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Personal use only. For copyright permission information:Published online http://www.cconline.org 2010 American Association of Critical-Care Nurses
doi: 10.4037/ccn20099202010;30:29-38Crit Care NurseJenni ShortUnitUse of Dexmedetomidine for Primary Sedation in a General Intensive Care
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Promotion of rest and
sleep in critically ill
patients facilitates heal-ing. Multisystem
adverse effects of sleep
deprivation have been reported.1
Physical activity also plays a pivotal
role in recovery and long-term out-
comes.2 Use of sedation is important
to help achieve the right balance
between sleep and wakefulness; the
correct balance is essential for incor-
porating physical activity andpatients cooperation in the plan of
care. Other goals of adequate seda-
tion include optimizing safety for
patients and caregivers, facilitating
mechanical ventilation, reducing
anxiety and delirium, inducing
Use of Dexmedetomidinefor Primary Sedation in a
General Intensive Care Unit
sleep, and, ultimately, providing
comfort and safety.3
Continuous chemical sedationin the intensive care unit (ICU) is
commonly used to control respira-
tory rate and anxiety and thus pro-
mote sleep and ultimately optimize
care. The sedatives used most often
include propofol, midazolam, and
lorazepam.4 All 3 of these medica-
tions provide adequate sedation but
also can cause oversedation. Overse-
dation can lead to prolonged dura-tion of mechanical ventilation, longer
ICU and hospital stays, increased
incidence of ventilator-associated
pneumonia, and inability of patients
to communicate with health care
providers or family members.5
Undersedation is also harmful and
can lead to anxiety, ventilator dysyn-
chrony, dislodged equipment, delir-
ium, increased oxygen consumption,
and hyperactivity.6 Making the dis-tinction between too much sedation
and not enough sedation can some-
times be difficult when propofol,
midazolam, or lorazepam is used.
Achieving adequate sedation
can also be a financial burden. Costs
associated with undersedation
include increased nursing and
Jenni Short, RN, MSN, ARNP-BC
Feature
PRIME POINTS
Use of sedation isimportant to help achievethe right balance betweensleep and wakefulness.
This study showed thatdexmedetomidine canhelp reduce duration ofmechanical ventilation
and number of days in theintensive care unit.
As more studies ondexmedetomidine arebeing performed, andpositive results are beingreported, the drug isbecoming more popular.
2009 American Association of Critical-
Care Nurses doi: 10.4037/ccn2009920
www.ccnonline.org CriticalCareNurse Vol 30, No. 1, FEBRUARY 2010 29
This article has been designated for CE credit.A closed-book, multiple-choice examination fol-lows this article, which tests your knowledge ofthe following objectives:
1. Review the goals of adequate sedation forpatients receiving mechanical ventilation
2. Compare the effects of midazolam, lorazepam,and propofol with dexmedetomidine
3. Examine study presented for use in yourown practice
CEContinuing Education
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respiratory care staffing, discomfort
and dissatisfaction of patients and
their families, decreased staff satis-
faction, adverse physiological conse-
quences, and potential to progress to
oversedation. Costs associated with
oversedation include inadequateexaminations of patients, increased
costs of diagnostic imaging and other
tests, possible delay in the diagnosis
of treatable problems, prolonged
duration of mechanical ventilation,
prolonged stay in the acute care set-
ting, and prolonged hospital stay.
The purpose of this article is to
increase nurses awareness of the
pros and cons of chemical sedation
in the ICU and of newer, alternative
options. Dexmedetomidine has been
available for more than 10 years, but
information on its use and effective-
ness is just now being published. In
this article, I compare the profile of
dexmedetomidine with the profiles
of other common sedative agents
used in the ICU. As more studies on
dexmedetomidine are being per-
formed, and positive results arebeing reported, the drug is becom-
ing more popular. I describe the
results of one hospitals experience
with dexmedetomidine and the use-
fulness and benefit of this sedative
in the ICU.
