Patient can't stop moving while under GA! SSRI implicated?

[soorg]

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62 y/o F, on Cymbalta x 25 years and amlodipine x 5 years for htn. Nervous Nelly in OR. Knee scope, surgeon likes GA.
Easy everything. At 1.0 MAC Sevo for start of operation. Pt moves. I do the usual (prop bolus, increase sevo), surgeon
tries again, again patient moving like crazy. Again, I deepen-pt still moving! Fed up with looking like a spam sandwich,
I give 30 mg rocuronium, after which she finally stops moving. What gives? Only thing I could think of was the Cymbalta-I
vaguely remember something like this happening with previous patients on SSRIs/mood stabilizers. Anyone else have this
happen to them?

 

[FiO2@21]

I always keep the LMA patients on 1.3 - 1.5 MAC before incision because I was tired of looking like an incompetent resident.

We have a ton of MJ smokers and anecdotally they require more.

 

[nimbus]

MAC is a statistical concept. At 1 MAC, half of patients will move on incision. Some people require 2-3 MAC. Some people only require 0.5 MAC. Roc is a good solution.

 

[GassYous]

What you see in your end tidal is not exactly what the brain is getting. Even if the blood is saturated and that is reflected in what the lungs see, it takes time for the brain tissue to equilibrate with the blood. Surgeon can put a bunch of local or you can paralyze. Some people are just on the far side of the curve.

I've noticed these nervous nelly types (freak out with the mask on face, start screaming when the prop hits) can be labile in terms of hemodynamics. I think when your sympathetic system is always going off with benign stimuli, when your body is hit something significant the catecholamine surge is that much worse.

 

[drmwvr]

A MAC of anything without anything else is guaranteed to not be enough more than 50% of the time (prolly more like (90%)

 

[coffeebythelake]

62 y/o F, on Cymbalta x 25 years and amlodipine x 5 years for htn. Nervous Nelly in OR. Knee scope, surgeon likes GA.
Easy everything. At 1.0 MAC Sevo for start of operation. Pt moves. I do the usual (prop bolus, increase sevo), surgeon
tries again, again patient moving like crazy. Again, I deepen-pt still moving! Fed up with looking like a spam sandwich,
I give 30 mg rocuronium, after which she finally stops moving. What gives? Only thing I could think of was the Cymbalta-I
vaguely remember something like this happening with previous patients on SSRIs/mood stabilizers. Anyone else have this
happen to them?

12 minutes needed for 3 time constants
Give some roc
Or give some fentanyl

 

[leaverus]

no opioid??

 

[BLADEMDA]

62 y/o F, on Cymbalta x 25 years and amlodipine x 5 years for htn. Nervous Nelly in OR. Knee scope, surgeon likes GA.
Easy everything. At 1.0 MAC Sevo for start of operation. Pt moves. I do the usual (prop bolus, increase sevo), surgeon
tries again, again patient moving like crazy. Again, I deepen-pt still moving! Fed up with looking like a spam sandwich,
I give 30 mg rocuronium, after which she finally stops moving. What gives? Only thing I could think of was the Cymbalta-I
vaguely remember something like this happening with previous patients on SSRIs/mood stabilizers. Anyone else have this
happen to them?

Yes. I see this all the time in my practice. Those with anxiety especially so. May I suggest a few things?

1. Midazolam- 2 mg IV rarely does much to these patients. I find 4-5 mg IV to be a better dosage with no delay of discharge.

2. Sevo- May I suggest MAXING out the vaporizer for the first 3-5 minutes provided the EF is good? I typically max out the SEVO bringing the MAC to 1.7-1.9 in these types of patients before backing down.

3. Sux- I am not a big fax of sux but a small dose IV like 20-40 mg gives to time to deepen the anesthetic into the 1.7 MAC range. You chose Rocuronium but for a quick case of 20 minutes that could require reversal with sugammadex ($90 per vial). If the case exceeds 30 minutes in duration low dose Roc is a reasonable choice (20 mg).

4. Ketamine- I tread carefully here because this drug may promote anxiety postop. I have seen it. But, ketamine 50 mg iv would certainly help with deepening the anesthetic.

