Feature
Use of Dexmedetomidine
for Primary Sedation in a
General Intensive Care Unit
PRIME POINTS
• Use of sedation is
important to help achieve
the right balance between
sleep and wakefulness.
• This study showed that
dexmedetomidine can
help reduce duration of
mechanical ventilation
and number of days in the
intensive care unit.
• As more studies on
dexmedetomidine are
being performed, and
positive results are being
reported, the drug is
becoming more popular.
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Jenni Short, RN, MSN, ARNP-BC
P
romotion 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 and
patients’ 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
CEContinuing Education
This article has been designated for CE credit.
A closed-book, multiple-choice examination fol-
lows this article, which tests your knowledge of
the following 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
©2009 American Association of Critical-
Care Nurses doi: 10.4037/ccn2009920
CriticalCareNurse Vol 30, No. 1, FEBRUARY 2010 29
sleep, and, ultimately, providing
comfort and safety.3
Continuous chemical sedation
in 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
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 inadequate
examinations 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 are
being reported, the drug is becom-
ing more popular. I describe the
results of one hospital’s 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 α2-agonist with
anxiolytic, anesthetic, hypnotic, and
Author
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) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org.
30 CriticalCareNurse Vol 30, No. 1, FEBRUARY 2010
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analgesic properties.7 α-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 lists
presynaptic and postsynaptic activa-
tion of α2-adrenoceptors.8,9 Unlike
propofol and midazolam, which act
on the γ-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
Table 1 Presynaptic and post-
synaptic α2-adrenoceptor activationa
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
aBased on data from Gerlach and Dasta8 and
Kaygusuz et al.9
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 severe
liver 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.
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 that the drug can be used safely for
Table 2 Potential side effects of longer periods. Many institutions
dexmedetomidinea
Percentage that that allow prolonged infusions of
will experience dexmedetomidine in the ICU have
Adverse effect adverse effect
not had patients’ experiencing
Hypotension 30 hemodynamically significant, unex-
Hypertension 16 pected side effects.4,12 Approval by
Nausea 11 the Food and Drug Administration
Bradycardia 8 for use of infusions for longer than
Atrial fibrillation 7 24 hours is currently being explored.
Hypoxia 6 A 16% reduction in mean systolic
Anemia 3 blood pressure and a 21% reduction
Pain 3 in heart rate during the first 4 hours
Pleural effusion 3
of infusion but stabilization for the
Infection 2
duration of the infusion have been
reported.8 Even after abrupt discon-
Leukocytosis 2
tinuation of the infusion, no signifi-
Oliguria 2
cant clinical side effects occurred.
Pulmonary edema 2
In the Safety and Efficacy of
Thirst 2
Dexmedetomidine Compared With
a Based on data from Pandharipande et al.13
Midazolam study,4 the efficacy,
safety, and pharmacokinetics of pro-
In the MENDS randomized con- longed sedation with dexmedetomi-
trolled trial10 in patients receiving dine and midazolam in ICU patients
mechanical ventilation who were receiving mechanical ventilation
managed with individualized tar- were examined. Compared with
geted sedation, a dexmedetomidine patients treated with midazolam,
infusion resulted in more days alive patients treated with dexmedetomi-
without delirium or coma and more dine had a significantly lower cumu-
time at the targeted level of sedation lative incidence of delirium. Nurses
than did a lorazepam infusion. The thought that the patients treated
use of lorazepam and other agents
that stimulate γ-aminobutyric acid
receptors is a risk factor for delir- Table 3 Pharmacokinetics of dexmedetomidinea
ium. Therefore, medications, such as Elimination
Agent half-life, h
dexmedetomidine, that do not stim-
ulate these receptors may minimize Morphine 2.0-5.5
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 fewer
days 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-μg vial of
dexmedetomidine. The estimated
cost of therapy for a 70-kg patient
for 24 hours of treatment is $110 to
$305 for propofol and $114 to $342
for dexmedetomidine.8
Systemic clearance,
mL/kg per minute Potential for accumulation
8.6-23 Hepatic/renal insufficiency

