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Precedex Use

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SilverStreak

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I was reviewing the critical care fact sheet someone linked, and saw a reference to caution with use of precedex in CHF. I had never heard this, so I did a search on it. I was suprised to find that it should be used with caution in decompensated CHF patients who can't tolerate the alpha effects. I guess it suprised me because every single one of our hearts comes out on a precedex gtt, bar none I can think of. It also said not recommended for use with hypovolemia or cardiogenic shock patients, and I've seen plenty of these guys come out on it too. They all come from the OR on the current max recommended dose of 0.07 mcgs, and we start titrating down to wake them up for fast extubation. Is everyone using predecex so widely?
 

UTSouthwestern

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Decompensated CHF on the floor or in the ICU can be a totally different scenario than a fresh heart from the OR. Volume restriction, diuresis, afterload reduction, etc. are some of the things you will do to optimize a patient post on or off bypass and that will allow you to use Precedex with more confidence. In other words, your patient will likely not be in florid heart failure as they are rolling out of the room, so the use of Precedex is not a destabilizing factor.
 

militarymd

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UTSouthwestern said:
Decompensated CHF on the floor or in the ICU can be a totally different scenario than a fresh heart from the OR. Volume restriction, diuresis, afterload reduction, etc. are some of the things you will do to optimize a patient post on or off bypass and that will allow you to use Precedex with more confidence. In other words, your patient will likely not be in florid heart failure as they are rolling out of the room, so the use of Precedex is not a destabilizing factor.

When you say "florid heart failure"....are you referring to
1) myocardial failure

or

2) volume overload type "congestive heart failure" as seen in patients rolling into the ICU from the ER.
 

SilverStreak

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Well, in my experience we see both cases. I see what you're saying with the fresh open heart and precedex use. However, I was also thinking that as it has become so frequently used, sometimes the nurses ask for it for sedation on other patients. Sometimes, the MD on the phone doesn't really know much about it, have had those who both 1. went ahead and ordered it anyway and 2. those who declined because they did not feel comfortable ordered it without knowing enough depth on it. It makes me wonder when some of the ICU nurses ask for it, you got a doc on call for another doc in the middle of the night, he doesn't know all the patients history, I give him the highlights, but leave out the history of CHF or some other cautionary use with it, or I tell him and he doesn't know that's a flag to using it. Just wondering how often others are using it for sedation in ICUs. We're seeing it more and more.

Also, interesting patient a while back had crazy temp of 103-104, it was eventually decided it was a drug temp from the precedex. I thought the surgeons nurse was nuts, but it is listed as a side effect. I still wasn't convinced until we stopped it, switched to something else, few hours later, temp is 100 range. She'd been 103-104 in spite of cooling blanket, heavy judicious antibiotic use from ID guys-they're screaming it's an infection we're not catching somewhere, but we'd cultured any and every part of her time and time again with no growth on our cultures. Few days later, a doc on call switches her back to precedex and the temp climbs again, takes her off, temp trends down. It was something else. Anybody else had temperature problems with it?
 
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