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Dexmedetomidine

3 patients with non-dt withdrawl syndromes (J of Inten Care Med 2005;20(2):118

Effect of Sedation With Dexmedetomidine vs Lorazepam on Acute Brain Dysfunction in Mechanically Ventilated Patients

The MENDS Randomized Controlled Trial (JAMA. 2007;298(22):2644-2653. )

- I haven't needed to use a bolus, just started the drip at 0.5 to 0.7 mcg/kg/hr.
- Once patient extubated wean it over couple of hours or faster.

- Expensive so we use it judiciously.

- Used to try the usuals (fentanyl, propofol, haldol, benzos, etc)before trying precedex but now moving quicker to it.

- I believe FDA approved for 48 hrs but have heard multiple anecdotes by anesthesia colleagues using it for periods of up to 2 weeks. Have never had to use it for more than 24hrs.

- Not had ever any problems with bradycardia or hypotension, but never used a bolus.

Back in the early 90s, there was a big push to use a lot of lorazepam in the ICU because it was off patent and cheap and the others were on patent and expensive. Many of the papers extoling the virtues of lorazepam in Critical Care Medicine were thinly veiled advertisements. "Gee....we used a lot of it in the ICU and it worked just swell.....lets use more!!". then look down at the bottom of the page and see "This advertisement brought to you by a grant from Wyeth, makers of lorazepam".

Delirium occurs when pattern recognition is lost in the ICU. Elderly people start running on pattern recognition at some point in their lives. They simply get used to their shrinking environment. Like a blind dog in your house. You never know the dog is blind. He knows the house and never bumps into anything. Then they land in an ICU and all that pattern recognition evaporates. And they might as well be on mars. Mild or incipient dementia takes over and they become confused and confounded and try to escape, following which they are quickly restrained and the race is on.

Giving lorazepam simply decreases their ability to discern the thin grasp of reality, paradoxically increasing the delirium.

Use a sedative you can titrate to effect. Propofol or midazolam.

Ramsay Sedation Scale

Awake
1	Anxious, agitated, restless
2	Cooperative, orientated, tranquil
3	Responds to commands only
Asleep
4	Brisk response to light glabellar tap or loud auditory stimulus
5	Sluggish response to light glabellar tap or loud auditory stimulus
6	No response to light glabellar tap or loud auditory stimulus

Dose of Risperdal ranges from 0.25 mg daily for a frail 80 yo, to 2 mg
bid for a healthy robust young guy. I gave 1 mg bid to my 50 yo
polysubstance abuser.

Dose of valproate that I use is either 500 or 750 bid. Most pts
actually only get the Risperdal. Only the really agitated and more
robust pts get the Valproate. Typical pt who gets both is your
alcohol withdrawal pt. If put virtually all my pts with DTs on both
of these drugs, and encourage the hospitalists to do that too, as soon
as the pts are admitted. I believe it's saved quite a number from
needing transfers to the ICU, but I don't have rigorous data. I know
for sure that pts in DTs are now a relative rarity for us in the unit,
whereas a few years ago they were much more common.

Leo

________________________________
From: prasannasimha [mailto:prasannasimha@gmail.com]
Sent: Friday, August 25, 2006 5:54 AM
To: Leo I. Stemp, MD
Cc: 'International Critical Care Internet Group'
Subject: Re: ccml sedation management in SICU Trauma Patient

Can you give me the doses of Risperidone an Sodium Valproate.
Prasanna

Leo I. Stemp, MD wrote:
NMB?! Crazy. And by the way, like you said, avoid the NMBs with steroid
nucleus. Doesn't that mean avoiding the '-curonium' drugs (panc, vec, roc)?
We use only cis-atracurium here.

We see these pts routinely, have had huge reduction in problems since we
started using the new antipsychotics combined with valproate. At the
suggestion of a member of this List, I might add. One of the most impt new
developments in my practice in years.

Just had a success with it this week. Pt about 6 days post-esophagectomy,
agitated, not handling secretions. Intubated him for airway protection, got
him on Risperdal and valproate, extubated two days later fully awake and
oriented, looking great. In the old days, reintubating such a pt would have
been a calamity. No problem here.

Had another recent dramatic success: a 49 yo multi-substance abuser looser,
came in with ischemic bowel. E-lap, etc. Recurrent abdom sepsis
necessitated him going back to OR two more times, open abdomen, resulting in
the contents of his abdominal cavity being one large, scarred in,
soccer-ball sized lump of cement. Not a candidate for another operation bec
there would have been no tissue planes. Following that had mult radiologic
cavity drainage procedures. The guy was septic for a long time, but never
developed MOSF, only resp failure. So trached. No peg, had to be on TPN.
Once we started Risperdal (the orally disintegrating tabs) and valproate,
his general and resp course really smoothed out. Got him onto trach collar,
then out of the unit after two months or so, looking like a champ -- and
acting like the nicest guy in the world.

Leo

----Original Message----
From: David Crippen Sent: Thursday, August 24, 2006 5:24 PM
To: ccm-l@ccm-l.org
Subject: ccml sedation management in SICU Trauma Patient

He is on industrial strength doses of meds and I can't seem to get
them down. He is on Morphine 25 mg/hr, Lorazepam 10 mg/hr, and
haloperidol 15 mg/hr via constant infusion. Even with this, he
occasionally gets agitated

This is strong evidence for antecedent recreational drug dependence,
not matter what he or his family tells you. All those medications are
cross dependent to and cross tolerant to ethanol and many of the
recreational feel-goods. This will put you into a very big kink
trying to sedate him, as you have already found out.

Like it or not, "partial" neuromuscular blockade is the only way you
are going to get control of this without depleting the Eastern USA
supply of sedatives, and suffering all the side effects thereof. Not
total paralysis, neuromuscular blocker in a titrated dose only to
slow him down, not make him completely flaccid. After all, it is the
musculoskeletal hyperactivity that is the problem, not just the
subjective aspects of "discomfort". You need to stop the untoward
effect of hypermetabolism. Making him more "comfortable" is more
optional at this point. Get an EEG and make sure he isn't seizing in
the temporal lobe.

If you start a continuous infusion of (my recommendation) Rocuronium,
and simply have the nurse titrate it to the point where you can get
on propofol and fentanyl in somewhere reasonable doses. Morphine is
not potent enough to work. Haloperidol will do little as it isn't a
sedative. Lorazepam is like water. The combo of Propofol and
Fentanyl is the least cross tolerant combo and will give you the most
bang for your buck in the presence of loosening his ass up with
Rocuronium. Vecuronium a second choice. Don't use anything with a
steroid nucleus. Forget giving anything enterally.

If you have a cerebral (recreational) drug toxicity encephalopathy,
you're in for a rough ride as it can last for a month or longer.
Usually they loosen up eventually. Seems like Mike Hansen had a
Similar patient recently. Maybe he can comment on what happened to
that one.

--
David Crippen, MD

review of propofol deaths (anesthesiology Volume 105(5), November 2006, pp 1047-1051)

ICU Sedation

Dexmedetomidine

Delirium