Dexmetomidine

[izzy025]

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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
iz

 

[2ndyear]

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.

 

[coprolalia]

Biggest problem is that it's not an easy fast on...

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



-copro

 

[Bougie]

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...

 

[jetproppilot]

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
iz

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.

 

[Arch Guillotti]

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.

 

[Bougie]

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.

 

[cchoukal]

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.

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.

 

[urge]

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.

 

[2ndyear]

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.

 

[izzy025]

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

also for peds?

 

[seinfeld]

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

also for peds?

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.

 

[Idiopathic]

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.

 

[Fastrach]

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.

I had a staff who's also ICU trained tell me about some studies which came out recently that did not speak favorably to Dex's use in the ICU setting. There really is almost zero amnestic effect, so although pts are sedated, most of the ICU pts in the study had very explicit recall of every crummy moment of their ICU stay.... plus, how expensive must that be to run a Dex infusion over such a long span? Bottom line, I love it in the OR, but won't use it in the ICU for much other than an awake FOB, and possibly for an agitated pt whom they're trying to wean off the vent.

 

[bullard]

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.