5. Precedex- I have used this drug a few times in this situation with outstanding results intraop and excellent patient satisfaction postop. A bolus of 0.5-1.0 ug/kg up front works quite well. It does take around 5 minutes to see the full effect of the precedex but this drug never fails to deepen the anesthetic.

6. Fentanyl- This helps a great deal up front. For outpatients I limit the dosage but I find 50 ug IV to be helpful in these patients.

7. Propofol- I agree about giving more IV but there are some patients who will not stop moving even with 4mg/kg IV. Typically, once I have reached the 4-5 mg/kg dosage over just 2-3 minutes I stop and switch to something else. Myocardial depression is a real side-effect at that dosage.

 

[FiO2@21]

How comfortable are you guys paralyzing LMAs? My understanding is that they might be doing that in Europe.

 

[BLADEMDA]

How comfortable are you guys paralyzing LMAs? My understanding is that they might be doing that in Europe.

I have used muscle relaxants with LMAs many, many times. That said, there are times I have regretted it particularly when my access to the airway is limited like Prone and Beach Chair cases. Most of the time those patients do fine with an LMA but I have been forced to delay a case to change an LMA to an ETT more than once in Prone/Beach chair cases. This may cause a complete re-prep of the patient and won't enhance surgeon satisfaction.

 

[BLADEMDA]

How comfortable are you guys paralyzing LMAs? My understanding is that they might be doing that in Europe.

My friend they are doing that in the USA as well in many places.

LMA with positive pressure ventilation is safe! - PMC

www.ncbi.nlm.nih.gov

 

[Hork Bajir]

Damn. I’m happy to do a prone/lateral LMA, and I’m perfectly willing to give NMB to the right patient with an LMA... But both at the same time? Seems like you’re just asking for trouble. At that point what’s the downside of just putting in a tube? Not like it’s really that much slower

 

[BLADEMDA]

Damn. I’m happy to do a prone/lateral LMA, and I’m perfectly willing to give NMB to the right patient with an LMA... But both at the same time? Seems like you’re just asking for trouble. At that point what’s the downside of just putting in a tube? Not like it’s really that much slower

I routinely do lateral cases every day with LMAs; those are not the same as prone cases or even beach chair cases where the airway is not easily accessible.
If you need to "switch out" an LMA to an ETT it is quite difficult in the prone position. Once you have done enough cases (ASA3 and 4) with LMAs you will realize they do fail at inopportune times and they are not secure like ETTs. So, I recommend you evaluate each patient along with the procedure before proceeding with an LMA in the prone/beach chair position. Once you do enough of these cases the limitations of the LMA will become much clearer to the the attending Anesthesiologist.

 

[Arch Guillotti]

I recommend an ET tube if they are prone. No regerts.

 

[deleted59964]

just enough propofol to get them to close their eyes + nmb + LMA is a great technique for cvs stability in frail pateints with IHD - no sympathetic response to intubation.

otherwise if you just want patients to stay still with a mac of sevo (or less) for a short lma case, just give some alfentanil with the propofol.

 

[Consigliere]

No regerts.

Time for a Snickers bar.

 

[fakin' the funk]

Yes. I see this all the time in my practice. Those with anxiety especially so. May I suggest a few things?

1. Midazolam- 2 mg IV rarely does much to these patients. I find 4-5 mg IV to be a better dosage with no delay of discharge.

2. Sevo- May I suggest MAXING out the vaporizer for the first 3-5 minutes provided the EF is good? I typically max out the SEVO bringing the MAC to 1.7-1.9 in these types of patients before backing down.

3. Sux- I am not a big fax of sux but a small dose IV like 20-40 mg gives to time to deepen the anesthetic into the 1.7 MAC range. You chose Rocuronium but for a quick case of 20 minutes that could require reversal with sugammadex ($90 per vial). If the case exceeds 30 minutes in duration low dose Roc is a reasonable choice (20 mg).

4. Ketamine- I tread carefully here because this drug may promote anxiety postop. I have seen it. But, ketamine 50 mg iv would certainly help with deepening the anesthetic.