Profile of Dexmedetomidine
Dexmedetomidine was approved
for use in the United States in 1999.
It is a short-acting 2-agonist with
anxiolytic, anesthetic, hypnotic, and
analgesic properties.7 -Agonists
promote sedation by stimulating
the locus caeruleus, a part of the
brain stem involved in the sleep-wake
cycle. Sedation is caused by inhibi-
tion of the sympathetic vasomotor
center of the brain. Table 1 listspresynaptic and postsynaptic activa-
tion of2-adrenoceptors.8,9 Unlike
propofol and midazolam, which act
on the -aminobutyric acid system
and produce a clouding of conscious-
ness, dexmedetomidine produces
sedation by reducing sympathetic
activity and the level of arousal.7
The popularity of dexmedetomi-
dine is due to its ability to promote
cooperative sedation.8 Patients given
this drug remain awake, but calm,
and are able to communicate with
health care providers. Because the
patients remain awake, they may
experience insomnia and require
medication to facilitate sleep. The
MENDS trial10 showed that patients
given various doses of dexmedeto-
midine were completely arousable
from sedation with a mild stimulus,such as a gentle touch or verbal
stimuli. Dexmedetomidine does
not affect the respiratory drive and
therefore does not interfere with
weaning from mechanical ventila-
tion. Because of this characteristic,
infusions of dexmedetomidine can
be continued after extubation with-
out the risk of respiratory failure, a
complication that can occur with
propofol, lorazepam, and midazo-
lam.6,11 Control of anxiety after
extubation is important to prevent
reintubation. Studies10,12 have indi-
cated that the need for rescue mor-
phine postoperatively is reduced in
patients given dexmedetomidine.
The relatively short distribution
half-life of about 6 minutes of
dexmedetomidine results in rapid
onset of sedation, and an elimination
half-life of approximately 2 hours
facilitates clearance of the drug.10
Dexmedetomidine is highly bound
to protein and albumin. The drug is
extensively metabolized in the liver,
and its metabolites are excreted by
the kidneys.10
Patients with severeliver disease may require a lower
dose of dexmedetomidine than do
other patients because the disease
can increase the elimination half-life
of the drug and decrease clearance.10
Delirium is a common psychi-
atric problem in ICU patients. Up to
85% of ICU patients may experience
some degree of delirium,4 leading to
increased morbidity and mortality,
prolonged hospital stays, prolonged
duration of mechanical ventilation,
patient injury or self-extubation, and
respiratory complications.10 Table 2
lists the most commonly documented
side effects associated with infusion
of dexmedetomidine. Delirium has
not been identified as a potential
side effect of dexmedetomidine.
Jenni Short is an acute care nurse practitioner at Salina Regional Health Center, Salina,Kansas.
Corresponding author: Jenni Short,RN, MSN, ARNP-BC, 400 S Santa Fe Ave, Salina, KS 67401 (e-mail: jeshort@srhc.com).
To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656.Phone, (800) 8 99-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org.
Author
Table 1 Presynaptic and post-synaptic2-adrenoceptor activation
a
Inhibits release of norepinephrine
Reduces brain noradrenergic activity
Produces sedation
Inhibits sympathetic activity
Decreases blood pressure and heart rate
Reduces need for add-on morphine
a Based on data from Gerlach and Dasta8 andKaygusuz et al.9
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In the MENDS randomized con-
trolled trial10 in patients receiving
mechanical ventilation who were
managed with individualized tar-
geted sedation, a dexmedetomidine
infusion resulted in more days alivewithout delirium or coma and more
time at the targeted level of sedation
than did a lorazepam infusion. The
use of lorazepam and other agents
that stimulate -aminobutyric acid
receptors is a risk factor for delir-
ium. Therefore, medications, such as
dexmedetomidine, that do not stim-
ulate these receptors may minimize
the development of delirium.7
On the basis of the results of 2
randomized, double-blind, placebo-
controlled trials in which total dura-
tion of treatment could not exceed
24 hours, dexmedetomidine cur-
rently is approved by the Food and
Drug Administration for use in the
ICU for no more than 24 hours. Sev-
eral investigators4,7,8 have reported
that the drug can be used safely for
longer periods. Many institutions
that allow prolonged infusions of
dexmedetomidine in the ICU have
not had patients experiencing
hemodynamically significant, unex-
pected side effects.4,12
Approval bythe Food and Drug Administration
for use of infusions for longer than
24 hours is currently being explored.
