Small dose precedex on induction?

[Maverikk]

The place I'm currently doing locums at many of the MDs and crnas give a small dose (16-24) of precedex on induction. No infusion, for short and long cases. I use precedex for infusions for TIVAs, wakeups in drug addicts or people who look like they're going to be bucking broncos. I think it's somewhat institutional, but the usual response I get is to decrease opioid use but I don't see this and it clinically doesn't make sense given the dose/length of surgery. What is this providing? Is there any evidence for this?

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[medicine2wallstreet]

My guess is diminishing emergence delirium. I don't know of the data on opioid use but that sounds like an extension of ERAS protocols. Probably eras lite with the small bolus.

 

[GassYous]

I don't see the point

 

[Simba1711]

We use to do that in residency to decrease the risk of Ed and decrease opioid use. Now I’m an attending , I don’t add extra stuff and just keep it simple.

 

[vector2]

There's almost certainly no evidence for giving some random, small bolus on induction.


Furthermore, there is a 100% inverse correlation between degree of random daily precedex fckery and anesthesia skill/knowledge.

 

[DocMcCoy]

I’ve heard anecdotes of giving a small bolus around closing to “help smooth out emergence” in low/no narcotic sparing cases. Seems like a waste to crack open a 200mcg vial to give 20.

 

[cchoukal]

There have been a handful of studies looking at various doses dexmedetomidine for the prevention of various emergence phenomena. To my knowledge, the only one that was positive was for reducing cough on emergence, and that required 1 mcg/kg around 30 minutes prior to emergence.

Could there be some benefit to this approach that hasn't yet been studied? Sure, but their dose is so small, I doubt it does much of anything given that it takes 1 mcg/kg to reduce cough.

 

[abolt18]

In residency the pharmacy had syringes made that were 10mL, 4mcg/mL. The crnas would give EVERY. SINGLE. PATIENT. 8-40mcg of precedex during the case to "smooth out their wake up."

Tell you what, patients spent a lot more time in PACU after this trend started. Can't say it made a big difference in narcotics. Personally I only use it for my TAVRs and for post cardiac surgery sedation.

 

[Simba1711]

In residency the pharmacy had syringes made that were 10mL, 4mcg/mL. The crnas would give EVERY. SINGLE. PATIENT. 8-40mcg of precedex during the case to "smooth out their wake up."

Tell you what, patients spent a lot more time in PACU after this trend started. Can't say it made a big difference in narcotics. Personally I only use it for my TAVRs and for post cardiac surgery sedation.

Did we go to the same residency lol

 

[UnoMas]

I never bought into the idea of precedex. Personally I have never found it helpful to justify diluting it out from a vial. I only occasionally use it for peds patients, even then, propofol usually does the trick. Residents when they bring up using precedex for cases with me I shoot it down pretty quickly, tell them to stick to the KISS principle.

 

[norski]

Fentanyl does the trick.

 

[cytocide]

Precedex is really hot right now. They put it in nebulizers for PDPH - why nebulized and not snorted? Because after it is absorbed through the lungs it targets the meninges.

 

[pgg]

In a word, no.

Some of our CRNAs give Precedex to patients like it's some kind of elixir of life. I don't really get it. There's a role for it in reducing emergence delirium in peds but as an "adjunct" for all comers I don't like the practice.

Its not a hill I choose to die on though.

As time goes by I use less and less of the stuff. At this time the only patients I routinely use it for TAVR sedation and post cardiac surgery patients, but I'm rethinking that and wondering if I'd be happier with propofol.

 

[DG51]

Classic example of people overcomplicating anesthesia...prop sux tube ftw

 

[Beeftenderloin]

Precedex is really hot right now. They put it in nebulizers for PDPH - why nebulized and not snorted? Because after it is absorbed through the lungs it targets the meninges.

Mowafy SMS, Ellatif SEA. Effectiveness of nebulized dexmedetomidine for treatment of post-dural puncture headache in parturients undergoing elective cesarean section under spinal anesthesia: a randomized controlled study. J Anesth. 2021 Aug;35(4):515-524. doi: 10.1007/s00540-021-02944-6. Epub 2021 May 16. PMID: 33993346.

Soliman OM, Aboulfotouh AI, Abdelhafez AM, Abedalmohsen A. Nebulized dexmedetomidine versus neostigmine/atropine for treating post-dural puncture headache after cesarean section: a double-blind randomized controlled trial. Minerva Anestesiol. 2023 Oct;89(10):867-875. doi: 10.23736/S0375-9393.22.16906-3. Epub 2023 Jan 18. PMID: 36651373.

You better believe I’m doing nebulized precedex, 2 tabs of fioricet, a liter of crystalloid and✌🏼next time I get called out of bed at 2am for one of these.

