So this episode addresses a big gap in the EMCrit content, namely a discussion of the myriad uses of dexmedetomine. This is one of the primary agents I use for post-intubation sedation (PAD), but also for things like NIPPV sedation and procedural sedation.
Upsides of Dexmedetomine (Precedex)
- No respiratory depression
- Opioid sparing/analgesic effect
- Preserves Sleep Architecture
- Sympatholysis
- May be delirium-protective
- May be more hemodynamically stable than propofol
- Good for neurocritical care
Downsides of Dexmedetomidine
- Bradycardia
- Hypotension (especially when the pt is volume depleted)
Cost(much less of an issue now that it is generic)- Diuretic effect
- Slow onset
- Constipation
Useful for…
- Post-intubation sedation
- NIPPV sedation
- Procedural sedation
- Add-on to propofol
Other Stuff on EMCrit
- Podcast 115 – A New Paradigm for Post-Intubation Pain, Agitation, and Delirium (PAD)
- PulmCrit Wee- Extubating the agitated patient: dexmedetomidine vs. cowboy-style?
- Dexmedetomidine to facilitate noninvasive ventilation
Studies
- The Effect of Propofol and Dexmedetomidine Sedation on Norepinephrine Requirements in Septic Shock Patients (Critical Care Medicine: February 2019 – Volume 47 – Issue 2 – p e89–e95)
- https://www.ncbi.nlm.nih.gov/pubmed/21812509
- https://www.ncbi.nlm.nih.gov/pubmed/27035758
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Editor-in-Chief, at EMCrit.org
An ED Intensivist from NY.
Professor
Nassau University Medical Center
No conflicts of interest (coi).
Professor
Nassau University Medical Center
No conflicts of interest (coi).
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Dex definitely better than clonidîe for most these indications…. Though for procedural sedation, wondering yet whether remimazolam will prove better or not
Great post. One thing of note, at least in the US, is although its generic price for dexmedetomidine is still significantly higher than propofol for a mechanically ventilated patient. Feel free to see attached image with rough calculations. Per patient, not a big difference, but at scale it could be. Obviously balancing LOS and intubated patients resource requirements if you’re trying to wean or chill out an agitated patient, but the blanket statement of generic meds being cheap is not always true
Andrew, thank you for that information!!!!! Once my hospital stops complaining about the cost, I usually stop thinking about it much, but you are absolutely right! that is still definitely a sig. difference.
Great episode, I fully agree dexmedetomidine has benefits over propofol and definitely over midazolam. There is 1 drawback I do want to bring up, and it’s the volume of infusion. Because it’s doses per kg, on larger adults sometimes the volume infusion can be quite high. It’s less of an issue in the ED but can add up quickly in the ICU over a few days. I first noticed this when doing I/O checks on patients and trying to figure out why we kept ending the days 1-2L positive despite careful crystalloid management. Its not the worst offender, but it… Read more »
Yep, def a bunch of fluid though it is possible to concentrate the med
That depends on the concentration you use. At the units I had worked most of the time we use a 4-8mcg/ml concentration at a normal level we don’t end the day with to much positive balance, of course we adjust all the fluids
I am currently a 3rd year Nurse Anesthesia Trainee and have encountered dex available in 20mcg/5ml syringes (made by OR pharmacy) at several of the academic medical centers where I’ve done rotations here in Chicago. We were taught to give adult patients boluses of 4-12 mcg at a time to aid in smoothing emergence where coughing or agitation was a risk (especially in patients with PTSD or prior emergence delirium). We also gave after extubation prn. Seemed to kick in pretty quick (5-10 minutes) in extubated patients when 8-12 mcg given IVP. Introp most seemed to work in dex as… Read more »
thanks Philip!
Thanks for the post Scott. What’s your approach to the hypertension/tachycardia many pts seem to exhibit upon discontinuation when they have been on Dex for a number of days? Have seen some use beta blockers, some use clonidine patch or oral taper.
