Lets talk precedex

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Questions questions..

I know absolutely nothing about this drug except that it costs a bundle and thats why we do not have it. Apparently, we are getting it (at least for a short time) to trial.

I have read the regular BS, what im looking for is expert clinical opinions on where it is most useful and when you use it the most.

Appreciated.
 
Hmmm... more expensive? Is it more or less expensive than, say, using propofol for temporary prolonged sedation? Might want to compare some numbers on that.

Anyway, you're a resident. You should get some practice using it. Personally, I find that it has limited value in the OR, but can be a somewhat useful adjunct in the ICU when you're trying to wean a patient off of the ventilator and are planning extubation.

Find a good scenario and ask to try it out. You're in residency, and now is the time to play with it. I won't tell you the dosing, because it varies based on the patient (but, I have pushed up to 0.8 mcg/kg/hr on maintenance and have found that you will still get patients who will not be sufficiently sedated yet have profound side effects). Also, I won't tell you whether or not to use it by itself or supplementing other hypnotic/anesthetic regimens. After you get some experience with it, you'll form your own opinion. However, I will tell you that overall I feel it is a drug with limited practical clinical application. And, watch out for bradycardia... especially in a patient who may not be able to tolerate it...

-copro
 
CremeSickle said:
Questions questions..

I know absolutely nothing about this drug except that it costs a bundle and thats why we do not have it. Apparently, we are getting it (at least for a short time) to trial.

I have read the regular BS, what im looking for is expert clinical opinions on where it is most useful and when you use it the most.

Appreciated.
Click to expand...

Used it extensively at previous gig. We used it on every CABG, every carotid, on most major back cases.

Would come in in the AM, holding room RN would have bolus instituted on CABG pt, lines placed on sleepy pt, roll into room, very little medicine needed for induction...usually a cuppla mg midaz and 10 mg etomidate + 10 mg pancuronium.

Entire CABGs routinely done with total opiod dose of 250 ug fentanyl. Less opiod means faster wake ups.

Dramatically reduces intraoperative volatile agent requirement.

Dramatically reduces hemodynamic lability.

Very impressive, useful drug.

TrinityAlumnus was there. He can vouch for its efficacy on the 400-some CABGs we did annually, in addition to the other cases.
 
We use it a ton at the BID


-at the SAMBA (society 4 ambulatory anesth) meeting 2006 Linn presented "Dex vs Propofol: Cost comparison" and showed that depending on metrics, dex is not necessarily more expensive

-it's $57 a 200 mcg vial, but if you break each vial up into 4 syringes of 50 mcg each and use it on 4 patients, it's not that expensive


............it's great as an adjunct for when

-you want to prevent bucking on the tube at the end of the case

-you want to do a deep MAC (ie antagonizes the tachycardia, agitation, and drool-inducement of ketamine, doesn't add too much to propofol-apnea) I do this quite often in GI/remote (ie, prone, spont breathing like for vertebroplasty or ERCPs)

-if you use it right, you don't get bradycardia...or in healthy patients, it doesn't matter

-great for awake FOIs b/c significantly reduces coughing and maintains cooperation and spont ventilation

-downside: can be sedated for awhile in PACU if going home that day
 
My experience with Precedex:

1. I use it for all of my hearts. The BP and HR lowering effects are tremendously useful especially in fasttracking hearts and postoperatively to keep patients comfortable and keep the HR and BP from shooting up in patients not extubated after valve replacements, decortications, etc., while allowing them to wake up and assess their neurologic function.

2. Awake craniotomies. Just a Godsend for those.

3. Awake portions of spinal cord stimulator testing and placement. If you haven't done those yet, look forward to it. Prone patient not intubated, undergoing a thoracic/lumbar/thoracolumbar laminectomy then having to be awake for testing lead placement. Patient usually a narcotics nightmare preoperatively. You want to blast them with narcotics, but you have to be careful not to snocker them or get them so comfortable that the testing is useless. Precedex's alternative mechanism of action gives you a way to keep the patient comfortable in a titratable fashion.