 

[cytocide]

just do precedex blood patches

 

[pgg]

You better believe I’m doing nebulized precedex, 2 tabs of fioricet, a liter of crystalloid and✌🏼next time I get called out of bed at 2am for one of these.

Sort of reminds me of the recent fad of dripping lidocaine into the noses of PDPH patients to hit the sphenopalatine ganglion. Relieve the headache long enough for the next shift to come on, shake their heads, and do an EBP.

 

[neutro]

Thus never made sense to me
People do it

 

[nimbus]

Precedex is really hot right now. They put it in nebulizers for PDPH - why nebulized and not snorted? Because after it is absorbed through the lungs it targets the meninges.

Is there a reason it’s not just given IV?

 

[cytocide]

Is there a reason it’s not just given IV?

I was wondering this myself. I’m sure someone somewhere will put precedex on a qtip to put in a nose.

You better believe I’m doing nebulized precedex, 2 tabs of fioricet, a liter of crystalloid and✌🏼next time I get called out of bed at 2am for one of these.

I guess I will too… couldn’t access those studies at my institution.

 

[PlayToWin]

We frequently use it in our practice. I give up to .5 ug/kg , but typically 0.25ug/kg; given in aliquots of 4-8 ug at a time. works great, just higher incidence of bradycardia/hypotension

 

[GassYous]

There's almost certainly no evidence for giving some random, small bolus on induction.


Furthermore, there is a 100% inverse correlation between degree of random daily precedex fckery and anesthesia skill/knowledge.

We frequently use it in our practice. I give up to .5 ug/kg , but typically 0.25ug/kg; given in aliquots of 4-8 ug at a time. works great, just higher incidence of bradycardia/hypotension

 

[IlDestriero]

One of my colleagues is a rabid anti opiate coolaid drinker. In post op all of their T&As sleep forever, are significantly bradycardic, and then wake up in bad pain, get hypertensive, and need to stay even longer for post op opiates. It’s like they’re single handedly trying to get all the pacu nurses to quit. But, “it works in Seattle.” … 🧐

 

[pgg]

One of my colleagues is a rabid anti opiate coolaid drinker. In post op all of their T&As sleep forever, are significantly bradycardic, and then wake up in bad pain, get hypertensive, and need to stay even longer for post op opiates. It’s like they’re single handedly trying to get all the pacu nurses to quit. But, “it works in Seattle.” … 🧐

It's no coincidence that our cohort of CRNAs who give Precedex to E V E R Y O N E also all rely on deep extubations and take every single patient to the PACU totally obtunded with an oral airway (usually placed immediately after induction and left there the whole case to inflict palate and uvula pressure ulcers).

If I was a praying man I'd pray for a hospital-wide Precedex shortage. Or maybe pharmacy could start treating it as controlled substance, just to punish the people using it with an extra pointless administrative task.

 

[DirtDocMD]

I’ve seen lots of folks who think that the answer to every spike in pulse/BP is “fentanyl!!” or “precedex!!”.

You know what else cures that problem??? A simple 5mg of “Labetalol!!”. It’s amazing how well it smoothes things out, it doesn’t sedate, I don’t have to waste it, and it acts fast.

Not saying it’s a substitute for pain meds. I’m simply saying that the answer to every BP/HR spike is not narcotics or Precedex.

 

[Maverikk]

We frequently use it in our practice. I give up to .5 ug/kg , but typically 0.25ug/kg; given in aliquots of 4-8 ug at a time. works great, just higher incidence of bradycardia/hypotension

Works great for what?

 

[psychbender]

I’ve seen lots of folks who think that the answer to every spike in pulse/BP is “fentanyl!!” or “precedex!!”.

You know what else cures that problem??? A simple 5mg of “Labetalol!!”. It’s amazing how well it smoothes things out, it doesn’t sedate, I don’t have to waste it, and it acts fast.

Not saying it’s a substitute for pain meds. I’m simply saying that the answer to every BP/HR spike is not narcotics or Precedex.

The answer could also be... do nothing. Short periods of sympathetic simulation without lasting pain do not always require narcotics. The tourniquet coming up on three hours doesn't need 1-2mg of dulaudid.

It doesn't happen as often now, but I fondly remember all of the "smooth wakeups" I'd ruin when I was Army (independent CRNAs), and walked in and gave 40mcg narcan to the patient that was apneic, with ETCO2 >80, without measurable ETsevo, thirty minutes after the end of the procedure, with everyone still sitting in the room, and more cases to follow.

 

[Airway]

Works great for what?