A 16% reduction in mean systolic
blood pressure and a 21% reduction
in heart rate during the first 4 hours
of infusion but stabilization for the
duration of the infusion have been
reported.8 Even after abrupt discon-
tinuation of the infusion, no signifi-
cant clinical side effects occurred.
In the Safety and Efficacy of
Dexmedetomidine Compared With
Midazolam study,4 the efficacy,
safety, and pharmacokinetics of pro-
longed sedation with dexmedetomi-
dine and midazolam in ICU patients
receiving mechanical ventilation
were examined. Compared with
patients treated with midazolam,
patients treated with dexmedetomi-dine had a significantly lower cumu-
lative incidence of delirium. Nurses
thought that the patients treated
with dexmedetomidine were more
cooperative, better able to communi-
cate, and easier to treat overall than
were patients sedated with midazo-
lam. Patients given dexmedetomi-
dine required 44.6 fewer hours of
mechanical ventilation and 1.8 fewerdays in the ICU than did patients
given midazolam.4 Tables 3 and 4
compare the clinical effects and
pharmacokinetics of dexmedetomi-
dine with those of other commonly
used sedatives.
In a study performed in 2000,14
a total of 356 patients receiving
dexmedetomidine with midazolam
and propofol had lower total hospi-
tal charges, despite higher pharmacy
and anesthesia charges, than did
9996 patients receiving midazolam
and propofol without dexmedeto-
midine. The difference in total cost
was mainly due to shorter ICU stays.
The wholesale price is $55 to $61
for 100 mL of propofol and approx-
imately $57 for a 200-g vial of
dexmedetomidine. The estimated
cost of therapy for a 70-kg patientfor 24 hours of treatment is $110 to
$305 for propofol and $114 to $342
for dexmedetomidine.8
Table 2 Potential side effects ofdexmedetomidinea
Adverse effect
Hypotension
Hypertension
Nausea
Bradycardia
Atrial fibrillation
Hypoxia
Anemia
Pain
Pleural effusion
Infection
Leukocytosis
OliguriaPulmonary edema
Thirst
Percentage thatwill experienceadverse effect
30
16
11
8
7
6
3
3
3
2
2
22
2
a Based on data from Pandharipande et al. 13
Table 3 Pharmacokinetics of dexmedetomidinea
Agent
Morphine
Fentanyl
Diazepam
Midazolam
Lorazepam
Propofol
Clonidine
Dexmedetomidine
Haloperidol
Eliminationhalf-life, h
2.0-5.5
6.9-36.0
21-120
3.4-11
10-15
6.3-32
6-23
2
28-38
Systemic clearance,mL/kg per minute
8.6-23
8.6-15
0.4-0.9
4.3-6.6
1.2-4.1
17-31
1.9-4.3
0.32-0.64 mL/kg per hour
10-13
Potential for accumulation
Hepatic/renal insufficiency
Hepatic impairment
Hepatic/renal insufficiency
Hepatic/renal insufficiency
Hepatic insufficiency
None
Renal insufficiency
Hepatic insufficiency
Hepatic insufficiency
a Based on data from Pandharipande et al.13
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Research on the use of dexmede-
tomidine during pregnancy, labor,
delivery, and lactation is limited.
