March FY22

[kristenhorsman]

The March article is presented by Amy Swank and is titled "α2-Adrenergic Receptor Agonist, an Attractive but Underused ERAS Component in Improving Fast-Track Recovery and Surgical Outcomes". The article describes the unique analgesic properties of α2-agonists and their mechanism of action, benefits, application and potential side effects. 

Follow this link and answer the following two questions:

1. What are the side effects of alpha 2 agonists? Have you seen these clinically?

2. How have you incorporated using dexmedetomidine in your anesthesia practice? Any tips for use especially in the ambulatory, same-day surgery or ERAS setting?

[Dahlia Rouchon]

Thank you for this article on alpha 2 agonists in anesthesia. It is becoming more common place to see precedex used and it is a helpful adjunct for both sedation, FOI, and maintenance anesthesia when opioid sparing strategies are desired.
1. The side effects I have in alpha 2 agonists, precedex specifically as I have not used clonidine, are sedation without respiratory depression, in the elderly profound hypotension, bradycardia, and decreased analgesic requirements.
2. I have incorporated precedex in my practice more so for bolus use, 4mcg at a time until desired sedation achieved. In ambulatory anesthesia, 4mcg in preop as rolling to the OR can be useful in an anxious patient where less sedation is preferred with super morbid patients, OSA, COPD.
It is a useful medication with bring back to OR bleeding is noted and airway compromise is present where inducing with paralysis could be catastrophic. With FOI, this is a preferred drug with topicalization for non emergent awake intubations for me.

[Patricia Brissett]

Thank you for the article
1: Definitely see more bradycardia than hypotension more so with the use of Dexmedetomidine in my clinical practice. When using Clonidine, I have noted hypotension (greater than 20% decrease in baseline BP)
2: I do use Dexmedetomidine when feasible, allowing ample time for loading if/when using an infusion. In pediatric cases, I have used it in bolus increments and found a 'smoother' wake-up in this group.

[Matthew Soladay]

1. Sedation, bradycardia, hypotension, dizziness. I have seen bradycardia and sedation most often. Hypotension occasionally. Dizziness less common and hard to assess in somnolent child.
2. In pediatric anesthesia we have had convenient access to precedex for a couple years and use it on an almost daily basis. What I found out pretty quickly was that it became very easy to give the drug to a very wide selection of pediatric surgery patients due to the analgesic/opioid-sparing properties, the preservation of respiration, along with the post-anesthetic somnolence/sedation. Waking up a child from GA after administering precedex increased likelihood of a comfortable child without crying or delirium.

The downside was that the period of time in which the child spent waking up in the PACU was increased. This is particularly important in the ambulatory setting as timeliness of discharge is an important measure. This made it a non-ideal choice for a number of our pediatric patients who were not at high-risk of delirium or significant amounts of pain. Children who benefit most from precedex in the OR are those with higher expected postop pain scores (painful surgeries or inability to perform regional anesthesia), developmental delays, high risk emergence delirium, need for imobilization (such as after cath or delicate reconstructive surgeries), or patients in which opioids are best avoided (severe OSA).

The duration of action of the drug suggests that it should be used selectively in the ambulatory setting. Selective use is very helpful for some of the previously mentioned reasons.

Regarding ERAS cases, particularly for larger cases with higher postoperative pain scores, or for surgeries requiring a hospital stay, precedex is quite straight-forward to use and highly beneficial.

[LarSharVeA Bailey]

What a great article! The more esoteric side effects of alpha 2 agonists are paradoxical hypertension and tachycardia, more commonly seen with cessation of clonidine, although there are case reports of such occurrences with dexmedetomidine. Precedex is a great tool for sedation cases, in isolation at that. I start the drip at 1mcg/kg/hr as soon as the patient is in the room and then I proceed to connect monitors. This obviates the need for a bolus, thus decreasing the likelihood of profound bradycardia and hypotension. Clonidine 0.1mg is also a valuable adjunct in decreasing the postoperative opioid requirement, however, keep in mind that it does have sedative properties making it imperative to specify that it is given after all consents have been obtained.

[aileenm4]

1. side effects of Bradycardia, hypotension, dizziness, sedation listed as some examples in the article, I see most often bradycardia, this is profound in some pediatric patients and not desired at times as we use this drug in smaller babies as well. I agree with Matt Soladays statements and we use Dexmedetomidine routinely in peds for all the positive attributes of the medication: calmness, less emergence delerium, sedation and opiod sparing.
2. we in the peds department run infusions of Dex in the PACU often to keep younger, less cooperative children still post heart cath or IR cases where the child needs to lay still for hours. Dex is incredibly effective in an opiod sparing anesthetic for example our severe OSA children undergoing airway procedures, and it would be an excellent adjunt in ERAS cases for the opiod sparing effects etc.
also agree that the dose for ambulatory cases should be lowered as the patients are sleepy post Dex bolus in PACU

[Jessica Hadley]

1. Side effects of Dexmedetomidine that I have seen most frequently are bradycardia and hypotension.
2. I have used Dexmedetomidine with good success in awake FOI and for sedation in IR and NIR at times. I also find it to be a useful adjunct in a variety of outpatient MAC cases. Sometimes I run a low dose infusion eg. vitrectomy or carpal tunnel surgery. Other times I give a small bolus as an analgesic/ sedative adjunct. I do think it helps to facilitate a smoother emergence and cooperation during mac cases. I have found it can lead to longer sedation in doses above .5-1 mcg/kg.