the development of delirium.7 Fentanyl 6.9-36.0 8.6-15 Hepatic impairment

On the basis of the results of 2 Diazepam 21-120 0.4-0.9 Hepatic/renal insufficiency

randomized, double-blind, placebo- Midazolam 3.4-11 4.3-6.6 Hepatic/renal insufficiency
controlled trials in which total dura- Lorazepam 10-15 1.2-4.1 Hepatic insufficiency
tion of treatment could not exceed Propofol 6.3-32 17-31 None
24 hours, dexmedetomidine cur- Clonidine 6-23 1.9-4.3 Renal insufficiency
rently is approved by the Food and Dexmedetomidine 2 0.32-0.64 mL/kg per hour Hepatic insufficiency
Drug Administration for use in the Haloperidol 28-38 10-13 Hepatic insufficiency
ICU for no more than 24 hours. Sev- a Based on data from Pandharipande et al.
13

eral investigators4,7,8 have reported

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 Table 4 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 protection
Control of stress response
Reduction of shivering
Cooperative sedation
Mimicking of natural sleep
a Based on data from Pandharipande et al.13
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 advanced
heart 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
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Dexmedetomidine Benzodiazepines
X X
X X
X X
X
X
X X
X X
X X
X
X
X
X
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 μg/kg
per minute and titrate the dose by 5
to 10 μg/kg per minute every 5 to
10 minutes to reach the desired level
of sedation. The patient’s 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 μg/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
Propofol Opioids Haloperidol
X X X
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
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 Table 5 Printed orders for propofol infusiona

Patient Identification Salina Regional Health Center

PRINTED ORDERS
PROPOFOL (DIPRIVAN) INFUSION
FOR SEDATION

Printed orders require a specific physician’s order before implementation

Propofol dosage and administration
1. Start at 2.5 mcg/kg/min if receiving concurrent narcotics and/or sedatives
2. 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 both
2 = Cooperative, oriented, and tranquil
3 = Responds to commands only
Deep 4 = Brisk response to light glabellar tap or loud auditory stimulus
5 = 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 helps
to avoid acute overdose.
Concentration = 10,000 mcg/mL
Mcg/kg/min = conc × rate mL/hour = mcg/kg/min × 60 × wt
60 conc
wt
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 of
propofol required for sedation.
DAILY WAKEUP
Every 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 ______________________

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.

providers to any changes in a

Table 6 Ramsey Sedation Scalea patient’s function. Propofol is a
Score Definition lipid-soluble agent that provides
1 Patient anxious and agitated or restless or both 1.1 kcal/mL as fat.15 High doses of
2 Patient cooperative, oriented, and tranquil propofol in addition to enteral or
3 Patient responds to commands only parenteral feeding can lead to a high
4 Patient has a brisk response to a light glabellar tap or loud auditory stimulus caloric load. All of these issues can
5 Patient has a sluggish response to a light glabellar tap or loud auditory stimulus lead to prolonged duration of
6 Patient has no response to a light glabellar tap or loud auditory stimulus mechanical ventilation, prolonged
a
stay in the ICU, and a prolonged
Based on data from Sessler and Varney.6
hospital stay.15

