Precedex safety for sedation and patent expiration in 2019

[GCS8]

Would you consider precedex as a fairly ideal drug for administering deep sedation for short-term outpatient procedures (<1 hours on healthy young adult patients ASA1)? It's one of the few drugs that avoids respiratory depression while providing sedation, hypnosis, and analgesia making it ideal for providers with training less than that of anesthesiologist to provide outpatient sedation. I think one of the few drawbacks is the cost of $40/vial. However, with the patent expiring in 2019, I would think costs would reduce and it would quickly replace propofol and ketamine.

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[facted]

I don't like precedex at all for short outpatient procedures. It's not reversible, and it lasts forever. Why would you use it if your goal was to get pts out quickly after surgery is done?

Can definitely be a nice adjuvant for GA for peds to help post op delirium, but I personally don't see much utility for adult outpatient.

 

[Arch Guillotti]

Would you consider precedex as a fairly ideal drug for administering deep sedation for short-term outpatient procedures (<1 hours on healthy young adult patients ASA1)?

No.

 

[anbuitachi]

Would you consider precedex as a fairly ideal drug for administering deep sedation for short-term outpatient procedures (<1 hours on healthy young adult patients ASA1)? It's one of the few drugs that avoids respiratory depression while providing sedation, hypnosis, and analgesia making it ideal for providers with training less than that of anesthesiologist to provide outpatient sedation. I think one of the few drawbacks is the cost of $40/vial. However, with the patent expiring in 2019, I would think costs would reduce and it would quickly replace propofol and ketamine.

Precedex lasts too long in the system. To even get to deep sedation you will run high doses or bolusing. It's not a strong analgesic either so unless the procedure is pretty painless, it's not a good choice. But if it's relatively painless, theres no reason to choose it over propofol.

 

[Psai]

Precedex is a nice adjunct to ketamine, but it's not even close to a replacement for anything.

 

[GCS8]

Precedex is a nice adjunct to ketamine, but it's not even close to a replacement for anything.

You're right. Propofol-Precedex seems like a good replacement for propofol-ketamine. "Dexmedetomidine–propofol combination as TIVA during ERCP showed better intra- and post-procedural hemodynamic stability, less PONV, less postoperative cognitive dysfunctions and shorter recovery time when compared with ketamine–propofol combination." Propofol dexmedetomidine versus propofol ketamine for anesthesia of endoscopic retrograde cholangiopancreatography (ERCP) (A randomized comparative study)

 

[Robotic Wis-Hipple]

You're right. Propofol-Precedex seems like a good replacement for propofol-ketamine. "Dexmedetomidine–propofol combination as TIVA during ERCP showed better intra- and post-procedural hemodynamic stability, less PONV, less postoperative cognitive dysfunctions and shorter recovery time when compared with ketamine–propofol combination." Propofol dexmedetomidine versus propofol ketamine for anesthesia of endoscopic retrograde cholangiopancreatography (ERCP) (A randomized comparative study)

No. It takes to long to achieve effective therapeutic level, lasts too long once you get there, and it’s not an analgesic. Replacing ketamine with precedex makes little sense to me.

Precedex has its uses, I use it as an adjunct in TIVA cases but for a short procedure where I need sedation, I’ll continue to use propofol.

 

[Stank811]

You're right. Propofol-Precedex seems like a good replacement for propofol-ketamine. "Dexmedetomidine–propofol combination as TIVA during ERCP showed better intra- and post-procedural hemodynamic stability, less PONV, less postoperative cognitive dysfunctions and shorter recovery time when compared with ketamine–propofol combination." Propofol dexmedetomidine versus propofol ketamine for anesthesia of endoscopic retrograde cholangiopancreatography (ERCP) (A randomized comparative study)

Ya that is why I just use propofol why complicate the anesthetic

 

[GCS8]

Thanks everyone. I hate Baby Miller's. The book made it sound like precedex was a miracle drug. I went to Big Miller's and found a reference Dexmedetomidine as a Total Intravenous Anesthetic Agent. They had to give 10-times the normal sedation concentration for an acceptable level of anesthesia.