4. Awake intubations. Since it has no respiratory depressing effects as a sole agent for sedation, it has made my patients a lot more comfortable with this trying situation. Again, the BP and HR lowering effects are very, very useful and most of my patients remember the awake intubation as a very tolerable and not unpleasant experience.

Those are just a few situations I use it in off the top of my head, as well as major spinal fusions and corrections.
 
wow.

250 mcg of fent for the whole case.... im floored.

What sortof timeframe are you seeing clinically relevant analgesic/anesthetic effects? Not talking half life or any of that (i read that in the info), just youre experience with how long they are staying snowed
 
I've only done 2 months of anesthesia but where I'm at they are using it more in the ORs. I really, really liked it the times I used it- for deep MAC (and didn't have to hold the propofol jaw thrust at all!), bolused/single dose at the end of the case for a smoother wakeup, and one of our attendings purportedly did a little demo on the analgesic effects by using it for a medium-sized belly case (no block) and not using any narcotics, with a comfortable patient in the PACU (the resident was floored). Can't wait to get some more experience with it.
 
CremeSickle said:
wow.

250 mcg of fent for the whole case.... im floored.

What sortof timeframe are you seeing clinically relevant analgesic/anesthetic effects? Not talking half life or any of that (i read that in the info), just youre experience with how long they are staying snowed
Click to expand...

You can do a heart with no narcotics (and no epidural). Before they fell out of favor, a private practice guy at a hospital I rotated at would give a patient Vioxx the morning of his/her heart surgery, take them to surgery, control hemodynamic shifts with beta blockade, nitro, neo, gas, etc., have the surgeon inject 0.5% marcaine with epi at all incision sites, give 30 mg of Toradol 20 minutes before projected wake up time and extubate on the table with no problems at the end of the case. Not a 100% fullproof way, but in the right patient, he could usually do it or just use 1 cc of fentanyl the entire case, usually at sternal closure.
 
CremeSickle said:
wow.

250 mcg of fent for the whole case.... im floored.

What sortof timeframe are you seeing clinically relevant analgesic/anesthetic effects? Not talking half life or any of that (i read that in the info), just youre experience with how long they are staying snowed
Click to expand...

Because of the minimal opiod administered, Creme, one can reduce the dex infusion dose after the cannulas are out if you are trying to extubate on the table, or keep the infusion running if its a fast track extubation in the ICU....in other words, after some experience, one can dose properly so pt is not "over snowed"....just comfortable, with railroad-track hemodynamics most of the time.

One can conclude since the drug requires an infusion it isnt long before diminution of "snow effects" are seen....i.e. less than 30 minutes.

A BIS monitor is great in CABGs when you use dex as it allows you to gauge your anesthetic depth better.
 
CremeSickle said:
Questions questions..

I know absolutely nothing about this drug except that it costs a bundle and thats why we do not have it. Apparently, we are getting it (at least for a short time) to trial.

I have read the regular BS, what im looking for is expert clinical opinions on where it is most useful and when you use it the most.

Appreciated.
Click to expand...

Alcohol abusers get this added on in my book.
 
nutmegs said:
I've only done 2 months of anesthesia but where I'm at they are using it more in the ORs. I really, really liked it the times I used it- for deep MAC (and didn't have to hold the propofol jaw thrust at all!), bolused/single dose at the end of the case for a smoother wakeup, and one of our attendings purportedly did a little demo on the analgesic effects by using it for a medium-sized belly case (no block) and not using any narcotics, with a comfortable patient in the PACU (the resident was floored). Can't wait to get some more experience with it.
Click to expand...

sorry we don't have dex here but to echo your experience, some people have tried a strait epidural clonidine technique:
http://www.ncbi.nlm.nih.gov/sites/e...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
 
UTSouthwestern said:
3. Awake portions of spinal cord stimulator testing and placement. If you haven't done those yet, look forward to it. Prone patient not intubated, undergoing a thoracic/lumbar/thoracolumbar laminectomy then having to be awake for testing lead placement. Patient usually a narcotics nightmare preoperatively. You want to blast them with narcotics, but you have to be careful not to snocker them or get them so comfortable that the testing is useless.
Click to expand...


