Precedex For Post-Traumatic Encephalopathy

I have written before about using Precedex drip for the treatment of severe alcohol withdrawal and delirium tremens. The pathophysiology and the course of this condition make precedex a suitable alternative to more conventional treatment.

Another category of patients that often present a challenge to the clinician are the patients with post-traumatic encephalopathy.

There are several challenges that are to be overcome when caring for these patients. Often, marginal neurological status with periods of poor responsiveness and agitation does delay extubation of these patients.

Once extubated, the patients often remain restless, confused and disoriented. Managing agitation in these patients becomes a balancing act since over-sedation could compromise their respiratory status.

I have used Precedex on several patients with a severe post-traumatic encephalopathy with mixed results. There is no systematic data on this issue yet, though, Precedex does seem to facilitate weaning from mechanical ventilation.

The patient can be extubated while on the precedex infusion and this is a big advantage of this drug.

Once the patient is off the ventilator, sedation with Precedex is often ineffective or at least marginally effective.

Also, hypotension and bradycardia seem to occur more often in this patient population.

By no means should this observation be taken as a practice guideline. More data is necessary before Precedex could be recommended for routine use in patients with post-traumatic encephalopathy.

Using Precedex in everyday clinical practice is by no means straightforward. Many physicians are simply not comfortable using this newer medication and ask for a critical medicine consult if the patient is on Precedex drip. Using Precedex for Alcohol withdrawal is still controversial as well. In my opinion, the drug should be started as a last resort measure to prevent intubation. Precedex should be considered when a more traditional treatment for delirium tremens (DT) – escalating doses of benzodiazepines is simply not working.

Having used Precedex on multiple occasions for DTs, I have made several observations.

There is great variability in clinical response (dose adjusted) between different patients. There were patients who simply did not respond to the drug and required intubation. Most of the patients, though, did have a clinically significant response with improvement in agitation and restlessness and delirium.

In terms of the side effects, bradycardia and hypotension are the most commonly observed in my clinical practice. Low blood pressure is usually not clinically significant. In patients with severe DTs it, actually, might help to keep the patient normotensive.

Bradycardia, on the other hand, required the Precedex drip to be discontinued on several occasions. I have seen heart rate in low 30’s and 40’s. I also have seen prolonged QT interval, though, it is not possible to attribute this sided effect solely to Precedex (the patient was on multiple meds potentially affecting QT interval)

Both of theses adverse reactions are considered common side effects according to the information provided by the manufacturer.

DISCLAIMER: This is not an advertisement. The author of this post has no direct or indirect affiliation with Precedex manufacturer or its affiliates.
The post below is an author’s personal opinion and cannot be considered as practice guidelines.

There is a category of trauma patients; I call them “wild and unruly”. Usually it is a young male who ingests a large amount of alcohol along with some cocaine, marijuana or amphetamines and proceeds to have a good time at a party or elsewhere. Subsequently, he will get into some sort of altercation or accident and is brought to ER as a trauma patient.

At this point the patient, often, is wild, restless and combative. Evaluating this patient for possible injuries is almost impossible. The patient often gets intubated, sedated and paralyzed, just so that all the necessary XRs and CT scans can be done.

Afterwards, the patient is taken to the Intensive Care Unit. No significant head, chest or abdominal injuries are found to preclude the patient from being taken off the ventilator. Now, I am facing the task of extubating the patient as soon as possible. The “as soon as possible” part of this task can be very challenging.

A lot of these patients exhibit “all or nothing” behavior. The patient is either completely unresponsive while being sedated (Propofol in most cases) or is being wild and combative once the sedation is lightened up. The usual course of action is to wait until the patient is more cooperative. The thing is, though, it can take many hours or even a couple of days for some individuals to sober up.

Using Precedex as a bridge to the coherent and cooperative state might help to facilitate extubation. The patient can be started on Precedex along with Propofol. The Propofol drip will be weaned off. The patient will be assessed for readiness for extubation. This usually involves performing weaning trials in a pressure support mode.

Once the patient is off the ventilator, the Precedex drip will be slowly weaned off depending on the patient’s condition.

Once again, there are absolutely no randomized trials on using Precedex for these indications. This represents the author’s personal experience and cannot be considered as practice guidelines.

I was sitting in my office finishing my medical records (which is painful enough) when I realized that I could barely move my arms. It felt like I had been lifting weights. But then I remember that I had not been lifting weights but I had been trying to restrain a patient (along with four nurses) who was going throught bad alcohol withdrawal.
It is always the same scenario. For some reason the patient with alcoholism loses access to the beverage of choice and day or two later goes into the withdrawal. In severe cases it could be life-threatening. Some patients could even have seizures.

I am always amazed how strong the patients with Delirium Tremens (DT) could get. We often end calling security just to pin the patient down. The patient from this morning was, actually, a female weighing no more that 70 kilograms, yet it took five of us to contain her.

Sedating patients going through DTs could be challenging as well. I ended up asking for multiple doses of intravenous Ativan and, yet, after giving 16mg with no effect on the patient’s agitation, I “gave up” and ordered the Precedex drip.

It worked like a charm.

Precedex is a newer sedative medication, primarily used in anesthesiology for cardiac surgery patients. The mechanism of action is via centrally (in the brain) located alpha receptors. This is similar to how Clonidine (blood pressure medicine) works, which makes it even more suitable for alcohol withdrawal.

Even, though, expensive and approved only for a short term use (24 hours), there is a study showing that Precedex could be used safely for longer periods of time. The same study also showed that using Precedex vs. Versed for sedation could be cost-effective.

The most common side effect of Precedex is mild hypotension. This too makes it a good candidate for patients with DTs since most of them are hypertensive.

More studies are needed to expand the spectrum of indications for this medication, yet, I bet you we are going to see it more and more in the ICU practice.

I remember the time when Propofol just came on the market and the generic form was not available yet. Despite a high price tag, the benefits of using an ultra-short acting sedative for the critically ill patient became apparent very quickly. Rapid titration of the sedation allowed us to cut down on the ventilator days and decrease the length of stay in the Intensive Care Unit. Propofol is not without drawbacks, though. The price has been reduced so that now we have intermittent shortages of the medication. Lipid levels should be monitored since the drug is based on fat emulsion. Feared, but real, Propofol infusion syndrome limits it’s long term use in high doses. And, of course, the bad publicity this drug received after the death of a popular singer…

Now, we have a new player on the marker – Precedex or Dexmedetomide. The clinical data is yet limited and the medication is only approved for use for just 24 hours at at at time. Since it is an alpha-2 agonist, low blood pressure is the biggest concern. The greatest benefit, though, is that the patient does not have to be intubated to receive a continuous infusion of Precedex. This is a great benefit. In clinical practice, using Precedex for patients going through a severe alcohol withdrawal often works better than anything else. If the patient remains agitated despite escalating doses of benzodiazepines, Precedex works really well. Those are the patients who would be intubated and started on a Propofol infusion, otherwise.

A very recent study published in The Critical Care Medicine Journal compares the total cost of care when Precedex or Versed are being used. The patients in the Precedex group had reduced duration of mechanical ventilation and ICU length of stay. Sedation with Precedex was significantly less costly because of that. What is also remarkable – the drug was being used well beyond the recommended 24 hours without major safety concerns.

Well, it sounds like we have a new kid on the block. I predict that Precedex will definitely find it’s use in the Intensive Care Unit.