5. Precedex- I have used this drug a few times in this situation with outstanding results intraop and excellent patient satisfaction postop. A bolus of 0.5-1.0 ug/kg up front works quite well. It does take around 5 minutes to see the full effect of the precedex but this drug never fails to deepen the anesthetic.

6. Fentanyl- This helps a great deal up front. For outpatients I limit the dosage but I find 50 ug IV to be helpful in these patients.

7. Propofol- I agree about giving more IV but there are some patients who will not stop moving even with 4mg/kg IV. Typically, once I have reached the 4-5 mg/kg dosage over just 2-3 minutes I stop and switch to something else. Myocardial depression is a real side-effect at that dosage.

You know @BLADEMDA I normally just wince at your verbose blowhardishness, but you saying it takes 5 minutes for precedex to peak deserves a response, as that is so blatantly wrong it's dangerous. Please revise.

 

[fakin' the funk]

How comfortable are you guys paralyzing LMAs? My understanding is that they might be doing that in Europe.

If you think you'll be able to ventilate with low pressures and it's a reasonable timeframe, sure why not.

Also, if you're planning to paralyze for controlled ventilation, you should probably put in the device that was literally designed for that. After all, it's just a piece of effing plastic

 

[fakin' the funk]

62 y/o F, on Cymbalta x 25 years and amlodipine x 5 years for htn. Nervous Nelly in OR. Knee scope, surgeon likes GA.
Easy everything. At 1.0 MAC Sevo for start of operation. Pt moves. I do the usual (prop bolus, increase sevo), surgeon
tries again, again patient moving like crazy. Again, I deepen-pt still moving! Fed up with looking like a spam sandwich,
I give 30 mg rocuronium, after which she finally stops moving. What gives? Only thing I could think of was the Cymbalta-I
vaguely remember something like this happening with previous patients on SSRIs/mood stabilizers. Anyone else have this
happen to them?

You tellin us you paralyzed before giving opioid? Movement to painful stimulus is mediated by the spinal cord. Opioids primarily work in the spinal cord. This isn't that hard.

 

[deleted697127]

Precedex at a surgery center and 1mcg/kg? For a knee scope? Sounds expensive for minimal benefit. I would consider dose of 10-20mcg bolus in pacu for rescue pain relief after standard multimodal options are failing but routine precedex is just unnecessary. And with 1mcg/kg the hypotension in pacu would be a headache.

I usually underdose prop a bit so they don’t go completely apneic with LMA insertion. Give fent in 25mcg increments and get them deep like mentioned above. If MV is still >5 and i think they may move give a little prop prior initial incision or local.

 

[Hork Bajir]

I’d like to let the patients push their own propofol- I’ll just hand them the syringe and explain that if they think they’re going to move, they should give themselves another slug. Best part about this arrangement is that it leaves my hands free to film the whole thing

 

[BLADEMDA]

You know @BLADEMDA I normally just wince at your verbose blowhardishness, but you saying it takes 5 minutes for precedex to peak deserves a response, as that is so blatantly wrong it's dangerous. Please revise.

Precedex has an onset of action around 5 minutes with a peak effect at 10-15 minutes. It has a half life of 6 minutes with a context sensitivity half life of 4-5 minutes. This means that in a non elderly patient (under age 60) the bolus dose of Precedex is gone/not around around after 30 minutes. In younger patients I have not seen any issues with hypotension or delay of discharge in the PACU. That is not the case with elderly patients especially those over age 75.

I have used this drug hundreds of times in my practice. I am very familiar with it and for the right patient/situation I highly recommend it.