Oh yes, these are a pain in the a$$!
 
We use Dex on our lap gastric bypass fatties to minimize the narcage... MONEY.👍
 
UTSouthwestern said:
My experience with Precedex:

1. I use it for all of my hearts. The BP and HR lowering effects are tremendously useful especially in fasttracking hearts and postoperatively to keep patients comfortable and keep the HR and BP from shooting up in patients not extubated after valve replacements, decortications, etc., while allowing them to wake up and assess their neurologic function.

2. Awake craniotomies. Just a Godsend for those.

3. Awake portions of spinal cord stimulator testing and placement. If you haven't done those yet, look forward to it. Prone patient not intubated, undergoing a thoracic/lumbar/thoracolumbar laminectomy then having to be awake for testing lead placement. Patient usually a narcotics nightmare preoperatively. You want to blast them with narcotics, but you have to be careful not to snocker them or get them so comfortable that the testing is useless. Precedex's alternative mechanism of action gives you a way to keep the patient comfortable in a titratable fashion.

4. Awake intubations. Since it has no respiratory depressing effects as a sole agent for sedation, it has made my patients a lot more comfortable with this trying situation. Again, the BP and HR lowering effects are very, very useful and most of my patients remember the awake intubation as a very tolerable and not unpleasant experience.

Those are just a few situations I use it in off the top of my head, as well as major spinal fusions and corrections.
Click to expand...

Thanks, UT. Your post has really opened my eyes. I'll have to try to convince some of my attendings to try these techniques. Unfortunately, many of them are stuck in their ways and not always willing to try new things (which is a real shame, especially considering this is supposed to be the time for us to learn and try new things).

Again, my experience with Precedex has been limited mostly to the ICU's. And, it has been a bit disappointing. But, you've given us some good new ideas here. Thanks for posting.

-copro
 
I have used it in a few scenarios:

Sometimes for hearts, run as a background infsuion starting pretty much at the beginning of the case. Though I seem to end up giving the same amount of opiod it probably could lessen the dose given.

Awake intubations. Only used a couple of times but it was pretty slick.

In the vascular room for angios, etc. Seems to be pretty good at lightly sedating peopel and taking "the edge" off whilst they are still able to wake up to follow commnds for breath holding, etc.

Inetrestingly, I know fo a case where the precedex infusion was grossly miscalculated and the pt. ended up getting a huge syringe (50 cc's) in very short order. Resulted in extreme hypertension. The alpha 2 receptors got overwhelmed and so the precedex hit the alpha ones pretty hard. I heard that stick after stick of ntg had t be rapidly pushed to get the BP down.
 
in my experience precedex is really nice as an adjunct. It doesn't replace any drug that we use now, but can reduce opioid requirements and provide sedation- ie difficult airway, icu, lap gbp. Try it for peds too for emergence delirium 0.2-0.4 mcg/kg bolus - this works great. It is not the greatest thing to ever happen to anesthesia - I have met some who say this, but it can definitely be useful.
 
UTSouthwestern said:
My experience with Precedex:

1. I use it for all of my hearts. The BP and HR lowering effects are tremendously useful especially in fasttracking hearts and postoperatively to keep patients comfortable and keep the HR and BP from shooting up in patients not extubated after valve replacements, decortications, etc., while allowing them to wake up and assess their neurologic function.