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 I worked with a pharmacist to
develop a protocol for initiation of
the dexmedetomidine infusion.
Dexmedetomidine is supplied in a
single 2-mL clear-glass vial at a con-
centration of 100 μg/mL. It must be
diluted to a final concentration of
4 μg/mL.10 The infusion is prepared
with 200 μg of dexmedetomidine in
50 mL of normal saline (concentra-
tion=4 μg/mL). The decision was
made to omit the loading dose
because patients in the ICU com-
monly experience hypotension, and
the loading dose is associated with a
high risk for hypotension. After
obtaining a physician’s order, the
nurse would start the infusion at
0.2 μg/kg per hour and titrate up
to a maximum of 0.8 μg/kg per
hour to the desired level of sedation,
typically a score of 2 or 3 on the RSS.
According to the protocol (Table 7),
if a patient requires the maximum
dose of dexmedetomidine and agi-
tation persists, a fentanyl infusion
could be started at 50 μg/h. The
protocol also allows the nurse to
administer midazolam 1 to 5 mg
intravenously as needed for proce-
dures. Zolpidem is available on the
physician’s routine orders if it is
needed for sleep at night.
At times, agitation was severe
enough that the maximum dose of
dexmedetomidine plus fentanyl did
not keep a patient calm. In this cir-
cumstance, a physician would be
contacted, the dexmedetomidine
and fentanyl would be discontinued,
and treatment with propofol would
be started. Patients given propofol
typically required titration of the
drug to an RSS score of 4, which is
defined as a brisk response to light
glabellar tap or loud auditory stimu-
lus. This level of sedation is higher
34 CriticalCareNurse Vol 30, No. 1, FEBRUARY 2010
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Table 7 Printed orders for dexmedetomidine infusiona
Patient Identification Salina Regional Health Center
PRINTED ORDERS
PRECEDEX INFUSION
Printed orders require a specific physician’s order before implementation
Dexmedetomidine (Precedex) infusion
1. Physician order to initiate Precedex infusion:
Prepare 200 mcg/50 mL 0.9% NaCl inj (concentration = 4 mcg/mL)
Per package insert
2. Do not give loading dose unless otherwise specified
3. Initiate infusion at 0.2 mcg/kg/hr
4. Titrate infusion up to maximum dose of 1 mcg/kg/hr to the desired Ramsay score
5. Monitor for hypotension
6. If agitation continues of maximum dose, may initiate Fentanyl infusion at 50 mcg/hr
(if no contraindications)
7. Midazolam (Versed) 1-5 mg IV as needed for agitation during procedures
8. Dexmedetomidine (Precedex) is INCOMPATIBLE with Amphotericin B and diazepam
___________________________________________________________________
Physician Signature Date
Abbreviations: IV, intravenously; mcg, microgram; NaCl, sodium chloride.
a Reprinted with permission from Salina Regional Health Center, Salina, Kansas.
than that typically used at the cen- track of the patients receiving
ter, but protecting the patient from dexmedetomidine. This tool was
harm (eg, self-extubation, pulling used to track diagnosis, date of
out catheters) is always the first pri- intubation, dose of dexmedetomi-
ority. When these patients’ clinical dine, use of other sedatives, mean
status was stable and they were ready blood pressure, mean heart rate,
to be weaned from mechanical ven- score on the RSS, ventilator set-
tilation, the propofol dose would be tings, and any weaning from
titrated down and dexmedetomidine mechanical ventilation that was
would be initiated to alleviate anxi- started. Of the 42 patients, only 4
ety. This drug combination seemed continued to be agitated when
to keep the patients calm enough to given the maximum dose (dexmede-
