Precedex...

What have been your experiences with this medication. How do you compare it to the use of propofol? Better/worse??? :) We are being trained on it; as our physicians have started to use it more frequently. Any advice, experience in the use of it, etc. would be greatly appreciated!!!!!!!!!!!!!!!!!!

I've only used precedex once on a pt we were trying to wean off propofol/fentanyl gtts. Did not work for this pt and we abondoned the regimen.

In the open heart ICU we mix a precedex gtt (400mcg/100cc) standard for each patient admitted from the OR. We titrate it from 0.2 - 0.7 mcg/kg/hr to a Ramsey of 3, and up to 1mcg/kg/hr for some cases (rarely though.) We use precedex on the ventilated patients until extubated. It's great because it doesn't sedate them as much as propofol and can be weaned to off easily. It also doesn't depress the respiratory system. An extubated patient can be sedated on precedex whereas a non-intubated patient on a propofol gtt must have conscious sedation protocol in effect. Only problem is when patients are hypotensive as it has a an effect on BP.

In the open heart ICU we mix a precedex gtt (400mcg/100cc) standard for each patient admitted from the OR. We titrate it from 0.2 - 0.7 mcg/kg/hr to a Ramsey of 3, and up to 1mcg/kg/hr for some cases (rarely though.) We use precedex on the ventilated patients until extubated. It's great because it doesn't sedate them as much as propofol and can be weaned to off easily. It also doesn't depress the respiratory system. An extubated patient can be sedated on precedex whereas a non-intubated patient on a propofol gtt must have conscious sedation protocol in effect. Only problem is when patients are hypotensive as it has a an effect on BP.

You mentioned that a non-intubated patient on a propfol gtt must have conscious sedation protocol. I'm training in the ICU; just started. Can you explain what your protocol is. Also, how hypotensive have your patient(s) been and what interventions did you perform??

I have been using Precedex for a little over 3 years in our CVICU. We use it from immediate post-op for all post cabg pt's until the next morning(we keep it on after extubation). This allows the patients to stay calm thru the night, get some rest, cough and deep breathe and we have found our patients use less narcotics with this drug. Dosage for CABG is .2 to .7 mcg/kg/min. We have started using this on Thoracotomy patients that have difficult to control pain (no epidural) and it works great. This is also used at my facility for "De-Tox" patients and we take it up to 1.5 mcg/kg/min as needed. This is a good drug that is not a negative inotrope like diprivan and doesn't drop your B.P. as much. It took me about 1-2 months to get comfortable with it after we switched to it from Diprivan. There has not been an increased # of self extubations either as we thought when first using this.

This is a good drug that is not a negative inotrope like diprivan and doesn't drop your B.P. as much.

I disagree, after 1 year of using this drug I have found that I experience as much hypotension as propofol if the patient does not have adequate-high filling pressures. We try to keep our hearts here on the dry side, less incidence of pleural effusions, etc. Yes there are advantages to using dexmedetomidine HCl as described by others. You also have to take in consideration that a run of Precedex is about three times more expensive than propofol. You can never have the amnesic effects you can with propofol. You can't use dexmedetomidine HCl for more than 24 hours per the manufacturer, then you go off label.

I have used Precedex twice now on non-intubated patients. It worked well for one pt, the other was sitting up in bed yelling on the max dose. I prefer diprivan but these pts weren't intubated. I'm pretty sure we run out Precedex at mcg/kg/hr but I will have to check. It can only run for 24 hours so you better find another method of keeping your pt calm quickly.

I am an ICU nurse but I floated to CVICU last month and witnessed the trial use of Precedex on CABG patients. The patient did not fare well on Precedex, became highly agitated and fighting to the point where three nurses were needed to hold him down (fresh open heart with balloon pump, vent, lines, pacer - the whole nine). Ativan didn't touch him and eventually Propofol was started.

Over this past weekend, I received an intubated patient from OR after an E-lap. The PACU nurse reported to me that the patient was on a Precedex gtt. It took me 30 seconds before I remembered what Precedex was, considering we do not use it in ICU. I asked them to change it over to Diprivan before the patient was transported, but it wasn't done. The patient arrived groggy but easily aroused, then became highly agitated. I quickly changed him over to Diprivan for the remainder of the night.

This is also used at my facility for "De-Tox" patients and we take it up to 1.5 mcg/kg/min as needed.

A couple of years ago one of our genius psych attendings decided to get involved with a Dex study with our cardiac post-op patients who had a high probability for ETOH withdrawal during recovery. We had very strict protocols about which pain meds and additional sedation (eg: versed, ativan, haldol) we could give during and after the dex infusion - when the patient was intubated and after extubation, even sleeping aides and really anything that effected the CNS.