For hypotension and time in pacu

Opioid-free anesthesia: Time to regain our balance

www.ncbi.nlm.nih.gov

 

[nimbus]

I worked with some early dexmedetomidine investigators in the early-mid 1990s. At that time they jokingly called it “deathmedetomidine”.

 

[drmwvr]

Precedex is really hot right now. They put it in nebulizers for PDPH - why nebulized and not snorted? Because after it is absorbed through the lungs it targets the meninges.

Just cut to the chase and put it in the CSE.

 

[Beeftenderloin]

I will add to the discussion that my hospital system pushes hard for the administration of at least 2 opioid sparing modalities for virtually every scheduled case. It’s a quality metric we’re tracked on. IV lido, ketamine, precedex, NSAIDs, ofirmev, regional /neuraxial all count. As a result we get 5ml 4mcg/ml precedex syringes (and other non-opioid adjuncts) made very accessible.

Sometimes it’s just about checking a box to keep the man off your back.

 

[kidthor]

Noting that I only do peds, we end up giving precedex to a lot of our patients - I personally often give it on or around induction if I plan to use it. I think it's useful for peds as an anesthetic adjunct and to prevent emergence issues.

I really only use it for those cases or patients where I think it'll have a benefit. I think it's good for things like tonsillectomies, ear surgeries, and a lot of plastics cases. It's useful for rambunctious patients and also for cases where they intentionally want the patient a bit sedated preop (e.g. anything with groin access where they want the patient lying there for awhile post op).

But this thing where CRNAs give 12mcg to everyone like a panacea without thought is a problem.

 

[Ashers]

I worked with some early dexmedetomidine investigators in the early-mid 1990s. At that time they jokingly called it “deathmedetomidine”.

I took over a sedation at the VA as an early resident from a CRNA, and they had what seemed like high dose dexmed + propofol going for a MAC (I don't remember doses, this was 13 years ago). I turned the dexmed off, and it was almost the end of the case. The patient was fine on monitors after the infusion was stopped, on the way to PACU, he became nonresponsive, and his HR was in the 20s when we ran to PACU. My attending laughed and said, "yeah, we saw that a lot in the original trials." I've hated it ever since.

As faculty, some AAs would give it for emergence delirium in adults at the end of every case, and I would always have to deal with hypotension for those patients in PACU. I haven't used it personally unless someone makes me. Which now is never.

 

[nimbus]

I took over a sedation at the VA as an early resident from a CRNA, and they had what seemed like high dose dexmed + propofol going for a MAC (I don't remember doses, this was 13 years ago). I turned the dexmed off, and it was almost the end of the case. The patient was fine on monitors after the infusion was stopped, on the way to PACU, he became nonresponsive, and his HR was in the 20s when we ran to PACU. My attending laughed and said, "yeah, we saw that a lot in the original trials." I've hated it ever since.

As faculty, some AAs would give it for emergence delirium in adults at the end of every case, and I would always have to deal with hypotension for those patients in PACU. I haven't used it personally unless someone makes me. Which now is never.

It has its place but I take care of a lot of young healthy drug addicts getting I&Ds.

 

[nimbus]

Noting that I only do peds, we end up giving precedex to a lot of our patients - I personally often give it on or around induction if I plan to use it. I think it's useful for peds as an anesthetic adjunct and to prevent emergence issues.

I really only use it for those cases or patients where I think it'll have a benefit. I think it's good for things like tonsillectomies, ear surgeries, and a lot of plastics cases. It's useful for rambunctious patients and also for cases where they intentionally want the patient a bit sedated preop (e.g. anything with groin access where they want the patient lying there for awhile post op).

But this thing where CRNAs give 12mcg to everyone like a panacea without thought is a problem.

In the old days the peds folks I know used IV clonidine to chill out the cleft palate wakeups.

 

[nimbus]

I will add to the discussion that my hospital system pushes hard for the administration of at least 2 opioid sparing modalities for virtually every scheduled case. It’s a quality metric we’re tracked on. IV lido, ketamine, precedex, NSAIDs, ofirmev, regional /neuraxial all count. As a result we get 5ml 4mcg/ml precedex syringes (and other non-opioid adjuncts) made very accessible.

Sometimes it’s just about checking a box to keep the man off your back.

Yep like 2 antiemetics.

 

[brominator]

One of my colleagues is a rabid anti opiate coolaid drinker. In post op all of their T&As sleep forever, are significantly bradycardic, and then wake up in bad pain, get hypertensive, and need to stay even longer for post op opiates. It’s like they’re single handedly trying to get all the pacu nurses to quit. But, “it works in Seattle.” … 🧐

Depends if intracap vs extracapsular tonsillectomy - intracap opioid free , extracap opioids - talk with surgeon

 

[woopedazz]

It's such a waste of an expensive drug. A one-off bolus of clonidine works about as well to soothe the agitated anaesthetist at a fraction of the price.

