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Discussion in 'Anesthesiology' started by izzy025, May 13, 2008.

  1. izzy025

    izzy025 New Member 7+ Year Member

    Apr 27, 2006
    i'm a novice when it comes to dexmetomidine. i do alot of MAC cases using propofol what are the typical pros/cons of dexmetomidine the dosing patterns to maintain spont. vent for a MAC case contrindications.

    also for icu sedation does the same dosing apply.

    thanx in advance
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  3. 2ndyear

    2ndyear Senior Member 10+ Year Member

    Jul 11, 2002
    New England
    Biggest problem is that it's not an easy fast on, fast off drug like propofol, or even midazolam for that matter. To really get the full effect you need a 1mcg/kg bolus over 15 minutes, and then an infusion. It does have its place, but certainly not in quick high turnover situations like endoscopy. It's also really not an amnestic.
  4. coprolalia

    coprolalia Bored Certified 2+ Year Member

    Aug 5, 2007
    No, the biggest problem is people actually spelling dexmedetomidine correctly.


  5. Bougie

    Bougie Junior Member 2+ Year Member

    Jun 4, 2006
    I use Precedex for those long painful MAC vascular cases.

    You know...the ones where they need the patient to hold their breath once every hour or so to fluro and of course that's precisely when the patient decides to get disinhibited and flail since your attending thinks 7mg of Versed and nothing else is a good idea in a 79 year old vasculopath with Alzheimer's.

    Those cases...and the bradycardia helps with diastolic coronary blahblahblah...
  6. jetproppilot

    jetproppilot Turboprop Driver 10+ Year Member

    Mar 12, 2005
    level at FL210
    Great, great drug.

    Acts like 2nd Year posted.

    Great for CABGs, big backs, etc.

    Good for long MACs too if you can endure the 10-15 minutes up front.

    I'd say start with midaz for the initial buzz....simultaneously start the dex infusion sans bolus for a long MAC case.
  7. Arch Guillotti

    Arch Guillotti Senior Member Administrator Physician Lifetime Donor Classifieds Approved 10+ Year Member

    Aug 8, 2001
    I have found it is useful for those long *** broing vascular cases as well. I have limited use for it as an aid in AFOI. I saw a couple of case reports a while ago (can't remember where dammit) where dex was used for AFOI sedation and the pts. required no topicalization at all!

    I have also found that fat persons w/OSA will obstruct their airway on dex.
  8. Bougie

    Bougie Junior Member 2+ Year Member

    Jun 4, 2006
    My experience as well. I've had to have near perfect topicalization to get away with just Precedex on awake fiberoptics otherwise they wake up just as you stick the scope in the nose.
  9. cchoukal

    cchoukal Senior Member Moderator 10+ Year Member

    Jul 10, 2001
    SF, CA
    We've got a research protocol using this for AFOI at U of Chicago, but we still topicalize! Agree about the long MAC cases. I use this consistently for:

    1) MAC cases on pts w/ pulm HTN (we're a center for this, so we get lots of these pts)

    2) head/spine cases with monitoring, along with an opiate infusion and 1/2 MAC of whatever

    3) it's a great MAC agent when you need the pt to be cooperative. It's like, one minute they're sawing logs, but if you talk to them, they're right there with you.
  10. urge

    urge 10+ Year Member

    Jun 23, 2007
    It's a drug for dummies. Not of use for any specific reason. You can get away with versed/fent/prop, although a lot more skill is needed(which new people never get since they are used to dex).

    In my hosp it is being used like water by CRNAs and residents:

    1General cases- gives you nice numbers, pts extubated calmly
    2Fatties w sleep apnea- cut down on narcs, pts extubated calmly
    3Peds- bolus at the end, pts extubated calmly

    It seems like nobody can do a nice extubation unless they use precedex.

    I have tried it for AFOI but results were not as spectacular as reported in literature.

    Lastly, I think the price is too high for the benefit in 95% of the time it is being used.
  11. 2ndyear

    2ndyear Senior Member 10+ Year Member

    Jul 11, 2002
    New England
    An interesting point about the drug is that, as far as I know, there are no restrictions on it for use by non-anesthesia providers like there are for propofol. This is of course both good and bad for us. In department that is short staffed, perhaps it is appropriate for use in IR, MRI, and those other off site locations that can be a burden to schedule anesthesia for. I know there are studies about its use in pedi-MRI that were generally favorable. Personally I could do without going to pedi-MRI ever again.
  12. izzy025

    izzy025 New Member 7+ Year Member

    Apr 27, 2006
    so what is the recommended dosings u guys use, loading dose and then continuous infusion??

    also for peds?
  13. seinfeld

    seinfeld ASA Member 7+ Year Member

    Apr 12, 2007
    0.2-0.7 mcg/kg/hr after the 1 mcg/kg bolus over 15min. I have seen the paradoxical HTN with higher doses (ie 1.2 or higher) but that was just one time. After using it many times i still feel it is not a reliable a sedative as propofol for MAC. Some are nice and cozy others are wigging. Like it for backs but IV clonidine seems just as effective. I want to use it for hearts when the come off hyperdynamic but i seem to always get the LVAD or the dead heart mitral when i am doing cardiac.
  14. Idiopathic

    Idiopathic Newly Minted Lifetime Donor Classifieds Approved 10+ Year Member

    Apr 21, 2003
    Here, our policy is no higher than 0.7 and for no longer than 24 hours (i.e. ICU sedation). However, we have some ICu delirium trials using three times that dose for 5+ days, so some interesting stuff may come out of that. Ill occasionally use it on a TIVA spine case, but Im not sure you need it, if you are also using prop/remi.

    With that said, we do have an attending who is doing spine cases with dex/lidocaine infusions and 0.5 MAC volatile. No narcotic after induction.
  15. Fastrach

    Fastrach New Member 5+ Year Member

    Aug 24, 2006
  16. bullard

    bullard Senior Member 10+ Year Member

    Oct 15, 2005
    Precedex was taken off our formulary at Northwestern a few years ago before I began residency. Apparently a couple of attendings were using it like water and running up the bill. Nobody seems to miss it as far as I can tell.

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