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.

[clarkheart]

It's plain insane to use Precedex as an induction drug. Etomidate and versed/fentanyl usually work much better with another paralytic if needed. Precedex can be hit and miss but we use it exclusively to wean and extubate our open hearts. We also use Precedex when we want to change to shorter acting sedation in anticipation of weaning to extubation on our med/surg patients. Have extubated many times while still on Precedex and even continued while patient was either on BIPAP or on simple mask. It doesn't suppress respiratory drive and can seems to be the right combination for patients who are still anxious or going through drug withdraws.

[xtine618]

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

This is my main problem with Precedex. We actually see it fairly often where their heart rate just wont tolerate turning the gtt rate up so you fight between sedation or circulation. We have never used it for RSI. Usually we start with Propofol then switch to Precedex. It is nice to be able to keep it on during CPAP trials and after extubation. Especially for that dreaded BiPAP like someone else had posted. Although we have never used it on ETOH withdrawal patients who are not intubated, I think I will suggest that next time. I once gave someone enough Ativan to kill a horse and it still didn't keep her down.

[Guest193822]

I'll be honest when I get an order for Precedex, I'm in the habit of pulling out Propofol. I've used this medication since it appeared in my hospital & I'm not a fan of it. It doesn't work for everybody & it does have have effects I'm not crazy about like bradycardia.

Is a short term thing for extubation in 24hrs like an overnight PACU. I don't suggest it for long term basis, but we use it short time for Neuro assessment however once we get the good assessment we back to Propofol.

This medication is Not for intubation.

[core0]

I'll give my perspective after using it for about a year. First it seems to have a binomial distribution. It either works or it doesn't. Unlike Propofol where you can increase the dose until you get an effect, some patients will never calm down on Precedex no matter what the dose. Also it takes longer to work (we don't use loading doses). So if you expect it to work right away you are going to be disappointed.

Bradycardia is a problem but its relatively uncommon (10-15% at a guess). Its just a flip side of hypotension you see with propofol.

Its a great drug if you use it correctly, but its not the be all end all. To me its definitely my go to drug in two specific areas. The post surgical patient you are planning on extubating in the next day or two who is still snowed from surgery. Turn it on and by the time they wake up its to full effect. The other place is the patient who is agitated on their SBT. Keep the propofol on, titrate the Precedex up and then turn off the propofol. SBT on Precedex then extubate on precedex. Once extubated turn of the Precedex. Works great.

As far as RSI with Precedex - wow, just wow.

[kessadawn, BSN, RN]

My understanding of Precedex is this: it allows the patient to be roused easily for neuro checks and easily fall back to comfortable level, so how in the world would that be appropriate for RSI? Also, with intubated patients we always use a narcotic gtt as well, morphine, dilaudid, etc. Precedex works best this way. Those docs are clueless.

[Teleflurry, DNP]

I encourage Precedex. A lot of people dont know that the use of propofol increases the ICU delirium in patients, and many doctors attempt to wean it as soon as possible. Precedex , like others have said, is great extubation because you can still use it even without intubation. Proper titration is key - usually starting at 0.4mcg/kg/hour and increasing by 0.1mcg per ten minutes to a max of 1.5mcg/kg/hr.

Dont let the size of the patient fool you either - Ive had a 300lb lurch heighted man zonked out like a moose on the minimal dosage. As with all medications - its patient specific.

[matt2401, MSN, RN]

Precedex for induction is just plain insane. I can't see how any doctor in his right mind would look at either 1) the FDA labelling, 2) the mechanism of action, 3) the literature available and say "hey I am going to use this to intubate a patient. Stupid, Stupid, Stupid.

Our facility allows a max dose of 0.7mcg/kg/hr. There are two patient populations that I LOVE precedex in: CIWA/ETOH withdrawal patients and those anxious on BiPap. The first CIWA patient I talked an intensivest into using it on was buck wild crazy on 10mg/hr of Ativan (not intubated). Precedex 0.1mcg + Ativan 0.5mg/hr = RASS of -1 and a very happy nurse.