cooperate with weaning. tomidine 0.8 μg/kg per hour plus
fentanyl 50 μg/h) and had to be
Results given propofol. Table 9 gives the
During the study period (Sep- study results. None of the 42
tember 2006 through May 2007), a patients experienced hypotension
dexmedetomidine infusion was or bradycardia sufficient to require
started in 42 patients. A data tool discontinuation of the dexmedeto-
(Table 8) was developed to keep midine infusion.
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 stay before dexmedetomidine was
Table 8 Dexmedetomidine (Precedex) data collection toola used (October 2006 through May
Dexmedetomidine data collection 2007) and during use of the drug
Patient initials _____ DOB ________ Sex _____ (October 2007 through May 2008).
Diagnosis/Co-morbidities _______________________ Date of intubation ________ Total ICU days were 1686 for Octo-
ber 2006 through May 2007 and
DAY 1
_____
DAY 2
_____
DAY 3
_____
DAY 4
_____
DAY 5
_____
DAY 6
_____
DAY 7
_____
1414 for October 2007 through May
2008, a 19% decrease (272 fewer
Dose of days) in total ICU days (P = .05).
dexmedetomidine
Mean length of stay decreased from
Other sedatives/route
2.34 days to 2.31 days (1.5% reduc-
Avg BP
tion; P = .05). All of these results are
statistically significant.
Avg HR
Discussion
Ramsey score Decreasing the duration of
mechanical ventilation and length
Vent settings of stay in the ICU can have a signifi-
cant effect not only on the recovery
Other comments
period of a patient but also finan-
cially. Studies4-6 have confirmed that
Weaning initiated ________ Type of weaning ________ Comments __________ agitation can have a deleterious effect
Weaning initiated ________ Type of weaning ________ Comments __________ on patients by contributing to venti-
Weaning initiated ________ Type of weaning ________ Comments __________ lator dysynchrony and an increase
Weaning initiated ________ Type of weaning ________ Comments __________
in oxygen consumption, situations
that can lengthen the duration of
Weaning initiated ________ Type of weaning ________ Comments __________
mechanical ventilation.4-6 The use
Weaning initiated ________ Type of weaning ________ Comments __________
of sedatives is essential in the ICU.15
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. This study showed that dexmedeto-
midine can help reduce duration of
mechanical ventilation and number
2007) and dur- of days in the ICU. Because dexmede-
Table 9 Study results
ing use of the tomidine facilitates a cooperative
42 patients included in study drug (Septem- sedation, weaning from mechanical
14 patients required dexmedetomidine only ber 2007 ventilation can be started sooner,
24 patients required dexmedetomidine + fentanyl through May and patients are able to cooperate
4 patients required transition to propofol 2008). Total with physical therapy while commu-
Mean duration of infusion: 4.75 days ventilator days nicating their needs. Both of these
Maximum duration of infusion: 15 days were 1003 for factors are important in recovery,
Shortest duration of infusion: 1 day September which can be hastened when a
Mean dose of dexmedetomidine: 0.6 µg/kg per hour 2006 through patient is alert. Dexmedetomidine
May 2007 and is as effective as propofol and mida-
928 for Septem- zolam for sedation of critically ill
Table 10 gives the data on days ber 2007 through May 2008, an 8% patients.4,6,10 In this study, patients
of mechanical ventilation (ventilator decrease (75 fewer days) in total days receiving dexmedetomidine were
days) before dexmedetomidine was of mechanical ventilation (P = .05). calm, in stable hemodynamic sta-
used (September 2006 through May Table 11 gives data on ICU length of tus, and able to participate in the