Current role of dexmedetomidine in clinical anesthesia and intensive care - PMC

Dexmedetomidine is a new generation highly selective α2-adrenergic receptor (α2-AR) agonist that is associated with sedative and analgesic sparing effects, reduced delirium and agitation, perioperative sympatholysis, cardiovascular stabilizing ...

www.ncbi.nlm.nih.gov

Effect of single-dose dexmedetomidine on postoperative recovery after ambulatory ureteroscopy and ureteric stenting: a double blind randomized controlled study - PMC

Ambulatory surgery has recently gain popularity, as it is a good method of optimizinghospital resources utilization. To support ambulatory surgery, anaesthetic goals nowrevolve around patients’ early recovery with minimal pain and nausea, ...

www.ncbi.nlm.nih.gov

http://ether.stanford.edu/asc1/documents/mac2.pdf

 

[WholeLottaGame7]

Precedex has an onset of action around 5 minutes with a peak effect at 10-15 minutes. It has a half life of 6 minutes with a context sensitivity half life of 4-5 minutes. This means that in a non elderly patient (under age 60) the bolus dose of Precedex is gone/not around around after 30 minutes. In younger patients I have not seen any issues with hypotension or delay of discharge in the PACU. That is not the case with elderly patients especially those over age 75.

I have used this drug hundreds of times in my practice. I am very familiar with it and for the right patient/situation I highly recommend it.

Current role of dexmedetomidine in clinical anesthesia and intensive care - PMC

Dexmedetomidine is a new generation highly selective α2-adrenergic receptor (α2-AR) agonist that is associated with sedative and analgesic sparing effects, reduced delirium and agitation, perioperative sympatholysis, cardiovascular stabilizing ...

www.ncbi.nlm.nih.gov

Effect of single-dose dexmedetomidine on postoperative recovery after ambulatory ureteroscopy and ureteric stenting: a double blind randomized controlled study - PMC

Ambulatory surgery has recently gain popularity, as it is a good method of optimizinghospital resources utilization. To support ambulatory surgery, anaesthetic goals nowrevolve around patients’ early recovery with minimal pain and nausea, ...

www.ncbi.nlm.nih.gov

Going to agree with @fakin' the funk here. Not sure if you're getting your numbers out of a textbook or what. You see the bradycardia/hypertension with dexmedetomidine almost instantaneously (<30 sec). Sedative effects are a little slower which is why I often push prop/dex simultaneously on kids who are freaking out, but even solo they still go to sleep in less than 5 minutes. Maybe it takes a little longer in your geriatric patients with lower CIs, I dunno, or maybe you're running the bolus in over 5-10min?

 

[BLADEMDA]

Going to agree with @fakin' the funk here. Not sure if you're getting your numbers out of a textbook or what. You see the bradycardia/hypertension with dexmedetomidine almost instantaneously (<30 sec). Sedative effects are a little slower which is why I often push prop/dex simultaneously on kids who are freaking out, but even solo they still go to sleep in less than 5 minutes. Maybe it takes a little longer in your geriatric patients with lower CIs, I dunno, or maybe you're running the bolus in over 5-10min?

Of course I get bradycardia and HYPERTENSION when bolusing the Precedex upfront. The bradycardia can be severe leading to heart rates in the 30s so be prepared to pre-treat or treat with gylcopyrrolate. Then, after about 5 minutes the hypotension can and does occur. This requires treatment in the O.R. quite often. But, 30 minutes later the BOLUS effect has waned and the hypotension typically isn't an issue in the PACU for younger patient. For the elderly, the hypotension may persist for up to 1.5 hours after the bolus dose. The literature is simply incorrect on this fact because I have seen it many times.

The clinical effects of precedex (sedation, reduction in MAC) occur after about 4-5 minutes with a peak effect at 10-15 minutes.

 

[caligas]

Anyone else have a recurring dream where no matter how much you give the patient won’t stop moving or stay asleep?

...also, the patient is your mother in law.

 

[GassYous]

I recommend an ET tube if they are prone. No regerts.

 

[GassYous]

The only time I will do a prone lma is for a short case like an eua or quick debridement.

LMA for lateral and beach chair all the time for shoulders as well as other similar cases. But these are relatively healthy outpatients, I always tube the sick inpatients like blade. I have done a few beach chair shoulders with block, sedation and facemask in residency with an old school attending but one time the patient laryngospasmed and kept coughing for a few minutes so I stopped doing that.

