EMCrit 283 - Dexmedetomidine (Precedex) - You'd have to be Delirious Not to Use It (2024)

Adnane Lahlou

3 years ago

Dex definitely better than clonidîe for most these indications…. Though for procedural sedation, wondering yet whether remimazolam will prove better or not

Andrew Smith

3 years ago

Great post. One thing of note, at least in the US, is although its generic price for dexmedetomidine is still significantly higher than propofol for a mechanically ventilated patient. Feel free to see attached image with rough calculations. Per patient, not a big difference, but at scale it could be. Obviously balancing LOS and intubated patients resource requirements if you’re trying to wean or chill out an agitated patient, but the blanket statement of generic meds being cheap is not always true

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Andrew, thank you for that information!!!!! Once my hospital stops complaining about the cost, I usually stop thinking about it much, but you are absolutely right! that is still definitely a sig. difference.

3 years ago

Great episode, I fully agree dexmedetomidine has benefits over propofol and definitely over midazolam. There is 1 drawback I do want to bring up, and it’s the volume of infusion. Because it’s doses per kg, on larger adults sometimes the volume infusion can be quite high. It’s less of an issue in the ED but can add up quickly in the ICU over a few days. I first noticed this when doing I/O checks on patients and trying to figure out why we kept ending the days 1-2L positive despite careful crystalloid management. Its not the worst offender, but it…Read more »

Philip Kaiser

3 years ago

I am currently a 3rd year Nurse Anesthesia Trainee and have encountered dex available in 20mcg/5ml syringes (made by OR pharmacy) at several of the academic medical centers where I’ve done rotations here in Chicago. We were taught to give adult patients boluses of 4-12 mcg at a time to aid in smoothing emergence where coughing or agitation was a risk (especially in patients with PTSD or prior emergence delirium). We also gave after extubation prn. Seemed to kick in pretty quick (5-10 minutes) in extubated patients when 8-12 mcg given IVP. Introp most seemed to work in dex as…Read more »

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Chris Walker

3 years ago

Thanks for the post Scott. What’s your approach to the hypertension/tachycardia many pts seem to exhibit upon discontinuation when they have been on Dex for a number of days? Have seen some use beta blockers, some use clonidine patch or oral taper.

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Claude Sylvain

3 years ago

Always greatly appreciate how relevant and applicable your content is.Thank you for consistently making our collective practice better!

3 years ago

Thanks for sharing your perspective on dexmedetomidine. In the veterinary world we have been using Alpha-2’s for a long time. Our approach is typically starting with a bolus and then starting an infusion. We typically give 1-5 mcg/kg IV push followed by an infusion of 0.1 – 1 mcg/kg/hr. For procedural sedation we might use 10-20 mcg/kg IV push or IM. We get the same bradycardia and peripheral hypertension. Only downsides in the ICU setting is that it can make peripheral pulse oximetry challenging.

Michael Meier

3 years ago

Please keep in mind that alpha2 agonists will massively inhibit bowel movements (it is a common adverse effect).
That is why we stopped using them routinely as sedatives at our surgical ICU in Germany (we ditched continuous opioid infusions, too) and see great improvements in lieus and gastroparesis rates.

Especially for neuro patients who spend a long time in the ICU, paralytic ileus will have huge impacts on their outcome, but it is always overlooked in trials.

Erlend Berge

3 years ago

In regards to max dosing: A couple of years ago in our icu, a nurse had an accident in programming the syringe driver, resulting in an infusion of 1.4mcg/kg/MIN, for 30 minutes. Result: good sedation, mildly bradycardia, and that’s it… this is of course a n=1 incident, but after this I have no problems increasing max dosing to 2.0 mcg/kg/min, even though the producer only recommends 1.4.

2-4 ug’s per kg intranasaly is also a great
sedation for kids before surgery, mri and so on.

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Egad

3 years ago

Not sure the evidence is there for any of this.

Arnold Palmer

3 years ago

Can you explain the statement of the “no respiratory depression” given that some studies found compared to propofol it had similar effects on hypoxia/hypercapnia and upper airway collapse?

https://pubmed.ncbi.nlm.nih.gov/27483127/
https://pubmed.ncbi.nlm.nih.gov/31403974/

thomas fiero

3 years ago

excellent Scott. thank you.

Klaus Skrudland

3 years ago

Thanks for the podcast! Great as always, I´m a bit late to the party here, but I just wanted to add that a relatively common side effect that we see here, is fever. I didn´t hear you mention it or see anyone else comment it, so I thought I´d just add it here. We´ve been using Dexmedetomidine for some years now, in many ICU settings, but mainly for handling delirium and withdrawal effects. We also use it for better NIV mask acceptance/compliance. Other side effects are those you mention, with bradycardia and hypotension as the most common. We usually start…Read more »

Devin Holden

3 years ago

Very nice podcast – well said review of the use of dex! I have two comments: I would be careful saying dexmedetomidine maintains sleep architecture – I would definitely say it does not worsen it (like benzo’s and Propofol do) but what studies I have seen it does not increase REM sleep or slow wave sleep but may improve sleep fragmentation. I think the jury is still out on what medication is best for sleep. (see: Alexopoulou, C., et al. (2014). “Effects of dexmedetomidine on sleep quality in critically ill patients: a pilot study.” Anesthesiology 121(4): 801-807.) I think the…Read more »

James Case

3 years ago

I use a lot of dex but have noticed two other effects that weren’t discussed. First is the bradycardia that seems almost always to be hemodynamically neutral with no effect on the blood pressure but also lasting several hours (often up to 24) after cessation of the dex infusion. Since it doesn’t effect the blood pressure it’s usually a moot point but everyone talks about holding the medication for asymptomatic bradycardia. The second curious effect I’ve noticed is that the effect seems to be widely variable between patients. Some patients will be snowed at 0.3 mcg/kg/min while others are climbing…Read more »