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 through May 2007 and 1 case June
Table 10 Ventilator days before and after initiation of dexmedetomidine
through September 2007. This
Before dexmedetomidine After dexmedetomidine finding supports the well- estab-
Ventilator Ventilator lished fact that less time receiving
Month and year days, No. Month and year days, No. mechanical ventilation helps pre-
September 2006 85 September 2007 99 vent pneumonia.
October 2006 135 October 2007 120 Because patients in the ICU
account for nearly one-third of total
November 2006 109 November 2007 111
inpatient costs, efforts to reduce
December 2006 121 December 2007 55 duration of mechanical ventilation,
January 2007 167 January 2008 85 time in the ICU, and complications
February 2007 91 February 2008 116
associated with being in the ICU
have a significant effect on hospital
March 2007 91 March 2008 137
costs.16 In the experience at Salina
April 2007 86 April 2008 96 Regional Medical Center,
May 2007 118 May 2008 109 dexmedetomidine is a safe, effective
sedative for use in the ICU. CCN
Total ventilator days 1003 Total ventilator days 928

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Before dexmedetomidine After dexmedetomidine
Month Patient Length Month Patient Length of Financial Disclosures
and year days of stay, d and year days stay, d None reported.
October 222 2.4 October 172 2.1
2006 2007 References
1. Salas RE, Gamaldo CE. Adverse effects of
November 210 2.1 November 186 2.5 sleep deprivation in the ICU. Crit Care Clin.
2006 2007 2008;24:461-476.
2. Hodgin KE, Nordon-Craft A, McFann KK,
December 247 2.4 December 142 1.8 Mealer ML, Moss M. Physical therapy uti-
2006 2007 lization in intensive care units: results from
January 253 2.9 January 183 1.8 a national study. Crit Care Med. 2009;37(2):
561-568.
2007 2008 3. Murthy PG. Managing sedation in inten-
February 230 3.2 February 201 2.4 sive care. J Anaesthesiol Clin Pharm. 2007;
2007 2008 23:241-247.
4. Riker RR, Shehabi Y, Bokesch PM, et al;
March 2007 171 1.7 March 2008 162 2.3 SEDCOM (Safety and Efficacy of Dexmede-
tomidine Compared With Midazolam) Study
April 2007 158 2 April 2008 224 2.9 Group. Dexmedetomidine vs midazolam
for sedation of critically ill patients. JAMA.
May 2007 195 2 May 2008 144 2.7
2009;301(5):489-499.
Total, 1686 Mean, 2.34 Total, 1414 Mean, 2.31 5. Rowe K, Fletcher S. Sedation in the intensive
care unit. Contin Educ Anaesth Crit Care Pain.
2008;8(2):50-55.
6. Sessler CN, Varney K. Patient-focused seda-
weaning process more quicker than tion and analgesia in the ICU. Chest. 2008;
133(2):552-565.

•
d tmore

To learn more about sedation assessment,
read “Consensus Conference on Sedation
were patients given midazolam or
propofol.
An incidental discovery was that
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: an
updated review [published correction appears
Assessment: A Collaborative Venture by the rate of ventilator-associated in Ann Pharmacother. 2007;41(3):530-531].
Ann Pharmacother. 2007;41:245-254.
Abbott Laboratories, American Association pneumonia was 0% during the time 9. Kaygusuz K, Gokce G, Gursoy S, Ayan S,
of Critical-Care Nurses, and Saint Thomas Mimaroglu C, Gultekin Y. A comparison of
Health System” in Critical Care Nurse, 2004; dexmedetomidine was used. Previ-
sedation with dexmedetomidine or propofol
24(2):33-41. Available at www.ccnonline.org. ously the center had 5 cases February during shockwave lithotripsy: a randomized

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

Downloaded from http://ccn.aacnjournals.org/ by AACN on August 25, 2019

 controlled trial. Anesth Analg. 2008;106 15. O’Leary-Kelley CM, Puntillo KA, Barr J,
(1):114-119. Stotts N, Douglas MK. Nutritional adequacy
10. Lam SW, Alexander EA. Dexmedetomidine in patients receiving mechanical ventilation
use in critical care. AACN Adv Crit Care. who are fed enterally. Am J Crit Care. 2005;
2008;19(2):113-120. 14(3):222-230.
11. Gómez-Vázquez ME, Hernández-Salazar E, 16. Ebert TJ, Hall JE, Barney JA, Uhrich TD,
Hernández-Jiménez A, Pérez-Sánchez A, Colinco MD. The effects of increasing plasma
Zepeda-López VA, Salazar-Páramo M. Clini- concentrations of dexmedetomidine in
cal analgesic efficacy and side effects of humans. Anesthesiology. 2000;93(2):382-394.
dexmedetomidine 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 care
unit: an overview. Crit Care Forum.
2008;12(suppl 3):S4.
13. Pandharipande PP, Pun BT, Herr DL, et al.
Effect of sedation with dexmedetomidine vs
lorazepam on acute brain dysfunction in
mechanically ventilated patients: the
MENDS randomized controlled trial.
JAMA. 2007;298(22):2644-2653.
14. Dasta JF, Jacobi J, Sesti AM, McLaughlin TP.
Addition of dexmedetomidine to standard
sedation regimens after cardiac surgery: an
outcomes analysis. Pharmacotherapy. 2006;
26(6):798-805. Cited in: Gerlach AT, Dasta
JF. Dexmedetomidine: an updated review
[published correction appears in Ann Phar-
macother. 2007;41(3):530-531]. Ann Phar-
macother. 2007;41:245-254.