Paralysis for lmas is no big deal. I do it all the time. Roc 10 is easy to give and doesn't need to be reversed. TVs are always good by the end of the case. If you would like, you can give neo 1/glyco 0.2 at any time. The only time I've had someone regurgitate is when they were having a bronchoscopy with an igel 5 in place without paralysis. I prefer to tube for these cases but the pulmonologist requested it to for ultrasounding lymph nodes. Pulled the lma and intubated that one mid-case as I regretted placing the lma.

I have also seen the hypertension with bolusing precedex. I think it's rarer if you do a pump bolus (start them on 1.5 ug/kg/h as soon as they get into the room). We use precedex only anesthetics a lot for our tavrs. It does take around 5 minutes for them to get in a state where they will tolerate the procedure.

I have seen the hypotension in pacu several times after including precedex 50 ug in my tap blocks which required a fluid bolus. I stopped adding precedex after that happened a few times even though it does give you an extra few hours of pain relief. The interesting thing is that the patient will have a hemodynamically stable intraoperative course and hypotension occurs around 2 hours later. Probably due to the slower absorption from between the muscular layers.

 

[BLADEMDA]

The only time I will do a prone lma is for a short case like an eua or quick debridement.

LMA for lateral and beach chair all the time for shoulders as well as other similar cases. But these are relatively healthy outpatients, I always tube the sick inpatients like blade. I have done a few beach chair shoulders with block, sedation and facemask in residency with an old school attending but one time the patient laryngospasmed and kept coughing for a few minutes so I stopped doing that.

Paralysis for lmas is no big deal. I do it all the time. Roc 10 is easy to give and doesn't need to be reversed. TVs are always good by the end of the case. If you would like, you can give neo 1/glyco 0.2 at any time. The only time I've had someone regurgitate is when they were having a bronchoscopy with an igel 5 in place without paralysis. I prefer to tube for these cases but the pulmonologist requested it to for ultrasounding lymph nodes. Pulled the lma and intubated that one mid-case as I regretted placing the lma.

I have also seen the hypertension with bolusing precedex. I think it's rarer if you do a pump bolus (start them on 1.5 ug/kg/h as soon as they get into the room). We use precedex only anesthetics a lot for our tavrs. It does take around 5 minutes for them to get in a state where they will tolerate the procedure.

I have seen the hypotension in pacu several times after including precedex 50 ug in my tap blocks which required a fluid bolus. I stopped adding precedex after that happened a few times even though it does give you an extra few hours of pain relief. The interesting thing is that the patient will have a hemodynamically stable intraoperative course and hypotension occurs around 2 hours later. Probably due to the slower absorption from between the muscular layers.

I too have stopped adding the Precedex to my TAP blocks and have moved away from adding it to my local for any of my nerve blocks. Your post is solid and shows experience with cases. Despite being at this for 3 decades I still am surprised to see what can happen from time to time. If you do this long enough the humility comes with the experience.

If you can use Precedex on a TAVR (which I agree with) you can use it on just about anyone provided you pay close attention to the vitals. I think this drug is truly a gem in our arsenal now that it is generic.

 

[soorg]

Thanks for all the responses. I had given 50 ug fentanyl upfront, don't have Precedex at the ASC I was at, and reversing with Neo/Glyco was fine with just 30mg of roc on board. Am aware of what MAC is. Pt kept moving at 1.5 MAC.

 

[deleted875186]

Thanks for all the responses. I had given 50 ug fentanyl upfront, don't have Precedex at the ASC I was at, and reversing with Neo/Glyco was fine with just 30mg of roc on board. Am aware of what MAC is. Pt kept moving at 1.5 MAC.

Maybe patient is a chronic pain patient. Monotherapy with cymbalta is suspicious for a fibro patient, many of them have been on opioids it benzodiazepines or some other medication in the past. These people can take a lot of medicine.

 

[propadope]

In terms of precedex onset, I think that the sympatholytic effects occur sooner than the sedative effects and maybe thats what lowers MAC. If you are using it to sedate as a sole agent then you are definitely going to have to wait longer. This is my clinical experience for what its worth.

