Clinical Article - December 2019

Dexmedetomidine (Precedex) has demonstrated less delirium than the commonly used benzodiazepines and propofol

Jennifer Nopoulos, MSNEd, RN, CPAN

In pursuit of anesthetic agents that have a high safely profile and could possibly reduce the use of intra-operative opioids, newer sedative agents are being considered during the peri-operative period. When used for sedation, dexmedetomidine (Precedex) has demonstrated less delirium than the commonly used benzodiazepines and propofol (Evered, Culley, & Eckenhoff, 2020).  These results have encouraged the use of dexmedetomidine as an anesthetic adjunct for both regional and general anesthesia cases (Evered, Culley & Eckenhoff, 2020). Reducing unwanted emergence symptoms such as coughing, tachycardia, and shivering have been attributed to the use of dexmedetomidine (Vuyk, Sitsen & Reekers, 2015). Dexmedetomidine can also be used as a pre-procedure medication, administered intravenously 15 minutes prior to surgery. For small children, nasal or buccal administration is readily absorbed and easily administered, ideally one hour prior to surgery (Vuyk, Sitsen & Reekers, 2015).

Dexmedetomidine is neither a benzodiazepine such as midazolam, nor a drug like propofol. Like clonidine, it is a selective alpha 2-adrenergic agonist, which results in a decrease in the release of norepinephrine from sympathetic neurons. It acts in the central nervous system (CNS) to produce both analgesia and sedation yet does not cause respiratory depression (Burchum & Rosenthal, 2016). It is approved for sedation prior to and throughout surgical and procedural care, and is also used for several off-label peri-anesthetic applications such as awake procedures, and for treatment of post-anesthetic shivering (Burchum & Rosenthal, 2016).  The drug is helpful in epilepsy surgical procedures as evidence of seizure foci is not suppressed, spine surgeries, and as an adjunct for sedation or regional anesthesia due to producing less brain depression and a sleep like state (Bokoch & Eilers, 2018).

The decrease of norepinephrine accounts for the more common side effects of hypotension and bradycardia (Burchum & Rosenthal, 2016). These can be treated by slowly titrating the infusion rate, providing additional intravenous fluids, or giving anticholinergic medication. Foregoing a loading dose or limiting it to 0.4 mcg/kg is suggested to reduce the chance of hypotension (Vuyk, Sitsen & Reekers, 2015). Withdrawal symptoms such as nausea, hypertension, agitation, and tachycardia have been reported up to 24-48 hours after infusion discontinuation. Caution is advised with pre-existing conditions of ventricular dysfunction, diabetes, hypertension, high degree heart blocks, hypovolemia, and in elderly clients (Gahart & Nazareno, 2020). Medication clearance, as opposed to opioids, is not based on adipose mass, and awareness that large doses based on weight may be too high. Authors also recommend reducing the dose in the setting of hepatic impairment (Budithi & Dolinski, 2019).

The use of dexmedetomidine has been shown to ease and facilitate emergence due to reduced cognition depression, less respiratory depression, and decreased opioid use. Nursing care following the perioperative use of dexmedetomidine is consistent with other types of sedation and general anesthesia, including continuous monitoring of vital signs, cardiovascular and respiratory function. Finally, dexmedetomidine promises to reduce the use of perioperative opioids and improve pain relief patient satisfaction scores (Bokoch & Eilers, 2018).

 

References

Bokoch, M.P., & Eilers, M. (2018). Intravenous anesthetics. In Basics of Anesthesia (7th ed., pp.104-122). Retrieved from https://www.clinicalkey.com/#!/browse/book/3-s2.0-C20140048964

Budithi, R., & Dolinski, S.Y. (2019). Anesthesia for patients with chronic obstructive pulmonary  disease. Retrieved from https://www.uptodate.com/contents/anesthesia-for-patients-with-chronic-obstructive-pulmonary-disease/print

Burchum, J.R.,  & Rosenthal, L.D. (2016). Lehne’s Pharmacology for nursing care, 9th ed. St. Louis, Missouri: Elsevier.

Evered, L., Culley, D.J., & Eckenhoff, R.G. (2020). Cognitive dysfunction and other long-term complications of surgery and anesthesia. In Miller’s Anesthesia (9th ed., 2639-2653). Philadelphia, Elsevier.

Gahart, B., Nazareno, A., & Ortega, M. (2020). Gahart’s 2020 intravenous medications, 36th ed. St. Louis, Missouri:  Elsevier.

Vuyk, j., Sitsen, E.,  & Reekers, M. (2015). Intravenous anesthetics. In Miller’s Anesthesia (8th ed., pp. 821-863). Philadelphia:  Elsevier.

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