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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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3/12

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


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: [email protected]).

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, [email protected].

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

30 CriticalCareNurse Vol 30, No. 1, FEBRUARY 2010 www.ccnonline.org



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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 insufficiency

None

Renal 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





6/12

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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8/12

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 __________






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




9/12

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


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.

References1. Salas RE, Gamaldo CE. Adverse effects of

sleep deprivation in the ICU. Crit Care Clin.2008;24:461-476.

2. Hodgin KE, Nordon-Craft A, McFann KK,Mealer ML, Moss M. Physical therapy uti-lization in intensive care units: results froma national study. Crit Care Med. 2009;37(2):561-568.

3. Murthy PG. Managing sedation in inten-sive care.J Anaesthesiol Clin Pharm. 2007;23:241-247.

4. Riker RR, Shehabi Y, Bokesch PM, et al;SEDCOM (Safety and Efficacy of Dexmede-tomidine Compared With Midazolam) StudyGroup. Dexmedetomidine vs midazolamfor sedation of critically ill patients.JAMA.2009;301(5):489-499.

5. Rowe K, Fletcher S. Sedation in the intensivecare unit. Contin Educ Anaesth Crit Care Pain.

2008;8(2):50-55.6. Sessler CN, Varney K. Patient-focused seda-

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Now that youve read the article, create or contributeto an online discussion about this topic using eLetters.

Just visit www.ccnonline.org and click Respond toThis Article in either the full-text or PDF view ofthe article.

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.




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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





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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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Test ID: C1012 Form expires: February 1, 2012 Contact hours: 1.0 Fee: AACN members, $0; nonmembers, $10 Passing score: 9 correct (75%) Category: A, Synergy CERP ATest writer: Jane Baron, RN, CS, ACNP

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