 

[anbuitachi]

Thanks everyone. I hate Baby Miller's. The book made it sound like precedex was a miracle drug. I went to Big Miller's and found a reference Dexmedetomidine as a Total Intravenous Anesthetic Agent. They had to give 10-times the normal sedation concentration for an acceptable level of anesthesia.

10mcg/kg/min??? I never read baby miller before..

 

[vector2]

10mcg/kg/min??? I never read baby miller before..

7-10 mcg/kg/hr. Apparently with doses like that you can rigid bronch and y-stent people with mediastinal masses using only precedex

Dexmedetomidine for anesthetic management of anterior mediastinal mass. - PubMed - NCBI

 

[Steege305]

I disagree on the "not an analgesic" response. Dexmedetomidine does have some analgesic properties as an alpha-2 agonist. Unfortunately the patients are going to be hanging out in the PACU for hours if you run it as a primary anesthetic for a sedation case (bolusing 1mcg/kg and running it at around 0.6 to 0.7mcg/kg/hr) with some propofol or ketamine running in the background.

I would use it for a 70 y/o vasculopath for an angio. I would NOT use it for a healthy 20 y/o. Those patients are getting all the propofol.

 

[Robotic Wis-Hipple]

I disagree on the "not an analgesic" response. Dexmedetomidine does have some analgesic properties as an alpha-2 agonist. Unfortunately the patients are going to be hanging out in the PACU for hours if you run it as a primary anesthetic for a sedation case (bolusing 1mcg/kg and running it at around 0.6 to 0.7mcg/kg/hr) with some propofol or ketamine running in the background.

I would use it for a 70 y/o vasculopath for an angio. I would NOT use it for a healthy 20 y/o. Those patients are getting all the propofol.

“Some” analgesic properties is not the same as being an analgesic. Are you giving Dex to patients in the PACU as a single agent?

I’m unaware of any study showing reduced pain scores or effective reduction of pain using dex alone. Everything I’ve seen has only showed reduction in total dose of opioid for equivalent analgesia. So sure, it’s an adjunct, and it likely reduces opioid requirement, but it’s not an analgesic in my mind.

 

[Psai]

“Some” analgesic properties is not the same as being an analgesic. Are you giving Dex to patients in the PACU as a single agent?

I’m unaware of any study showing reduced pain scores or effective reduction of pain using dex alone. Everything I’ve seen has only showed reduction in total dose of opioid for equivalent analgesia. So sure, it’s an adjunct, and it likely reduces opioid requirement, but it’s not an analgesic in my mind.

Openanesthesia says that epi in an epidural provides analgesia through alpha 2 agonism

 

[koan]

I would use it for a 70 y/o vasculopath for an angio. I would NOT use it for a healthy 20 y/o. Those patients are getting all the propofol.

This. Precedex is ok for a long angio case where you don't need much sedation (0.3-0.5 mcg/kg/hr) especially knowing that these patients will be hanging in the pacu for a couple hours anyway. Main issue at higher infusion rates is prolonged bradycardia / hypotension long after sedation and any whiff of analgesia has worn off.

 

[AdmiralChz]

I think what we will see more of going forward isn’t really more of an intraoperative use - it’s slow onset and lingering effects make it not so desirable for most cases as others have said. I love it for sedation TAVRs personally, but it takes a LOT of patience.

Not fellowship trained in the area, but I suspect where you’ll start to see it more is postoperatively in the ICU for sedation. It’s not as vasodilating or as respiratory depressing as propofol and you can keep it running for a while after extubation to help out with a smoother transition - think about those trauma alcoholics/poly drug users that come in and can’t get extubated. Really great for those shaky cardiac patients in the immediate postoperative period as well. I don’t think it’ll become a magic bullet by any stretch, but it will likely help push out most remaining use of continuous benzos.

