Precedex for DT's

[MunoRN, RN]

We've recently started using Precedex for DT's, a patient was requiring 10mg valium q 30 minutes for an extended period of time and there was concern that we were just going to transition the patient into delirium from the DT's (due to a high benzo load), so the patient was swithched to precedex.

Our soft limit is 0.7mcg and our hard limit is 1.4mcg for general precedex use, although I've heard rumors that other facilities may use a limit closer to 2.5 for DT's patients (since the most common concern is bradycardia and hypotension with precedex, which is rarely a problem with patients in severe DT's).

Does anybody else here use precedex for DT's? What's your range? Do you still give benzos as well?

[classicdame, MSN, EdD]

this would be a good topic for REAL investigation from authoritative sources. If you do, please share.

[MunoRN, RN]

this would be a good topic for REAL investigation from authoritative sources. If you do, please share.

If there was anything useful to be found from "authoritative sources" I would still be interested in how that compares to the experience of those who actually give and evaluate the response to the drug. But as it stands, a group of RN's are probably the most authoritative sources to be found on the subject.

The first RCT on the use of precedex with alcohol withdrawl, which is currently in the pre- recruitment stage, is expected to be published in 2014. The only other data we have available is in the form of case studies, one of which was done on a patient in only mild withdrawl, not true DT's, another was done a patient who was still receiving high doses of benzos, and the third was unable to determine the specific actual dosages used from the version of the patient chart they had access to.

[XingtheBBB, BSN, RN]

I'd be interested, too. I have read that case study and would like to see more meta analysis on the topic. I recently had a DT pt that I would have liked to try on Precedex. Like you said, dosing is the question, we're still pretty conservative with the dosing where I work and would not be trying higher doses, which may be better than the alternatives... in this case we were infusing propofol at about 70 mcg. Can we say PRIS?

Likewise, I'm eagerly waiting the publish of ongoing studies validating Precedex use for over 24 hours. That's holding us back, too.

[MunoRN, RN]

I'd be interested, too. I have read that case study and would like to see more meta analysis on the topic. I recently had a DT pt that I would have liked to try on Precedex. Like you said, dosing is the question, we're still pretty conservative with the dosing where I work and would not be trying higher doses, which may be better than the alternatives... in this case we were infusing propofol at about 70 mcg. Can we say PRIS?

Likewise, I'm eagerly waiting the publish of ongoing studies validating Precedex use for over 24 hours. That's holding us back, too.

Maybe we're one of the few, but we do use precedex for >24 hours, and that would definitely be a limiting factor when treating DT's. I've been told there are studies that show it's safe beyond 24 hours, although I'm only aware of one. It was moderately sized at 375 subjects and compared >24 use of precedex to versed, which showed 23% less delirium in the precedex patients and an average time on the vent that was almost 2 full days shorter. There are still adverse effects with long term use, but they are still pretty tame compared to long term high dose benzo and opiate use.

Japan has approved precedex for use >24 hours, and even though FDA approval is still only for

It would stand to reason that large doses would be needed for DT's considering the dosages of benzos required for DT patients. The one I had still had CIWA scores greater than 30 with 10mg of IV valium every half hour, and the general patient max dose of 1.4mcg was not sufficient either as the bleeding fingernail wounds on my arm can attest to, I can only imagine what it would have been like if I would have stuck to the FDA approved limit of 0.7mcg. Even at 1.4mcg, the patient's SBP was still 130's to 180 and a HR of 70's to 80's, so there would seem to be some room there.

[Nurseboy1]

My unit commonly uses precedex for patients in DTs. We have found that especially for our alcoholics who get intubated for say a GI bleed that the precedex generally helps us to get them down without just burying them in benzos or propofol. The only problem is that sometimes our docs feel that the precedex blunts their physiological symptoms (tachycardia and hypertension) that they use to help dose their ativan/valium (our unit does not use the CIWA protocol). Otherwise we use it to bridge the people to extubation, start the precedex and wean their sedation until they can follow commands and get extubated. We also will start people on precedex who are un-intubated, however, we don't go very high on the doses 0.6-0.8mcg/kg/hr, if they are intubated we go up to 1.6-1.8mcg/kg/hr.