 

[fakin' the funk]

Going to agree with @fakin' the funk here. Not sure if you're getting your numbers out of a textbook or what. You see the bradycardia/hypertension with dexmedetomidine almost instantaneously (<30 sec). Sedative effects are a little slower which is why I often push prop/dex simultaneously on kids who are freaking out, but even solo they still go to sleep in less than 5 minutes. Maybe it takes a little longer in your geriatric patients with lower CIs, I dunno, or maybe you're running the bolus in over 5-10min?

@BLADEMDA didn't disappoint. I should have taken the Blade-Bingo square where he mentions he's done something "hundreds of times." (Btw, how does he do this hundreds of times in between the hundreds of suprascapular catheters he does every day????)

Precedex as a sole or primary sedative agent takes AT LEAST 15 minutes to have any significant effect after a bolus on the order of 1mcg/kg.

It also hangs around a LONG time, like 60-90 minutes at least. That makes it ideal as a sole sedative for a short-medium length MAC case that isn't very stimulating, like endovascular stuff, lumps and bumps, etc.

I don't know why someone would give a young patient 1mcg/kg for analgesia...

 

[Arch Guillotti]

Of course I get bradycardia and HYPERTENSION when bolusing the Precedex upfront.

I have only seen or even heard of precedes causing hypertension once, and that was with an inadvertent large overdose.

 

[propadope]

I have only seen or even heard of precedes causing hypertension once, and that was with an inadvertent large overdose.

Also depends on how fast its given.

 

[Arch Guillotti]

Also depends on how fast its given.

It was given very fast in the instance I am familiar with.

 

[propadope]

Anyone else have a recurring dream where no matter how much you give the patient won’t stop moving or stay asleep?

...also, the patient is your mother in law.

Yes! I get that dream every now and then. Not a relative or anyone I know

 

[BLADEMDA]

@BLADEMDA didn't disappoint. I should have taken the Blade-Bingo square where he mentions he's done something "hundreds of times." (Btw, how does he do this hundreds of times in between the hundreds of suprascapular catheters he does every day????)

Precedex as a sole or primary sedative agent takes AT LEAST 15 minutes to have any significant effect after a bolus on the order of 1mcg/kg.

It also hangs around a LONG time, like 60-90 minutes at least. That makes it ideal as a sole sedative for a short-medium length MAC case that isn't very stimulating, like endovascular stuff, lumps and bumps, etc.

I don't know why someone would give a young patient 1mcg/kg for analgesia...

Uh..No that is blatantly false as I utilize Precedex routinely in my practice for cases ranging from 30-60 minutes. The onset in the room occurs in about 5 minutes and I have most of the patients ready to go home after a 30 minute PACU stay. These are ASA 2 patients under the age of 60. For the elderly the recovery time is longer in the range of 60-90 minutes.

I typically run Propofol TIVA with the Precedex bolus which together works great to avoid any postop nausea.

 

[BLADEMDA]

"Its onset of action is less than 5 min and the peak effect occurs within 15 min."

Dexmedetomidine in Current Anaesthesia Practice- A Review - PMC

Dexmedetomidine is an alpha 2 adrenergic receptor agonist, even ten times more selective than clonidine. It is a very versatile drug in anaesthesia practice, finding place in increasing number of clinical scenarios and is no more limited to ...

www.ncbi.nlm.nih.gov

 

[propadope]

Makes a big difference if you use Precedex as an adjunct vs sole agent. Again I think a lot of it is due to sympatholytic vs sedative effects. You are going to get MAC sparing effects much sooner than sedation

 

[BLADEMDA]

Also depends on how fast its given.

Cardiovascular: Hypotension (24% to 56%), bradycardia (5% to 42%), systolic hypertension (28%), tachycardia (25%), hypertension (diastolic; 12%), hypertension (11%)

The bolus of dexmedetomidine may result in a transient increase in blood pressure and a reflex decrease in heart rate, especially in younger patients. This response is likely related to direct vasoconstriction of peripheral vessels.

1. The AMOUNT/DOSAGE of precedex has a big affect on the hypertension then 10-15 minutes later hypotension. As the dosage exceeds 0.5 ug/kg the incidence goes up. I see it often with the 1 ug/kg IV dosage but it is transient.