[Wai-Ling Lo]

1. What are the side effects of alpha 2 agonists? Have you seen these clinically?
The most common side effects I have encountered are hypotension and bradycardia. The prolonged hypotension in PACU is troublesome and concerning. Dexmedetomidine has a distribution half life of 6 minutes and an elimination half life of 2 hours in healthy volunteers. However, hypoalbuminemia, end-organ damage, changes in hemodynamics, and decreased cardiac output may all contribute to a reduction of plasma clearance of the drug. Therefore, I don't use it in cardiac pts with decrease EF and/or liver issues.

2. How have you incorporated using dexmedetomidine in your anesthesia practice? Any tips for use especially in the ambulatory, same-day surgery or ERAS setting?
I found small boluses of dexmedetomidine are useful for smooth emergence or MAC cases that require light sedation.

[kels]

sedation , diziness , bradycardia and hypotesion are some side effects . Clinically I have encountered hypotension and bradycardia but I do not use dex often in my clinical practice

[Anne McNulty]

1.The side effects of dexmedetomidine are hypotension and bradycardia. I have experienced these effects many times. On occasion the bradycardia was clinically significant to require termination of the infusion. Dexmedetomidine decreases BP and HR by decreasing sympathetic outflow without significantly affecting stroke volume.

2.I first started using dexmedetomidine 20 years ago for gastric bypass patients. I started the infusion at 0.2ug /kg/hr and titrated up to 0.6 ug/kg/hr, I did not use loading doses. I had a few instances of terminating the infusion due to bradycardia and hypotension. I terminated the infusion one hour before the end of the surgical procedure. The patients were always extubated and calm. The opioid sparing effect was awesome as well as the lack of respiratory depression in PACU. I have also used this drug in many other settings such as spine surgery in morbidly obese patients. In many institutions the PACU nursing staff is trained and educated in administration of dexmedetomidine. All the patients that I sent to pacu with this drug infusing were extubated in less than 2 hours, were calm and cool and tolerated weaning from the vent very well. I use this drug in MAC cases , sometimes as a low dose infusion or small bolus doses. I have recently used dexmedetomidine with ketamine in the or for emergence delirium. It worked well with the ketamine. I have never seen this drug used in an ERA protocol.

[kelseyleonard]

1. Side effects of precedex I have most often seen is bradycardia occasionally accompanied by hypotension. Bradycardia I have seen is most often associated either during the initial loading dose of 1mcg/kg or in PACU if a prolonged infusion has been used in the OR. I have not used clonidine in my practice.

2. I love to use precedex for sedation cases in conjunction with other drugs. A low dose propofol infusion combined with precedex infusion will yield a nice deep sedation with much less respiratory depression than the typical high dose propofol infusions most of us are used to. It is also very beneficial to use bolus doses of about 0.25-0.5mcg/kg titrated in just prior to emergence to smooth wake up, particularly in those prone to delirium.

[Tracey Trainum]

Great article especially with the increased usage of precedex in the anesthesia setting.
1. Side effects of alpha 2 agonists are primarily hypotension and bradycardia. Incidence of symptomatic bradycardia is low, but the article recommends limiting administration in patients with AV nodal dysfunction. Also, because alpha 2 agonists can produce hypotension, the article also suggests limiting use in patients with renal insufficiency.

I have seen both bradycardia &/or hypotension - especially when I have used precedex in higher doses. I do not have any experience with clonidine.

2. I love using precedex for sedation cases. I use it regularly in colonoscopies when I work with providers that have long endoscopy times and that tend to use abdominal pressure for advancement of the scope into the cecum. In this area it provides some analgesia during the times when abdominal pressure is used- reducing the amount of propofol utilized which ultimately reduces risk of airway obstruction and/or aspiration. I also use precedex routinely during sedation for prone cases- especially the pain cases. Again, it greatly reduces the amount of propofol needed which in turn decreases risk of airway obstruction/airway issues during prone sedation. I also find it helpful for sedation in patients that are obese and/or have OSA. The key is to give it early. If I am using it it is always the first drug I administer in my sedation regimen and I give it in preop if I can. I do not find that it's use hinders PACU stay- IF given early and in appropriate doses. So yes..... I love precedex.