The Food and Drug Administration
has classified dexmedetomidine as a
category C pregnancy risk, so the
drug should be used with extreme
caution in women who are preg-
nant. Dexmedetomidine should not
be used in patients with advancedheart block or severe ventricular
dysfunction.7 Studies have indicated
the safety of dexmedetomidine infu-
sions in intubated children and its
benefit in providing sedation for
procedures, such as magnetic reso-
nance imaging.8
Methods
Salina Regional Health Center,
Kansas, is a 200-bed regional med-
ical center with a 12-bed general
medical-surgical ICU. Dexmedeto-
midine was first used in the center
in September 2007, with prompting
and support from the pulmonary/
critical care specialist. Previously,
propofol was the primary drug for
sedation. Midazolam was used
occasionally if a patient had an allergy
to propofol or another medical rea-
son the drug could not be used. The
types of patients who commonly
received propofol included postop-
erative patients and patients who had
respiratory failure or sepsis. The ICU
had a routine order set for patients
receiving propofol (Table 5). A nurse
would start the infusion at 5 g/kgper minute and titrate the dose by 5
to 10 g/kg per minute every 5 to
10 minutes to reach the desired level
of sedation. The patients level of
sedation was assessed by using the
Ramsay Sedation Scale (RSS; Table
6). Typically, the target score was 3
(responds to commands only). At 5
AM each day, the nurse would
decrease the propofol infusion by 5
to 10 g/kg per minute every 5 to
10 minutes until the patient reached
light levels of sedation. Once the
nurse was confident the patient
would awaken and move all extrem-
ities, an evaluation was performed
to determine if the patient was ready
for weaning from mechanical ventila-
tion. If the patient was ready for
weaning, the propofol infusion would
be left at a low level so the patient
could participate in weaning. If the
patient was not ready for weaning,
the propofol dose would be increased
to provide a level of adequate seda-
tion (according to the RSS).
The dissatisfaction associated
with oversedation that commonly
occurs with propofol and other seda-tive agents5 led to the consideration
of experimenting with dexmedeto-
midine. Other problems encountered
with the use of propofol included
the daily wake-up not being per-
formed, disorientation or delirium
with prolonged use (>48 hours),
and the excessive amount of calories
associated with high rates of propo-
fol administration.
A daily assessment of neurologi-
cal status must be performed on
patients receiving sedative agents.
Prolonged immobility paired with
critical illness places patients at high
risk for central nervous system events,
such as strokes. A daily decrease in
sedation and assessment of neuro-
logical status will alert health care
Table 4 Clinical effects of dexmedetomidinea
Effects
Sedation
Alleviation of anxiety
Analgesic properties
Promotion of arousability during sedationFacilitation of ventilation during weaning
No respiratory depression
Control of delirium
Organ protection
Control of stress response
Reduction of shivering
Cooperative sedation
Mimicking of natural sleep
Dexmedetomidine
X
X
X
XX
X
X
X
X
X
X
X
Benzodiazepines
X
X
Propofol
X
X
Opioids
X
X
Haloperidol
X
X
X
a Based on data from Pandharipande et al.13
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providers to any changes in a
patients function. Propofol is a
lipid-soluble agent that provides1.1 kcal/mL as fat.15 High doses of
propofol in addition to enteral or
parenteral feeding can lead to a high
caloric load. All of these issues can
lead to prolonged duration of
mechanical ventilation, prolonged
stay in the ICU, and a prolonged
hospital stay.15
Table 6 Ramsey Sedation Scalea
Score1
2
3
4
5
6
DefinitionPatient anxious and agitated or restless or both
Patient cooperative, oriented, and tranquil
Patient responds to commands only
Patient has a brisk response to a light glabellar tap or loud auditory stimulus
Patient has a sluggish response to a light glabellar tap or loud auditory stimulus
Patient has no response to a light glabellar tap or loud auditory stimulus
a Based on data from Sessler and Varney.6
Table 5 Printed orders for propofol infusiona
Printed orders require a specific physicians order before implementation
Propofol dosage and administration1. Start at 2.5 mcg/kg/min if receiving concurrent narcotics and/or sedatives2. Initial propofol infusion rate _________ (2.5-10 mcg/kg/min-lean body weight)3. Titrate dose 5-10 mcg/kg/min every 5-10 minutes to reach desired level of sedation
Desired level of sedations:Modified Ramsay Sedation Scale
Light 1 = Anxious and agitated or restless or both2 = Cooperative, oriented, and tranquil3 = Responds to commands only
Deep 4 = Brisk response to light glabellar tap or loud auditory stimulus5 = No response to light glabellar tap or loud auditory stimulus
A minimum of 5 minutes between adjustments should be allowed for onset of peak drug effect. This minimizes hypotension and helpsto avoid acute overdose.