2. Awake craniotomies. Just a Godsend for those.

3. Awake portions of spinal cord stimulator testing and placement. If you haven't done those yet, look forward to it. Prone patient not intubated, undergoing a thoracic/lumbar/thoracolumbar laminectomy then having to be awake for testing lead placement. Patient usually a narcotics nightmare preoperatively. You want to blast them with narcotics, but you have to be careful not to snocker them or get them so comfortable that the testing is useless. Precedex's alternative mechanism of action gives you a way to keep the patient comfortable in a titratable fashion.

4. Awake intubations. Since it has no respiratory depressing effects as a sole agent for sedation, it has made my patients a lot more comfortable with this trying situation. Again, the BP and HR lowering effects are very, very useful and most of my patients remember the awake intubation as a very tolerable and not unpleasant experience.

Those are just a few situations I use it in off the top of my head, as well as major spinal fusions and corrections.
Click to expand...

UT and others, any evidence that alpha-2-agonists are helpful for preventing perioperative MI's? Its clear that they decrease sympathetic output. Some evidence of hemodynamic stability in aortic cases.

I'd think Precedex would be ideal because of its ease of titration.

The reason we don't use Precedex downtown is that our pump runs are friggen ridiculous. 3,4,5 hours. Extremely sick patients. I don't wan't precedex counfounding my DDX on a hypotensive patient who is already tapped out sympathetically.
 
Planktonmd said:
One more thing to add:
Always remember that Dex is NOT an amnestic agent so expect awareness if you use it as the main anesthetic.
Click to expand...

Dex is considered "facilitated arousal" so I think that when the patient is in the sleeping mode, they don't remember this, but when they are aroused, they do remember - just like anyone who is sleeping.

VentdependenT said:
UT and others, any evidence that alpha-2-agonists are helpful for preventing perioperative MI's?
Click to expand...

There is very GOOD evidence that clonidine prevents perioperative MI's. In fact, I think the numbers are as good as beta-blockers.

I read an article last year (can't find it but I know it exists) that compared precedex to propofol for pedi MRI's and as expected, precedex had a much lower incidence of airway problems and morbidity. However, as expected, time to dischare was much greater.

I have used it for many things as mentioned above (airway cases that need spontaneously breathing patients, awake fibers, adjunct to general anesthesia, MAC cases) and would love to try it for other things (awake crani for one.) I think it is a wonderfully useful drug as JPP said.

I want to mention one place I used it that made my life SOOOO much easier. We treat a lot of shot up marines that recently returned from IRAQ and if you have had the great opportunity to do this, you know what a joy it is. They are CRAZY cuz i guess they come out of anesthesia thinking they are in a prison camp or something because they wake up swinging, etc. I even had one try to BITE me! Anyway, we were doing a case on a guy that had severe chronic pain issues and a very large opioid requirement and he had a history of waking up very, very poorly despite the multiple attempts at a smooth wakeup - plus, if any body deserved a ketamine infusion, this guy did, but I knew that would also potentially make his wake up and PTSD wake up worse. So, I ran precedex and ketamine (.25mg/kg/hr) through the case and turned off the ketamine ~45 minutes before the end of the long case and kept the precedex going. I extubated him with the precedex on (he was spontaneously breathing and opening eyes so it was an "awake" extubation) and then took him to the pacu. He chilled in the PACU for 1.5 hrs with no problems. It was very smooth.
 
epidural man said:
Dex is considered "facilitated arousal" so I think that when the patient is in the sleeping mode, they don't remember this, but when they are aroused, they do remember - just like anyone who is sleeping.



There is very GOOD evidence that clonidine prevents perioperative MI's. In fact, I think the numbers are as good as beta-blockers.

I read an article last year (can't find it but I know it exists) that compared precedex to propofol for pedi MRI's and as expected, precedex had a much lower incidence of airway problems and morbidity. However, as expected, time to dischare was much greater.

I have used it for many things as mentioned above (airway cases that need spontaneously breathing patients, awake fibers, adjunct to general anesthesia, MAC cases) and would love to try it for other things (awake crani for one.) I think it is a wonderfully useful drug as JPP said.