 

[shepardsun]

“Some” analgesic properties is not the same as being an analgesic. Are you giving Dex to patients in the PACU as a single agent?

Not as a single agent, no, but we use dex like water at my institution and if there is a pt with pain that hasn't responded to the first round of fent/dilaudid, I will bolus them 20-30 mcg of dex and usually get a great response. Now is that because they're now sedated? Probably, but I've had patients refuse opioids and beg me for more of the stuff "in the small green syringe" (our labels for it are green). Also anecdotally great with post-op nausea and shivering. Don't give it to anybody who is going to be discharged home, but if they're going back up to the floor and can afford to be a little sleepy, it works pretty great.

 

[WholeLottaGame7]

You're right. Propofol-Precedex seems like a good replacement for propofol-ketamine. "Dexmedetomidine–propofol combination as TIVA during ERCP showed better intra- and post-procedural hemodynamic stability, less PONV, less postoperative cognitive dysfunctions and shorter recovery time when compared with ketamine–propofol combination." Propofol dexmedetomidine versus propofol ketamine for anesthesia of endoscopic retrograde cholangiopancreatography (ERCP) (A randomized comparative study)

I would much rather have ketamine than precedex for anything stimulating.

 

[anbuitachi]

I think what we will see more of going forward isn’t really more of an intraoperative use - it’s slow onset and lingering effects make it not so desirable for most cases as others have said. I love it for sedation TAVRs personally, but it takes a LOT of patience.

Not fellowship trained in the area, but I suspect where you’ll start to see it more is postoperatively in the ICU for sedation. It’s not as vasodilating or as respiratory depressing as propofol and you can keep it running for a while after extubation to help out with a smoother transition - think about those trauma alcoholics/poly drug users that come in and can’t get extubated. Really great for those shaky cardiac patients in the immediate postoperative period as well. I don’t think it’ll become a magic bullet by any stretch, but it will likely help push out most remaining use of continuous benzos.

I feel like its already heavily used in ICUs everywhere

 

[AdmiralChz]

I feel like its already heavily used in ICUs everywhere

Very institution-dependent. It’s off-formulary for many which greatly restricts its use in the hospital’s I’ve worked at

 

[Robotic Wis-Hipple]

Very institution-dependent. It’s off-formulary for many which greatly restricts its use in the hospital’s I’ve worked at

It’s definitely a good sedative, especially in the ICU setting. Tons of data for icu sedation and less delirium than other sedative agents used in the ICU. But again, it just isn’t the quick on quick off stuff we need for a lot of these cases.

 

[somedumbDO]

Only use it for post op delirium and neonate Mri sedation... otherwise prop or ketamine

 

[leaverus]

short-term outpatient procedures (<1 hours on healthy young adult patients ASA1)

i've never used it for procedural sedation but i would think this is exactly the demographic you wouldn't want to waste it on.

 

[facted]

Only use it for post op delirium and neonate Mri sedation... otherwise prop or ketamine

I don't do peds really, but I have colleagues that use high dose precedex in lieu of narcotics in tonsills, especially sleep apnea kids.

 

[anbuitachi]

It’s definitely a good sedative, especially in the ICU setting. Tons of data for icu sedation and less delirium than other sedative agents used in the ICU. But again, it just isn’t the quick on quick off stuff we need for a lot of these cases.

Yea if patients say they can't sleep, give them some precedex.

 

[deleted697127]

I don't do peds really, but I have colleagues that use high dose precedex in lieu of narcotics in tonsills, especially sleep apnea kids.

Where I’m at we’re tuaght that precedex induces your normal sleep pattern. If your normal sleep pattern is obstructive sleep apnea, expect obstructive sleep apnea. But as always I’m sure there are plenty of ways to do it and am curious what other people’s experiences are.