www.ccnonline.org CriticalCareNurse Vol 30, No. 1, FEBRUARY 2010 37

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CCN Fast Facts CriticalCareNurse
Use of Dexmedetomidine for Primary Sedation
in a General Intensive Care Unit
Facts
Continuous 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 α2-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).
Table Clinical effects of dexmedetomidinea
Effects Dexmedetomidine
Sedation
Alleviation of anxiety
Analgesic properties
Promotion of arousability during sedation
Facilitation 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
a Based on data from Pandharipande et al.1
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.
38 CriticalCareNurse Vol 30, No. 1, FEBRUARY 2010
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The journal for high acuity, progressive, and critical care
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 γ-aminobutyric
acid receptors—a 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 a
cooperative sedation, weaning from mechanical ventilation
can be started sooner, and patients are able to cooperate
with physical therapy while communicating their needs.
Reference
1. 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.
Benzodiazepines Propofol Opioids Haloperidol
X X X X X
X X
X X
X
X
X X
X X
X X
X
X
X
X
www.ccnonline.org
 CE Test Test ID C1012: Use of Dexmedetomidine for Primary Sedation in a General Intensive Care Unit
Learning 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

1. Which of the following is one goal of adequate sedation? 7. Which of the following medications can be continued after
a. Increasing anxiety extubation without risk for respiratory failure?
b. Increasing oxygen consumption a. Propofol c. Lorazepam
c. Inducing delirium b. Dexmedetomidine d. Midazolam
d. Improving comfort
8. Which of the following is not one of the top 3 potential side
2. Which of the following is one problem associated with effects of dexmedetomidine?
oversedation? a. Hypotension c. Nausea
a. Ventilator dyssynchrony b. Hypertension d. Delirium
b. Dislodged equipment
c. Ventilator-associated pneumonia 9. What is the half-life of dexmedetomidine?
d. Increased oxygen consumption a. 1 hour c. 6 hours
b. 2 hours d. 8 hours
3. Which of the following is one problem associated with
undersedation? 10. What is the length of time currently approved by the Food and
a. Ventilator dyssynchrony Drug Adminstration for dexmedetomidine administration?
b. Inability to communicate a. Intravenous (IV) bolus only
c. Ventilator-associated pneumonia b. IV infusion less than 12 hours
d. Prolonged intensive care unit (ICU) stays c. IV infusion less than 24 hours
d. No limitation of infusion
4. Which of the following medications is not currently used
for sedation? 11. Which of the following patients would benefit from dexmedeto-
a. Midazolam c. Fentanyl midine infusions?
b. Propofol d. Lorazepam a. Patients with advanced heart block
b. Patients with adult respiratory distress syndrome
5. Which of the following types of medications promote c. Patients with severe ventricular dysfunction
sedation by stimulating the locus caeruleus? d. Pregnant women
a. α-Agonists
b. γ-Aminobutyric acid stimulators 12. What were the findings of the study presented in the article?
c. β-Blockers a. Dexmedetomidine reduced duration of mechanical ventilation and
d. Dopamine stimulants number of days in the ICU when compared with propofol.
b. Propofol reduced duration of mechanical ventilation and number of
6. Which of the following explains why dexmedetomidine is a days in the ICU when compared with dexmedetomidine.
popular drug? c. There were no statistically significant findings in this study.
a. It is of minimal cost. d. Costs for patients taking dexmedetomidine were higher during this
b. It promotes cooperative sedation. study but comparable to propofol and midazolam over the length of
c. It has no effect on blood pressure or heart rate. the study.
d. It reduces insomnia.

Test answers: Mark only one box for your answer to each question. You may photocopy this form.

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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 A
Test writer: Jane Baron, RN, CS, ACNP
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Use of Dexmedetomidine for Primary Sedation in a General Intensive Care Unit
Jenni Short
Crit Care Nurse 2010;30 29-38 10.4037/ccn2009920
©2010 American Association of Critical-Care Nurses
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