Pre operative/Intra operative clonidine

[Mman]

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A wise and more experienced (with many years) explained to me that people don't use IV because in rare cases you can get malignant and untreatable hypertension from it - apparently pretty scary when it happens.

One of my old attendings in residency had us use IV clonidine all the time. I don't think you get any worse hypertension from an appropriate dose of IV clonidine compared to a dose of dexmeditomidine. I also don't know what "untreatable hypertension" is. It's always treatable.

 

[propadope]

One of my old attendings in residency had us use IV clonidine all the time. I don't think you get any worse hypertension from an appropriate dose of IV clonidine compared to a dose of dexmeditomidine. I also don't know what "untreatable hypertension" is. It's always treatable.

Im assuming it is dependent on rate of administration like dex? Can it be mitigated by slow administration?

 

[nap$ter]

Our peds guys discourage its use instead of midazolam, since it has no amnestic effect. Since the purpose of a pediatric premed is as much about their next surgery as it is for the current one, I tend to agree.

I think midaz is overused in adults and underused in kids. I'm not sure I see a good place for dexmedetomidine in kids.

this can be argued the other way..

the memory of a mask induction after dexmed premed is innocuous. the memory of an easy harmless induction in my mind is more helpful with the next induction than no memory at all ie mystery and fear of the unknown.

kids are totally relaxed and cooperative after a dexmed premed. no risk of paradoxical agitation or disinhibition. no respiratory depression. added analgesic benefit.

it's the perfect drug for T&A in kids with obstruction.

if you don't see a good place for dexmed in kids you haven't used it enough in that population.

cost and availability are the only reasons i don't use it more.

i do agree that midaz is overused in adults and underused in kids.

as for clonidine i haven't seen a good use for it since residency.

 

[propadope]

this can be argued the other way..

the memory of a mask induction after dexmed premed is innocuous. the memory of an easy harmless induction in my mind is more helpful with the next induction than no memory at all ie mystery and fear of the unknown.

kids are totally relaxed and cooperative after a dexmed premed. no risk of paradoxical agitation or disinhibition. no respiratory depression. added analgesic benefit.

it's the perfect drug for T&A in kids with obstruction.

if you don't see a good place for dexmed in kids you haven't used it enough in that population.

cost and availability are the only reasons i don't use it more.

i do agree that midaz is overused in adults and underused in kids.

as for clonidine i haven't seen a good use for it since residency.

Good points. Were you giving dex PO or IN? What dose and what was the onset time? Could the kids have tolerated an IV?

 

[pgg]

this can be argued the other way..

the memory of a mask induction after dexmed premed is innocuous. the memory of an easy harmless induction in my mind is more helpful with the next induction than no memory at all ie mystery and fear of the unknown.

Maybe that memory is innocuous for an adult but kids aren't rational creatures. We had reports of kids having night terrors lasting days to weeks after surgery with dex premeds (same as with no premeds). The incidence isn't anywhere near 100% of course, but I don't believe it's trivial. Midaz works; it's only downside might be slower discharge times if they also get a significant opiate dose.

if you don't see a good place for dexmed in kids you haven't used it enough in that population.

That could be.

My problem with dex (in general) is that I've given it about 100 chances to impress me in a bunch of different circumstances, and it just hasn't. The occasions when it's worked well were the kind of cases that probably would've been fine without it. And too often when I used it and counted on it, it wasn't good enough. I've felt for the better part of 10 years now that it's a really cool drug searching for an indication, a solution looking for a problem.

 

[nap$ter]

Good points. Were you giving dex PO or IN? What dose and what was the onset time? Could the kids have tolerated an IV?

pre- IV tolerance ages.

time to onset is longer by about 5 min. nasal dose of 1-2ug/kg.

 

[nap$ter]

Maybe that memory is innocuous for an adult but kids aren't rational creatures. We had reports of kids having night terrors lasting days to weeks after surgery with dex premeds (same as with no premeds). The incidence isn't anywhere near 100% of course, but I don't believe it's trivial. Midaz works; it's only downside might be slower discharge times if they also get a significant opiate dose.




That could be.

My problem with dex (in general) is that I've given it about 100 chances to impress me in a bunch of different circumstances, and it just hasn't. The occasions when it's worked well were the kind of cases that probably would've been fine without it. And too often when I used it and counted on it, it wasn't good enough. I've felt for the better part of 10 years now that it's a really cool drug searching for an indication, a solution looking for a problem.

i'm not sure why you had reports of night terrors. in my humble experience i have never seen this nor is it reported in the literature. i can speculate that your dose or time allowed between premed and induction weren't sufficient but that's only a guess. in my personal n of maybe 2-300 nasal premeds with 1-2ug/kg and approx 15 min between delivery and induction i have never once had a kid struggle or scream with the mask so dunno why any of em would get nightmares.

the fact that you have never been impressed and your opinion that your usual recipe would work just as well tell me that you possibly haven't selected the right kids/surgeries for dexmed use.

i completely agree that midaz works great the majority of the time (especially in the outpt ENT setting).

dexmed is a great premed for a couple of specific situations - the kid who has had paradoxical agitation with versed. the bouncing off the wall kid +/- adhd who has a history of emergence delirium. the fat T&A kid with obstruction - especially for this population <3yo when a little bit of airway swelling makes respiratory depression particularly dangerous.

the beauties of dexmed as a nasal premed (or as an intraop IV med) for kids - no respiratory depression, no paradoxical agitation, less emergence delirium, tasteless and odorless, fantastic analgesic (i give zero opiates to young kids with obstruction for T&A), reliable, etc.

the downsides - expensive and not always available, less familiarity (with surgeons, nurses, older partners), bradycardia. the bradycardia is as reliable as the sedation and can be pretty pronounced - i don't use dexmed in kids with down's. in normal kids however, i have never had a problem - if i give dexmed as a premed i always give glyco before laryngoscopy. if i give it intraop for tonsils i always do so as the mouth retractor goes in - the 2 effects cancel each other nicely.

back to clonidine - still don't use it, especially in the outpt setting.