 

[facted]

Where I’m at we’re tuaght that precedex induces your normal sleep pattern. If your normal sleep pattern is obstructive sleep apnea, expect obstructive sleep apnea. But as always I’m sure there are plenty of ways to do it and am curious what other people’s experiences are.

Again, I don't do peds, but these are peds fellowship trained people who know what they're doing and they are having great success with it. Lots of ways to do things, obviously.

 

[propadope]

Where I’m at we’re tuaght that precedex induces your normal sleep pattern. If your normal sleep pattern is obstructive sleep apnea, expect obstructive sleep apnea. But as always I’m sure there are plenty of ways to do it and am curious what other people’s experiences are.

Precedex mimics non-REM sleep. In children 80% of obstructive events occur during REM sleep.
Obstructive sleep apnoea in children: perioperative considerations | BJA: British Journal of Anaesthesia | Oxford Academic

The article does say obstruction is less likely with precedex and it is unknown if high doses of precedex will result in obstruction in children with OSA

 

[Swamp Gas]

Where I’m at we’re tuaght that precedex induces your normal sleep pattern. If your normal sleep pattern is obstructive sleep apnea, expect obstructive sleep apnea. But as always I’m sure there are plenty of ways to do it and am curious what other people’s experiences are.

0.5 mcg/kg bolus works like a charm. Smooth emergence and no bradycardia. I titrate morphine as well.

 

[thinkorswim]

0.5 mcg/kg bolus works like a charm. Smooth emergence and no bradycardia. I titrate morphine as well.

You clearly haven't bolused it quickly enough if you haven't seen bradycardia. I agree though, works like a charm for the younger and more combative patients.

 

[deleted697127]

Precedex mimics non-REM sleep. In children 80% of obstructive events occur during REM sleep.
Obstructive sleep apnoea in children: perioperative considerations | BJA: British Journal of Anaesthesia | Oxford Academic

The article does say obstruction is less likely with precedex and it is unknown if high doses of precedex will result in obstruction in children with OSA

Yeahh. youre right. What I said doesn't make any sense.

Dexmedetomidine infusion for analgesia and prevention of emergence agitation in children with obstructive sleep apnea syndrome undergoing tonsillec... - PubMed - NCBI

Head to head 2mcg/kg bolus followed by 0.7mcg/kg/hr infusion of dex until 5 minutes before end of surgery vs 1mcg/kg fentanyl bolus
This suggested less patients requiring morphine post op, quicker wake up, extubation, and fewer desats post op. ​

 

[Robotic Wis-Hipple]

This is clearly a peds vs adult Anesthesiologists debate. Precedex works great and quickly in the kiddos and you can give the 0.5mcg/kg boluses, but it just doesn’t have the efficacy, or onset in adults to be as useful. You definitely can’t be pushing 50+mcgs in the adults without some profound side effects.

I still use a fair amount of it in my TIVA/ERAS cases as an adjunct and our patients get it in their blocks as well. It’s also great in the gomers you’re trying to avoid a bunch of narcs in or the ocassional airway, body habitus/COPD, or predicted emergence delirium Pt for extubation if you get a bolus/load in 30min before wakeup. So it’s a good adjunct, but it’s not the silver bullet in the adult population. Though borderline BP and bradycardia are not infrequent PACU issues.....

 

[propadope]

Yeahh. youre right. What I said doesn't make any sense.

Dexmedetomidine infusion for analgesia and prevention of emergence agitation in children with obstructive sleep apnea syndrome undergoing tonsillec... - PubMed - NCBI

Head to head 2mcg/kg bolus followed by 0.7mcg/kg/hr infusion of dex until 5 minutes before end of surgery vs 1mcg/kg fentanyl bolus
This suggested less patients requiring morphine post op, quicker wake up, extubation, and fewer desats post op. ​

2ug/kg is a big bolus

 

[deleted697127]

2ug/kg is a big bolus

Thus illustrating relative safety for kids with osa going for tonsillectomy.