hoajonline.com

This was the 1 ug/kg bolus dose of Precedex via the Epidural. This is consistent with what I observe as well with doses over 0.5 ug/kg as a bolus:

Results: The dexmedetomidine shortened the onset and prolonged the duration of analgesia compared to fentanyl (p<0.05). Dexmedetomidine was associated with an increased incidence of maternal hypotension, bradycardia, motor block, and dry mouth (p<0.05), while the epidural fentanyl was associated with an increased incidence of maternal pruritus, nausea and vomiting, and respiratory depression (p<0.05). The incidence of shivering was lower in the dexmedetomidine group compared to fentanyl group (p=0.003).

 

[LivetoTell]

For what it's worth. I use it for c-sections mainly. 5ucg in spinals, 20 u for epidurals. It just tends to smooth things out. Very seldom do I have overly anxious patients complaining of this or that, which is one of the reasons why sections are such a pain. You notice that some will get drowsy, and some even remark about it " I'm so sleepy all of a sudden." Every now and then you see bradycardia, and complaints of nausea before the section starts (could be combo of bicitra & nerves w/ nausea). I never really use it for laboring epidurals. I'll use it for high maintenance patients or for break through pain, that can't seem to be controlled with the usual bolus/top up. I haven't had them call me about a prolonged motor block either. I also believe it's stated somewhere, that it helps with shivering which can be a pain when you want to know the BP.

 

[Hork Bajir]

What concentration are people using for neuraxial administration? 4mcg/ml could quickly add up to a lot of volume, but it’s a pain in the azz to find the more concentrated vials at my shop

(Edit for clarification:my concern is related to the fact that larger volumes would dilute out the concentration of whatever other local you are using)

 

[nimbus]

What concentration are people using for neuraxial administration? 4mcg/ml could quickly add up to a lot of volume, but it’s a pain in the azz to find the more concentrated vials at my shop

(Edit for clarification:my concern is related to the fact that larger volumes would dilute out the concentration of whatever other local you are using)

I just learned this week that our hospital acquisition cost for the 50ml (4mcg/ml) vial is $40 while the 2ml (100mcg/ml) vial is about $1.50. So our hospital is putting the 2ml vials in the anesthesia carts while the 50ml vials will stay in the central OR Pyxis.

 

[LivetoTell]

I use the 2ml (100mcg/ml) vial as well. Tiny amounts are used.

 

[nimbus]

I use the 2ml (100mcg/ml) vial as well. Tiny amounts are used.

I squirt the 2ml vial into a 50ml bag of NS and use it all day.

 

[BLADEMDA]

I squirt the 2ml vial into a 50ml bag of NS and use it all day.

Be careful about injecting preservatives in the Neuraxial space. For a spinal a tiny dose of 5 ug is all you need for the desired effect of prolonged sensory block with local anesthetic sparing/reduced dose. I doubt 5ug or 0.05 ml from the 2ml vial would do much harm to a patient when injected into the CSF.

 

[nimbus]

Be careful about injecting preservatives in the Neuraxial space. For a spinal a tiny dose of 5 ug is all you need for the desired effect of prolonged sensory block with local anesthetic sparing/reduced dose. I doubt 5ug or 0.05 ml from the 2ml vial would do much harm to a patient when injected into the CSF.

I haven’t used precedex for neuraxial yet. I’d handle it much more carefully if I did and treat the vial as a single dose vial.