 

[propadope]

pre- IV tolerance ages.

time to onset is longer by about 5 min. nasal dose of 1-2ug/kg.

I meant tolerated an IV after the dex

 

[propadope]

i'm not sure why you had reports of night terrors. in my humble experience i have never seen this nor is it reported in the literature. i can speculate that your dose or time allowed between premed and induction weren't sufficient but that's only a guess. in my personal n of maybe 2-300 nasal premeds with 1-2ug/kg and approx 15 min between delivery and induction i have never once had a kid struggle or scream with the mask so dunno why any of em would get nightmares.

the fact that you have never been impressed and your opinion that your usual recipe would work just as well tell me that you possibly haven't selected the right kids/surgeries for dexmed use.

i completely agree that midaz works great the majority of the time (especially in the outpt ENT setting).

dexmed is a great premed for a couple of specific situations - the kid who has had paradoxical agitation with versed. the bouncing off the wall kid +/- adhd who has a history of emergence delirium. the fat T&A kid with obstruction - especially for this population <3yo when a little bit of airway swelling makes respiratory depression particularly dangerous.

the beauties of dexmed as a nasal premed (or as an intraop IV med) for kids - no respiratory depression, no paradoxical agitation, less emergence delirium, tasteless and odorless, fantastic analgesic (i give zero opiates to young kids with obstruction for T&A), reliable, etc.

the downsides - expensive and not always available, less familiarity (with surgeons, nurses, older partners), bradycardia. the bradycardia is as reliable as the sedation and can be pretty pronounced - i don't use dexmed in kids with down's. in normal kids however, i have never had a problem - if i give dexmed as a premed i always give glyco before laryngoscopy. if i give it intraop for tonsils i always do so as the mouth retractor goes in - the 2 effects cancel each other nicely.

back to clonidine - still don't use it, especially in the outpt setting.

Yes I agree one of the big advantages over midaz is dex is way more palatable PO and it doesn't burn IN.

 

[nap$ter]

I meant tolerated an IV after the dex

never tried it. i doubt it would be reliably effective to that end.

if i premed a kid they get a mask induction.

why would you ever want place an "awake" IV after premed in the outpt dental world?

 

[propadope]

never tried it. i doubt it would be reliably effective to that end.

if i premed a kid they get a mask induction.

why would you ever want place an "awake" IV after premed in the outpt dental world?

Just curious since you were using it for children with OSA. Wondering if dex would provide enough sedation and analgesia for iv access (maybe+/- nitrous) at 2ug/kg? Its always better to have a line no? I don't use sevo for maintenance so for me its just needed to get the IV

 

[nap$ter]

Just curious since you were using it for children with OSA. Wondering if dex would provide enough sedation and analgesia for iv access (maybe+/- nitrous) at 2ug/kg? Its always better to have a line no? I don't use sevo for maintenance so for me its just needed to get the IV

the safety of mask induction in healthyish little ones vs IV inductions is very nearly equivalent - the risk of psychotrauma from placing an IV is thought to be higher.

i don't think nitrous/dexmed to get an IV is worth it - sevo inductions are very safe and effective.

the risk of T&A in kids with OSA is much less during induction than it is postop - in pacu or floor or home when given opiates. most of these OSA kids have airways that can be opened fairly easily by an anesthesiologist during induction - the greater risk is when there is opiate given without an anesthesiologist present after surgery.

if the kiddo is young/small enough or has other airway abnormalities in addition to OSA (ie enough to justify a pre-induction IV) they should be done in the hospital anyway and you shouldn't have to worry about them.

 

[propadope]

the safety of mask induction in healthyish little ones vs IV inductions is very nearly equivalent - the risk of psychotrauma from placing an IV is thought to be higher.

i don't think nitrous/dexmed to get an IV is worth it - sevo inductions are very safe and effective.

the risk of T&A in kids with OSA is much less during induction than it is postop - in pacu or floor or home when given opiates. most of these OSA kids have airways that can be opened fairly easily by an anesthesiologist during induction - the greater risk is when there is opiate given without an anesthesiologist present after surgery.

if the kiddo is young/small enough or has other airway abnormalities in addition to OSA (ie enough to justify a pre-induction IV) they should be done in the hospital anyway and you
shouldn't have to worry about them.

Thanks. I have not seen T & A in awhile( pun intended). Yes. If a kid has any inkling of OSA they go back to their pediatrician and get an ENT consult before I see them. You'd be surprised how often parents or even the pediatricians are not aware the kid may have OSA. They are so hung up on sore throats...