Concentration=10,000 mcg/mL
Mcg/kg/min=conc rate mL/hour= mcg/kg/min60wt60 concwt
Caution: If significant hypotension occurs, decrease propofol infusion rate by 50% and call physician
Wake up and assessment of CNS function should be carried out daily throughout maintenance to determine the minimum dose ofpropofol required for sedation.
DAILY WAKEUPEvery A.M. at ________, decrease propofol infusion by 5-10 mcg/kg/min every 5-10 minutes until patient reaches light level of seda-
tion. Evaluate using Glasgow Coma Scale. After evaluation, titrate to prescribed level of sedation by increasing infusion rate 5-10
mcg/kg/min at 5-10 minute intervals.Discontinue medication upon transfer from ICU.
Signature ________________________________________________ Date ______________________
Patient Identification Salina Regional Health Center
PRINTED ORDERSPROPOFOL (DIPRIVAN) INFUSION
FOR SEDATION
Abbreviations: conc, concentration; CNS, central nervous system; ICU, intensive care unit; mcg, microgram; wt, weight.a Reprinted with permission from Salina Regional Health Center, Salina, Kansas.
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Table 10 gives the data on days
of mechanical ventilation (ventilator
days) before dexmedetomidine was
used (September 2006 through May
2007) and dur-
ing use of the
drug (Septem-
ber 2007
through May
2008). Total
ventilator days
were 1003 for
September
2006 through
May 2007 and
928 for Septem-
ber 2007 through May 2008, an 8%
decrease (75 fewer days) in total days
of mechanical ventilation (P= .05).
Table 11 gives data on ICU length of
stay before dexmedetomidine was
used (October 2006 through May
2007) and during use of the drug
(October 2007 through May 2008).
Total ICU days were 1686 for Octo-
ber 2006 through May 2007 and
1414 for October 2007 through May2008, a 19% decrease (272 fewer
days) in total ICU days (P= .05).
Mean length of stay decreased from
2.34 days to 2.31 days (1.5% reduc-
tion;P= .05). All of these results are
statistically significant.
Discussion
Decreasing the duration of
mechanical ventilation and length
of stay in the ICU can have a signifi-
cant effect not only on the recovery
period of a patient but also finan-
cially. Studies4-6 have confirmed that
agitation can have a deleterious effect
on patients by contributing to venti-
lator dysynchrony and an increase
in oxygen consumption, situations
that can lengthen the duration of
mechanical ventilation.4-6 The use
of sedatives is essential in the ICU.15
This study showed that dexmedeto-
midine can help reduce duration of
mechanical ventilation and number
of days in the ICU. Because dexmede-
tomidine facilitates a cooperative
sedation, weaning from mechanical
ventilation can be started sooner,
and patients are able to cooperate
with physical therapy while commu-
nicating their needs. Both of these
factors are important in recovery,
which can be hastened when a
patient is alert. Dexmedetomidine
is as effective as propofol and mida-
zolam for sedation of critically ill
patients.4,6,10 In this study, patients
receiving dexmedetomidine were
calm, in stable hemodynamic sta-
tus, and able to participate in the
Table 8 Dexmedetomidine (Precedex) data collection toola
Dexmedetomidine data collection
Patient initials _____ DOB ________ Sex _____
Diagnosis/Co-morbidities _______________________ Date of intubation ________
Weaning initiated ________ Type of weaning ________ Comments __________
Weaning initiated ________ Type of weaning ________ Comments __________
Weaning initiated ________ Type of weaning ________ Comments __________
Weaning initiated ________ Type of weaning ________ Comments __________
Weaning initiated ________ Type of weaning ________ Comments __________
Weaning initiated ________ Type of weaning ________ Comments __________
DAY 1_____ DAY 2_____ DAY 3_____ DAY 4_____ DAY 5_____ DAY 6_____ DAY 7_____
Dose ofdexmedetomidine
Other sedatives/route
Avg BP
Avg HR
Ramsey score
Vent settings
Other comments
Abbreviations: BP, blood pressure; DOB, date of birth; HR, heart rate; vent, mechanical ventilator.a Reprinted with permission from Salina Regional Health Center, Salina, Kansas.
