Need some Precedex advise

[EyeSeeYouRnOhio]

We recently acquired two new intensivists, one from Texas, other from New York. We typically sedate w/propofol, however these two prefer Precedex. On two separate occasions when they opted for Precedex the pts were buck wild. We could not even initate intubation because the pts flopping all over the place. Both times we ended up abandoning Precedex and grabbing the propofol. After the first botched experience I read up on precedex and it sounds like you have to wait a good ten minutes for full effect, is this true? What are your experiences with Precedex? Any advice for future use would be greatly appreciated. The two new guys are not very approachable and both state they have never had this problem before(i.e. must be nursings fault). Thanks in advance.

[mskate]

I use precedex a lot and frankly, sometimes it works great - sometimes it doesn't. The big bonus to precedex is that you can use it on patients who are not intubated and you don't need to remove it to extubate others.

If they were using precedex as an RSI drug - thats just flat wrong. This is not a drug to use to sedate people to intubate them.

The general rule is to *try* to keep it less than 0.7mcgs/kg/hr, but 9x out of 10, you end up going up to the "max" dose of 1.2. I have seen it as high as 2.5 for some patients.

The special cocktail is usually a precedex gtt and a dilaudid gtt, and to keep a patient adequately down is usually .5-1mg.hr of dilaudid and up to 1.2 of dex. Its not at all uncommon to add a versed gtt on top of that, with the goal to wean down the versed as much as possible and eventually just keep them on the dilaudid and precedex. With our protocols, we DO NOT wean precedex for vent weaning and do not remove analgesic drugs for weaning either, although sometimes we have to drop the narcotic a bit just to perk the patient up a little.

There certainly have been times were we go back to propofol from the precedex - it isnt a magic drug for everyone but I don't hate it. I have learned to re-adjust my expectations on just how "down" i keep the patient because with the precedex, they DO wake up, but they should not be squirmy.

[EyeSeeYouRnOhio]

Thanks for the info mskate. They were definitely using this for RSI and it was a flaming diaster. After I read up on the drug(we had no heads up that these new guys were going to be changing things up, our NM is all about education) it did not seem appropriate and when I asked the one from NY I was talked to like I was 3 years old. So I thought I would see what others experience had been with the drug.

[edogs334]

We just had an in-service on Precedex and I can tell you that facilitation of intubation is definitely NOT one of the labeled indications for this drug. Those docs are either very ignorant or just plain crazy- the outcome of that intubation attempt is definitely their fault and not yours. I think some docs just like to use new(er) drugs like Precedex because it's the latest and greatest new thing and they just read all sorts of literature about how well it works. Well, evidence-based practice is all well and good, but sometimes they overlook the individual patient (as opposed to a population of patients in a study) when making decisions about which sedative to use. In my unit, we usually use Precedex for intubated patients who are closer to being weaned off the vent (ie- going on PS trials), but still have some intolerance of the ETT and/or being on the vent itself. Precedex is good alternative to Propofol and Versed in the sense that it doesn't have the respiratory suppresant effect that Propofol and Versed do. Plus, if (and that is, only if) Precedex actually works for a particular patient (there's a good percentage of patients in which it does not work), then you can also do accurate neuro assessments on them while maintaining them at a comfortable RASS of -1. Precedex is supposed to keep patients in a state where they are resting comfortably (RASS of -1), but they can wake up and follow commands when told to do so. Precedex also doesn't have as much of a hypotensive effect on patients in comparison to drugs such as Propofol.

So in my experience, Precedex is really hit or miss. There are some patients who will still be buck-wild on it, but for the patients in which Precedex is therapeutic, it's like dealing with a sleeping lion- they can become agitated when stimulated, but they go back to resting after a period of not being bothered.

[bellehill, RN]

In our neuro patients it seems to work very sporadically. We were just inserviced on Precedex and it is not to be used for the patient when they are wild. Ideally, you would get the patient calm with Ativan/Haldol/Versed and start the Precedex drip while those are wearing off. Our rep recommended this especially for patients who are at risk of alcohol withdrawal. Start the drip BEFORE the patient becomes uncontrollable, not once they are.

Personally, I like Precedex but it isn't for everyone. I like that the respiratory drive is not affected so I can use it on my non-vented patients and still do a good neuro assessment. Maybe your docs need to talk to the drug rep. Hospira makes it, just call them.

[sassyRN73, RN]

We use it, but def NOT for RSI! We have been using it for about a year and I still prefer propofol for sedation for intubated patients.

[sunnycalifRN]

We use it, but def NOT for RSI! We have been using it for about a year and I still prefer propofol for sedation for intubated patients.

I agree completely. Precedex is NOT a drug for RSI, period. We seldom use it for primary post-op sedation, however, it is a great drug to use for the "wild ones" who wake up kicking and swinging. For wild patients, we initiate a Precedex gtt, find the correct dosing (we've gone up to 1.7 for some), then turn off the fentanyl and versed and extubate a little later.

[sugarmagnolia3]

I have only used Precedex a handful of times, but I have been under the impression that this drug should only be used when anticipating the pt. being weaned from the vent in the next 24 - 48 hours. At least that's what happens in my ICU.

Also, I have seen it make people very bradycardic....

[getoverit, BSN, RN, EMT-P]

This is really good info on precedex. We use it occasionally, only on patients who are mechanically ventilated, I don't understand how any physician could understand the medication and still believe it would facilitate an RSI.

I'd never heard of using it in conjunction with a dilaudid gtt. that may make it more effective. to be honest, the few patients we use it on end up requiring something else to keep them tolerating the ETT. Our inservice presented it as "the next best thing" and that we'd love it. I'd bet you'd have a hard time finding anyone in my unit who would agree with the drug rep.

[NtannRN]

I agree Getoverit. We dont use it very often, I have yet to see the effects as advertised. Lol:yeah:

[Nero, RN]

Precedex, hit or miss as maintaining sedation, innappropriate for intubation related sedation induction.

We use the following depending on the pt, situation, etc...

Versed + Fentanyl as gen maintainance and induction.

Sometimes we will use paralytics, Etomidate for example for the intubation.

Prop on occasion for those that dont tolerate weaning off versed for breathing trials, extubation.

The MDs you speak of are a$$h@t$. This is the type of stuff that a 1st year fellow would try, not an attending worth their salt.

[noelia23RN]

That's crazy that they would use precedex for intubation, they probably have not been formerly educated with this drug. I have used it many times and we mainly use it to wean the pt off of the vent like other people have mentioned sometimes it works sometimes it doesn't. But when it works it works great.