 

[Airway]

It's such a waste of an expensive drug. A one-off bolus of clonidine works about as well to soothe the agitated anaesthetist at a fraction of the price.

Useless drug, but no longer expensive. At my last academic job IV clonidine cost more then dexmed

Edit: I’ve started giving moderate dose magnesium to people. I can’t tell if it works but it’s cheap, harmless and evidence based imo. Anyone else?

 

[drmwvr]

Useless drug, but no longer expensive. At my last academic job IV clonidine cost more then dexmed

Edit: I’ve started giving moderate dose magnesium to people. I can’t tell if it works but it’s cheap, harmless and evidence based imo. Anyone else?

Helps the roc last a little longer....

 

[Simba1711]

I don’t use precedex anymore. If they get rowdy on wake up I give a few ccs of propofol

 

[Simba1711]

Yeah I don’t routinely give magnesium. Same as precedex. Gave it a lot in residency because attendings wanted it. It might help but i feel like it also delays wake up and patients are floppy if you gave paralysis. I give it 1-2 times a year if patients have severe pain in pacu and opioids aren’t helping.

Useless drug, but no longer expensive. At my last academic job IV clonidine cost more then dexmed

Edit: I’ve started giving moderate dose magnesium to people. I can’t tell if it works but it’s cheap, harmless and evidence based imo. Anyone else?

 

[Radetzky]

Precedex is clonidine for posers 😄

 

[psychbender]

Useless drug, but no longer expensive. At my last academic job IV clonidine cost more then dexmed

Edit: I’ve started giving moderate dose magnesium to people. I can’t tell if it works but it’s cheap, harmless and evidence based imo. Anyone else?

It has it's uses, but they're not what many of the CRNAs with whom I work think they are. 8 or 12mcg of precedex given at a few random times during a three hour case won't change much of anything, other than the cost (because they're getting charged for the full 100mL bottle). I'm waiting for this to be the next thing about which pharmacy approaches us as a cost-saving measure (after they lost the suggamadex fight).

 

[nimbus]

Useless drug, but no longer expensive. At my last academic job IV clonidine cost more then dexmed

Edit: I’ve started giving moderate dose magnesium to people. I can’t tell if it works but it’s cheap, harmless and evidence based imo. Anyone else?

Our pharmacy told us the 200mcg/2ml vial is $2-3 but the 200mcg/50ml vial is close to $40. I just squirt the 2ml vial into a 50ml bag of saline.

And I think you’re right, IV clonidine is more expensive than the small vial of dex.

 

[woopedazz]

Dex used to be prohibitively expensive where I work, sounds like I should recheck the price judging by these comments.

 

[PpfSuxTube]

At this time the only patients I routinely use it for TAVR sedation and post cardiac surgery patients, but I'm rethinking that and wondering if I'd be happier with propofol.

I dropped it for my Tavis cause I'm lazy and found no difference. Prop/remi drip with 1mg midaz to get em going works just fine.

I do order it routinely as a prn for the nurses in cvisu for the post ops as well as the standard prop drip. It treats the nurses more than anything else... I think they can't live without it... but at least there there is some evidence... other than ED in peds, and delaying pacu discharge times is there any evidence for this stuff?

 

[KLPM]

I've given dexmedetomidine intra-operatively exactly twice (both as infusions). One person developed complete heart block and the other took so long to wake-up that I extubated them and stuck an LMA in for PACU.

I like giving IV clonidine 0.5 - 1mcg/kg for bigger abdominal cases or for people on lots of opioids at baseline both prescription and otherwise.

 

[psychbender]

I dropped it for my Tavis cause I'm lazy and found no difference. Prop/remi drip with 1mg midaz to get em going works just fine.

I do order it routinely as a prn for the nurses in cvisu for the post ops as well as the standard prop drip. It treats the nurses more than anything else... I think they can't live without it... but at least there there is some evidence... other than ED in peds, and delaying pacu discharge times is there any evidence for this stuff?

Logistically, it's easier for me to do precedex for TAVRs, as propofol is treated here as though it is a controlled substance, and remi is hardly ever used (maybe a couple anesthesiologists and CRNAs like it for carotids), so only in a few locations. I can have my tech check it out of any OR pyxis and set up the pump, then chuck it all at the end. I have started adding prop infusions, or ditching this whole sedation for TAVR in favor of prop TIVA with an LMA due to a recent string of old guys trying to fight the precedex, and getting themselves worked up.

 

[PpfSuxTube]

Precedex as a sole or main agent for tavi must be miserable. I think a colleague tried it once, and hated it...

It's just a miserable halfway house... not potent enough for sedation or apneic