Table 9 Study results
42 patients included in study
14 patients required dexmedetomidine only
24 patients required dexmedetomidine+ fentanyl
4 patients required transition to propofol
Mean duration of infusion: 4.75 days
Maximum duration of infusion: 15 days
Shortest duration of infusion: 1 day
Mean dose of dexmedetomidine: 0.6 g/kg per hour
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weaning process more quicker than
were patients given midazolam or
propofol.
An incidental discovery was that
the rate of ventilator-associated
pneumonia was 0% during the time
dexmedetomidine was used. Previ-
ously the center had 5 cases February
through May 2007 and 1 case June
through September 2007. This
finding supports the well- estab-
lished fact that less time receiving
mechanical ventilation helps pre-
vent pneumonia.
Because patients in the ICUaccount for nearly one-third of total
inpatient costs, efforts to reduce
duration of mechanical ventilation,
time in the ICU, and complications
associated with being in the ICU
have a significant effect on hospital
costs.16 In the experience at Salina
Regional Medical Center,
dexmedetomidine is a safe, effective
sedative for use in the ICU. CCN
Financial DisclosuresNone reported.
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7. Kemp KM, Henderlight L, Neville M. Pre-cedex: is it the future of cooperative sedation?Crit Care Insider. 2008;38(4)(suppl):50-55.
8. Gerlach AT, Dasta JF. Dexmedetomidine: anupdated review [published correction appearsinAnn Pharmacother. 2007;41(3):530-531].Ann Pharmacother.2007;41:245-254.
9. Kaygusuz K, Gokce G, Gursoy S, Ayan S,Mimaroglu C, Gultekin Y. A comparison ofsedation with dexmedetomidine or propofolduring shockwave lithotripsy: a randomized
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Table 10 Ventilator days before and after initiation of dexmedetomidine
Before dexmedetomidine After dexmedetomidine
Month and yearVentilatordays, No. Month and year
Ventilatordays, No.
September 2006 85 September 2007 99
October 2006 135 October 2007 120
November 2006 109 November 2007 111
December 2006 121 December 2007 55
January 2007 167 January 2008 85
February 2007 91 February 2008 116
March 2007 91 March 2008 137
April 2007 86 April 2008 96
May 2007 118 May 2008 109
Total ventilator days 1003 Total ventilator days 928
Table 11 Patient days and length of stay before and after dexmedetomidine
Before dexmedetomidine After dexmedetomidine
Monthand year
Patientdays
Lengthof stay, d
Monthand year
Patientdays
Length ofstay, d
October2006
222 2.4 October2007
172 2.1
November
2006
210 2.1 November
2007
186 2.5
December2006
247 2.4 December2007
142 1.8
January2007
253 2.9 January2008
183 1.8
February2007
230 3.2 February2008
201 2.4
March 2007 171 1.7 March 2008 162 2.3
April 2007 158 2 April 2008 224 2.9
May 2007 195 2 May 2008 144 2.7
Total, 1686 Mean, 2.34 Total, 1414 Mean, 2.31
To learn more about sedation assessment,read Consensus Conference on SedationAssessment: A Collaborative Venture byAbbott Laboratories, American Associationof Critical-Care Nurses, and Saint ThomasHealth System in Critical Care Nurse, 2004;24(2):33-41. Available at www.ccnonline.org.