I want to mention one place I used it that made my life SOOOO much easier. We treat a lot of shot up marines that recently returned from IRAQ and if you have had the great opportunity to do this, you know what a joy it is. They are CRAZY cuz i guess they come out of anesthesia thinking they are in a prison camp or something because they wake up swinging, etc. I even had one try to BITE me! Anyway, we were doing a case on a guy that had severe chronic pain issues and a very large opioid requirement and he had a history of waking up very, very poorly despite the multiple attempts at a smooth wakeup - plus, if any body deserved a ketamine infusion, this guy did, but I knew that would also potentially make his wake up and PTSD wake up worse. So, I ran precedex and ketamine (.25mg/kg/hr) through the case and turned off the ketamine ~45 minutes before the end of the long case and kept the precedex going. I extubated him with the precedex on (he was spontaneously breathing and opening eyes so it was an "awake" extubation) and then took him to the pacu. He chilled in the PACU for 1.5 hrs with no problems. It was very smooth.
Click to expand...

Did some reading on call yesterday and there are a few strong articles out to support decreased perioperative morbidity/mortality with clonidine usage.

Dex seems ideal for VATS/Thoracotomy patients as well. Comfy wake up with no unwanted beta-adrenergic bronchoconstriction AND the addition of cardiac protection. If the price comes down it'll be more useful.
 
VentdependenT said:
Did some reading on call yesterday and there are a few strong articles out to support decreased perioperative morbidity/mortality with clonidine usage.

Dex seems ideal for VATS/Thoracotomy patients as well. Comfy wake up with no unwanted beta-adrenergic bronchoconstriction AND the addition of cardiac protection. If the price comes down it'll be more useful.
Click to expand...

Vent,

I'm not familiar with beta-adrenergic bronchoconstriction, only beta-2 mediated bronchodilation, what receptor mediates this response?
 
epidural man said:
I want to mention one place I used it that made my life SOOOO much easier. We treat a lot of shot up marines that recently returned from IRAQ and if you have had the great opportunity to do this, you know what a joy it is. They are CRAZY cuz i guess they come out of anesthesia thinking they are in a prison camp or something because they wake up swinging, etc. I even had one try to BITE me!
Click to expand...

We recently had this happen at our hospital as well (I wasn't there, but a resident was talking about it the other day). I don't know the details and I don't think any biting was involved (except for on the tube), but yes, this is something we will be dealing with more for a while I suspect.

Also, football linebackers can be fun to wake up (so I've heard...)
 
Vent-

Dex is $57 a vial for 200mcg....often times you just need the loading dose of 1 mcg/kg/hr....I break the vial up into 2-4 syringes and use it for 2-4 patients....give a syringe to your buddy in the next room, etc....

I think it works out OK cheaper to use dex if you titrate it to save OR time, which I sometimes hear quoted as high as up to $16/minute (in the high end endovascular/minimally invasive rooms)
 
joshmir said:
Vent-

Dex is $57 a vial for 200mcg....often times you just need the loading dose of 1 mcg/kg/hr....I break the vial up into 2-4 syringes and use it for 2-4 patients....give a syringe to your buddy in the next room, etc....

I think it works out OK cheaper to use dex if you titrate it to save OR time, which I sometimes hear quoted as high as up to $16/minute (in the high end endovascular/minimally invasive rooms)
Click to expand...

I like your style.

Do you slow push the loading dose 10 minutes before wakeup? How do you use the stuff when divided up like that?

Thanks.
 
joshmir said:
I think it works out OK cheaper to use dex if you titrate it to save OR time, which I sometimes hear quoted as high as up to $16/minute (in the high end endovascular/minimally invasive rooms)
Click to expand...

one of the fellows here said yesterday that OR time costs around $50 per minute. I had heard $35 quoted in the past.
 
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