There were three different protocols. One was something like the Dex drip, morphine while intubated, percoset after extubation, and insy weeny tiny doses of versed for breakthrough sedation. Another protocol would be the Dex drip, fentanyl for pain during intubation, vicodin after extubation, and tiny weeny doses of haldol. And so on.

The patients of course had to give pre-op consent to be part of the study and we had to follow through with this (why oh why couldn't we have the control group?!?!).

It was pure hell.

I hated this drug. At times we had absolutely no choice but to ditch the study and use propofol or versed for patient safety as the Dex provided absolutely zero sedation and actually made patients MORE agitated and for longer. I found that I was giving narcotics for sedation instead of for pain relief (wrong, bad, terrible!). I really don't recall any of the titrateable dosing but I do remember that the Dex came in 100 ml bags at a time and ran for a total of 24 hours.

Since that study almost 2 years ago, I have seen this drug used in our CTICU once - the docs hated it too. This was pretty recent. We ended up on propofol in this case as well. The study also included the other large Med/Surg/ Trauma ICU in my hospital. I'm not sure how their patients faired with the drug.

I don't know, maybe it had something to do with night shift. It just didn't work on nights. Overall the outcome of the study was favorable for the use of Precedex for these types of patients though.

So I apologize to those who now use this drug regularly and don't like it as prophylaxis for ETOH withdrawal. I hope that our ICU's contribution to the efficacy of this drug didn't prompt more of it's wider use!

Also, as far as the use of this drug decreasing the need for pain meds, I find that giving around the clock toradol for the first 48 hours post-op cardiac surgery (if platelets are WNL) works 10,000,000% better than the makers of Dex can ever dream their drug accomplishing.

IMO!!

(hmmm, did that make sense?!)

What have been your experiences with this medication. How do you compare it to the use of propofol? Better/worse??? :) We are being trained on it; as our physicians have started to use it more frequently. Any advice, experience in the use of it, etc. would be greatly appreciated!!!!!!!!!!!!!!!!!!

Our cardiac surgeons use Precedex on our post op hearts when we are weaning them for extubation in the first few hours after surgery. The main problem I've had with it is hypotension esp. in more elderly patients. It certaintly creates a controlled sedation and still allows the patient to begin to awaken from the sedation and anesthesia from their surgery. I've had patients on CPAP for as long as 1.5 hours with no problems. The usual dose is 0.5mcg/kg/hr. We initially would bolus the patient with 1mcg/kg/hr for 10 minutes but we have found that really isn't necessary. I usu. start to titrate the dosage down as the patient begins to awaken more and as long as I have controlled sedation for the patient. I've actually extubated patients while on Precedex with no problems.

Also, as far as the use of this drug decreasing the need for pain meds, I find that giving around the clock toradol for the first 48 hours post-op cardiac surgery (if platelets are WNL) works 10,000,000% better than the makers of Dex can ever dream their drug accomplishing.

IMO!!

(hmmm, did that make sense?!)

Our CVICU, has increased our usage within the past year. I was wondering if you have read the P.I.? It indicates that Precedex is indicated as a sedative agent. I have been able to administer far less opoids, not to mention, that you can extubate while the patient continues to receive Precedex. I guess troubleshooting can be difficult for some, but you might take the time to educate yourself as Precedex is not a SOLO agent in terms of taking care of both sedation and pain.

Our CVICU, has increased our usage within the past year. I was wondering if you have read the P.I.? It indicates that Precedex is indicated as a sedative agent. I have been able to administer far less opoids, not to mention, that you can extubate while the patient continues to receive Precedex. I guess troubleshooting can be difficult for some, but you might take the time to educate yourself as Precedex is not a SOLO agent in terms of taking care of both sedation and pain.

Are you kidding?!

I did say at the end of my post you quoted: "hmmmm, did that make sense?"

Apparently, it did not.

If you read my post previous to the one you quoted I am WELL AWARE that Dex alone is NOT meant for pain relief.

The question I was addressing in the particular post that you quoted was...does Dex decrease the need for opiods? Or, is Dex a good adjuvant to opioids?

In my experience, administering a Dex drip post-op DID NOT decrease the NEED for opioids.

In my experience, giving Toradol around the clock for the first 48 hours post-op DID and DOES decrease the NEED for opioids.

1) Dex makers (or whoever) CLAIM that the need for opiods is less when giving their drug.

2) If the makers (or whoever) claim that Dex decreases this opioid need, then Dex can be considered an adjuvant drug just as Toradol is when it comes to enhancing the effects of, or decreasing the need for, opiois.

3) The need for opioids is LESS when given with an adjuvant such as Toradol. Dex is an adjuvant just like Toradol is (according to the makers - or whoever). BUT, the effectiveness of Dex as an adjuvant to opioids is NOT GOOD, in my experience and opinion. At least it is not as good as Toradol.

I NEVER said that Dex is a "solo" anything.