36 CriticalCareNurse Vol 30, No. 1, FEBRUARY 2010 www.ccnonline.org
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controlled trial.Anesth Analg. 2008;106(1):114-119.
10. Lam SW, Alexander EA. Dexmedetomidineuse in critical care.AACN Adv Crit Care.2008;19(2):113-120.
11. Gmez-Vzquez ME, Hernndez-Salazar E,Hernndez-Jimnez A, Prez-Snchez A,Zepeda-Lpez VA, Salazar-Pramo M. Clini-cal analgesic efficacy and side effects ofdexmedetomidine in the early postopera-
tive period after arthroscopic knee surgery.J Clin Anesthes. 2007;19(8):576-582.12. Gommers D, Bakker J. Medications for
analgesia and sedation in the intensive careunit: an overview. Crit Care Forum.2008;12(suppl 3):S4.
13. Pandharipande PP, Pun BT, Herr DL, et al.Effect of sedation with dexmedetomidine vslorazepam on acute brain dysfunction inmechanically ventilated patients: theMENDS randomized controlled trial.JAMA. 2007;298(22):2644-2653.
14. Dasta JF, Jacobi J, Sesti AM, McLaughlin TP.Addition of dexmedetomidine to standardsedation regimens after cardiac surgery: anoutcomes analysis.Pharmacotherapy. 2006;26(6):798-805. Cited in: Gerlach AT, DastaJF. Dexmedetomidine: an updated review[published correction appears inAnn Phar-macother. 2007;41(3):530-531]. Ann Phar-macother. 2007;41:245-254.
15. OLeary-Kelley CM, Puntillo KA, Barr J,Stotts N, Douglas MK. Nutritional adequacyin patients receiving mechanical ventilationwho are fed enterally.Am J Crit Care. 2005;14(3):222-230.
16. Ebert TJ, Hall JE, Barney JA, Uhrich TD,Colinco MD. The effects of increasing plasmaconcentrations of dexmedetomidine inhumans.Anesthesiology. 2000;93(2):382-394.
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Potential side effects of dexmedetomidine include
hypotension, hypertension, nausea, bradycardia, atrial
fibrillation, and hypoxia. Delirium has not been identified
as a potential side effect of dexmedetomidine. In fact, use
of dexmedetomidine may minimize the development of
delirium because it does not stimulate -aminobutyric
acid receptorsa risk factor for delirium.
This study showed that dexmedetomidine can help
reduce duration of mechanical ventilation and number of
days in the ICU. Because dexmedetomidine facilitates acooperative sedation, weaning from mechanical ventilation
can be started sooner, and patients are able to cooperate
with physical therapy while communicating their needs.
Reference1. Pandharipande PP, Pun BT, Herr DL, et al. Effect of sedation with
dexmedetomidine vs lorazepam on acute brain dysfunction in mechani-cally ventilated patients: the MENDS reandomized controlled trial.JAMA. 2007;298(22):2644-2653.
CCN Fast Facts CriticalCareNurseThe journal for high acuity, progressive, and critical care
FactsContinuous chemical sedation in the intensive care
unit (ICU) is commonly used to control respiratory rate
and anxiety and thus promote sleep and ultimately opti-
mize care. Propofol, midazolam, and lorazepam provide
adequate sedation but can cause oversedation and
undersedation. Achieving adequate sedation can also be
a financial burden.