The best approach to that is probably oral clonidine (followed by a gradual clonidine taper). Clonidine has essentially the same mechanism as dexmedetomidine so this makes the most sense. You often need a fairly high dose of clonidine to achieve this (e.g. 0.2-0.5 mg q6r) and you need the ability to dose-titrate your clonidine fairly rapidly so oral clonidine is generally the way to go (it might be hard to get a sufficiently high clonidine level using a clonidine patch). For patients who are NPO, sublingual clonidine could theoretically work as well with data showing similar bioavailability versus oral. The… Read more »
Always greatly appreciate how relevant and applicable your content is.Thank you for consistently making our collective practice better!
Thanks for sharing your perspective on dexmedetomidine. In the veterinary world we have been using Alpha-2’s for a long time. Our approach is typically starting with a bolus and then starting an infusion. We typically give 1-5 mcg/kg IV push followed by an infusion of 0.1 – 1 mcg/kg/hr. For procedural sedation we might use 10-20 mcg/kg IV push or IM. We get the same bradycardia and peripheral hypertension. Only downsides in the ICU setting is that it can make peripheral pulse oximetry challenging.
Please keep in mind that alpha2 agonists will massively inhibit bowel movements (it is a common adverse effect).
That is why we stopped using them routinely as sedatives at our surgical ICU in Germany (we ditched continuous opioid infusions, too) and see great improvements in lieus and gastroparesis rates.
Especially for neuro patients who spend a long time in the ICU, paralytic ileus will have huge impacts on their outcome, but it is always overlooked in trials.
Michael, thank you for your post. we use continuous opiod infusions and are battling gastroparesis. would you share your sedation technique. I work in a mixed medical and surgical ICU.
In regards to max dosing: A couple of years ago in our icu, a nurse had an accident in programming the syringe driver, resulting in an infusion of 1.4mcg/kg/MIN, for 30 minutes. Result: good sedation, mildly bradycardia, and that’s it… this is of course a n=1 incident, but after this I have no problems increasing max dosing to 2.0 mcg/kg/min, even though the producer only recommends 1.4.
2-4 ug’s per kg intranasaly is also a great
sedation for kids before surgery, mri and so on.
the argument made by manufacturer is not that the side effect profile will be markedly worse, but that there is no additional sedative effect beyond ~1.5mcg/kg/hr
Not sure the evidence is there for any of this.
Can you explain the statement of the “no respiratory depression” given that some studies found compared to propofol it had similar effects on hypoxia/hypercapnia and upper airway collapse?
https://pubmed.ncbi.nlm.nih.gov/27483127/
https://pubmed.ncbi.nlm.nih.gov/31403974/
excellent Scott. thank you.
Thanks for the podcast! Great as always, I´m a bit late to the party here, but I just wanted to add that a relatively common side effect that we see here, is fever. I didn´t hear you mention it or see anyone else comment it, so I thought I´d just add it here. We´ve been using Dexmedetomidine for some years now, in many ICU settings, but mainly for handling delirium and withdrawal effects. We also use it for better NIV mask acceptance/compliance. Other side effects are those you mention, with bradycardia and hypotension as the most common. We usually start… Read more »
How do you find yourself treating the fever? Do you stop the precedex at all? Stop and restart when no fever, or keep going with it?
Very nice podcast – well said review of the use of dex! I have two comments: I would be careful saying dexmedetomidine maintains sleep architecture – I would definitely say it does not worsen it (like benzo’s and Propofol do) but what studies I have seen it does not increase REM sleep or slow wave sleep but may improve sleep fragmentation. I think the jury is still out on what medication is best for sleep. (see: Alexopoulou, C., et al. (2014). “Effects of dexmedetomidine on sleep quality in critically ill patients: a pilot study.” Anesthesiology 121(4): 801-807.) I think the… Read more »
I use a lot of dex but have noticed two other effects that weren’t discussed. First is the bradycardia that seems almost always to be hemodynamically neutral with no effect on the blood pressure but also lasting several hours (often up to 24) after cessation of the dex infusion. Since it doesn’t effect the blood pressure it’s usually a moot point but everyone talks about holding the medication for asymptomatic bradycardia. The second curious effect I’ve noticed is that the effect seems to be widely variable between patients. Some patients will be snowed at 0.3 mcg/kg/min while others are climbing… Read more »