2. Speed of Infusion- the faster you give the bolus dose the more likely you will see Hypertension and bradycardia. Even doses as small as 0.5 ug/kg Iv as a 5 second bolus PUSH can cause the hypertensive response. Once the dosage increases to 1.0 ug/kg IV as a 5 second bolus the incidence of hypertension exceeds 50% or more. That is why many studies recommend a loading dose over 10 minutes.

I rarely utilize Precedex as my sole anesthetic agent. I typically combine the Precedex with Propofol for a synergistic (Additive?) effect. Typically, I can reduce my Propofol infusion about 30-40% with the Precedex on board with a lot less movement by the patient. I highly recommend the drug the next time you want to do a TIVA on a ASA 1 or 2 healthy female under the age of 60 having an outpatient procedure. IMHO, patient satisfaction is higher with the Propofol/Precedex combo than any other combo we currently have available for that patient population.

 

[fakin' the funk]

Precedex has an onset of action around 5 minutes with a peak effect at 10-15 minutes. It has a half life of 6 minutes with a context sensitivity half life of 4-5 minutes. This means that in a non elderly patient (under age 60) the bolus dose of Precedex is gone/not around around after 30 minutes. In younger patients I have not seen any issues with hypotension or delay of discharge in the PACU. That is not the case with elderly patients especially those over age 75.

I have used this drug hundreds of times in my practice. I am very familiar with it and for the right patient/situation I highly recommend it.

Current role of dexmedetomidine in clinical anesthesia and intensive care - PMC

Dexmedetomidine is a new generation highly selective α2-adrenergic receptor (α2-AR) agonist that is associated with sedative and analgesic sparing effects, reduced delirium and agitation, perioperative sympatholysis, cardiovascular stabilizing ...

www.ncbi.nlm.nih.gov

Effect of single-dose dexmedetomidine on postoperative recovery after ambulatory ureteroscopy and ureteric stenting: a double blind randomized controlled study - PMC

Ambulatory surgery has recently gain popularity, as it is a good method of optimizinghospital resources utilization. To support ambulatory surgery, anaesthetic goals nowrevolve around patients’ early recovery with minimal pain and nausea, ...

www.ncbi.nlm.nih.gov

http://ether.stanford.edu/asc1/documents/mac2.pdf

As usual, you think posting a lot of links (which don’t even address the topic in question, the timing of clinical sedation of dexmedetomidine after bolus) prove a point, when they in fact support my claim that you are a verbose blowhard.

 

[propadope]

Cardiovascular: Hypotension (24% to 56%), bradycardia (5% to 42%), systolic hypertension (28%), tachycardia (25%), hypertension (diastolic; 12%), hypertension (11%)

The bolus of dexmedetomidine may result in a transient increase in blood pressure and a reflex decrease in heart rate, especially in younger patients. This response is likely related to direct vasoconstriction of peripheral vessels.

Yes and dose and rate of administration will increase chances of seeing it

 

[fakin' the funk]

Uh..No that is blatantly false as I utilize Precedex routinely in my practice for cases ranging from 30-60 minutes. The onset in the room occurs in about 5 minutes and I have most of the patients ready to go home after a 30 minute PACU stay. These are ASA 2 patients under the age of 60. For the elderly the recovery time is longer in the range of 60-90 minutes.

I typically run Propofol TIVA with the Precedex bolus which together works great to avoid any postop nausea.

Why?!

Don't you supervise CRNAs?

Also...DRINK!

 

[repititionition]

I will routinely give a bolus of 0.5ucg/kg immediately on arrival to OR for MAC cases. In the time it takes to position and prep (academics), most patients start to report feeling good. After the precedex, a prop gtt turned on at 25-50 will then quickly have most patients at a great level of sedation within 2-5 minutes.

Edited to add that I’ve seen hypertension with this approach once, and bradycardia a handful of times. Each lasted less than 2-3 minutes. Most of these patients are appropriate to bypass PACU at the end of the case (average length 30 minutes).