Dexmedetomidine, a short-acting 2-agonist with
anxiolytic, anesthetic, hypnotic, and analgesic properties,has been available for more than 10 years, but informa-
tion on its use and effectiveness is just now being pub-
lished. As more studies on dexmedetomidine are being
performed, and positive results are being reported, the
drug is becoming more popular. The author compared
dexmedetomidine with other common sedative agents
used in the ICU (see Table).
Use of Dexmedetomidine for Primary Sedation
in a General Intensive Care Unit
Jenni Short. Use of Dexmedetomidine for Primary Sedation in a General Intensive Care Unit.Crit Care Nurse. 2010;30(1):29-39.
This article and an online version of the CE test can be found at www.ccnonline.org.
Table Clinical effects of dexmedetomidinea
Effects
Sedation
Alleviation of anxiety
Analgesic properties
Promotion of arousability during sedation
Facilitation of ventilation during weaning
No respiratory depression
Control of delirium
Organ protectionControl of stress response
Reduction of shivering
Cooperative sedation
Mimicking of natural sleep
Dexmedetomidine
X
X
X
X
X
X
X
XX
X
X
X
Benzodiazepines
X
X
Propofol
X
X
Opioids
X
X
Haloperidol
X
X
X
a Based on data from Pandharipande et al.1
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CE Test Test ID C1012: Use of Dexmedetomidine for Primary Sedation in a General Intensive Care UnitLearni ng objectives: 1. Review the goals of adequate sedation for patients receiving mechanical ventilation 2. Compare the effects of midazolam, lorazepam,and propofol with dexmedetomidine 3. Examine study presented for use in your own practice
Test answers: Mark only one box for your answer to each question. You may photocopy this form.
1. Which of the following is one goal of adequate sedation?a. Increasing anxietyb. Increasing oxygen consumptionc. Inducing deliriumd. Improving comfort
2. Which of the following is one problem associated withoversedation?a. Ventilator dyssynchronyb. Dislodged equipmentc. Ventilator-associated pneumoniad. Increased oxygen consumption
3. Which of the following is one problem associated withundersedation?a. Ventilator dyssynchronyb. Inability to communicatec. Ventilator-associated pneumoniad. Prolonged intensive care unit (ICU) stays
4. Which of the following medications is not currently usedfor sedation?a. Midazolam c. Fentanylb. Propofol d. Lorazepam
5. Which of the following types of medications promotesedation by stimulating the locus caeruleus?a. -Agonistsb. -Aminobutyric acid stimulatorsc. -Blockersd. Dopamine stimulants
6. Which of the following explains why dexmedetomidine is a
popular drug?a. It is of minimal cost.b. It promotes cooperative sedation.c. It has no effect on blood pressure or heart rate.d. It reduces insomnia.
7. Which of the following medications can be continued afterextubation without risk for respiratory failure?a. Propofol c. Lorazepamb. Dexmedetomidine d. Midazolam
8. Which of the following is notone of the top 3 potential side
effects of dexmedetomidine?a. Hypotension c. Nauseab. Hypertension d. Delirium
9. What is the half-life of dexmedetomidine?a. 1 hour c. 6 hoursb. 2 hours d. 8 hours
10. What is the length of time currently approved by the Food andDrug Adminstration for dexmedetomidine administration?a. Intravenous (IV) bolus onlyb. IV infusion less than 12 hoursc. IV infusion less than 24 hoursd. No limitation of infusion
11. Which of the following patients would benefit from dexmedeto-midine infusions?a. Patients with advanced heart blockb. Patients with adult respiratory distress syndromec. Patients with severe ventricular dysfunctiond. Pregnant women
12. What were the findings of the study presented in the article?a. Dexmedetomidine reduced duration of mechanical ventilation and
number of days in the ICU when compared with propofol.b. Propofol reduced duration of mechanical ventilation and number of
days in the ICU when compared with dexmedetomidine.
c. There were no statistically significant findings in this study.d. Costs for patients taking dexmedetomidine were higher during this
study but comparable to propofol and midazolam over the length ofthe study.
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