What is a sample order for dexmedetomidine (Precedex) with a Richmond Agitation-Sedation Scale (RASS) score?

From the Guidelines

A typical dexmedetomidine order with RASS (Richmond Agitation-Sedation Scale) monitoring would be: "Dexmedetomidine 0.2-0.7 mcg/kg/hr IV continuous infusion, titrate to achieve target RASS score of -1 to -2. Start at 0.2 mcg/kg/hr and increase by 0.1 mcg/kg/hr every 30 minutes as needed, maximum dose 1.4 mcg/kg/hr. Assess and document RASS score hourly. Hold infusion for heart rate <50 bpm, systolic blood pressure <90 mmHg, or if patient becomes unarousable."

Key Considerations

• The RASS score helps clinicians objectively assess sedation depth, with 0 being alert and calm, positive numbers indicating agitation (up to +4 for combative), and negative numbers indicating sedation (down to -5 for unarousable) 1.
• Targeting a RASS of -1 (drowsy) to -2 (light sedation) typically provides adequate comfort while allowing patient interaction when stimulated.
• Dexmedetomidine works as an alpha-2 adrenergic agonist, reducing sympathetic tone and providing sedation that mimics natural sleep 1.

Monitoring and Titration

• The onset of sedation occurs within 15 mins and peak sedation occurs within 1 hr of starting an IV infusion of dexmedetomidine 1.
• Sedation onset may be hastened by administering an initial IV loading dose of dexmedetomidine, but this is more likely to cause hemodynamic instability in critically ill patients 1.
• The elimination half-life is approximately 3 hrs in patients with normal liver function 1.

Potential Side Effects

• The most common side effects of dexmedetomidine are hypotension and bradycardia 1.
• IV loading doses can cause either hypotension or hypertension 1.
• Because dexmedetomidine does not significantly affect respiratory drive, it is the only sedative approved in the United States for administration in nonintubated ICU patients, and infusions can be continued as needed following extubation 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Dexmedetomidine Sample Order with RASS Score

• Dexmedetomidine is used for sedation in various medical settings, including intensive care units (ICUs) and for procedures requiring sedation without tracheal intubation 2, 3, 4, 5, 6.
• The Richmond Agitation-Sedation Scale (RASS) score is used to assess the level of sedation in patients, with a target score of -1 to +1 indicating adequate sedation 3, 4.
• Studies have shown that dexmedetomidine can be effective for sedation in ICU patients, with a loading dose ranging from 0.5 to 5 μg/kg and an infusion dose ranging from 0.2 to 10 μg/kg/h 3, 4, 5.
• The safety and efficacy of long-term dexmedetomidine administration have been evaluated, with results showing that it can be used for extended periods without significant increases in adverse effects 4.
• Dexmedetomidine has been compared to other sedatives, with studies suggesting that it may be useful for patients requiring sedation without tracheal intubation, particularly when spontaneous breathing is essential or sudden awakening is required 5.

RASS Score and Dexmedetomidine Dosing

• A study found that decreasing RASS score was significantly associated with increasing dexmedetomidine concentration, suggesting that the drug can be titrated to achieve desired levels of sedation 2.
• Another study found that high-dose dexmedetomidine (greater than 0.7 μg/kg/h) did not enhance sedation efficacy and may not be necessary for most patients 3.
• The optimal dosing of dexmedetomidine for sedation is still being studied, with recommendations for dosing ranging from 0.2 to 1.4 μg/kg/h for ICU patients and 0.5 to 5 μg/kg for procedural sedation 4, 5, 6.

Clinical Applications

• Dexmedetomidine has been used for sedation in various clinical settings, including:
  • ICU patients requiring mechanical ventilation 3, 4
  • Patients undergoing procedures without tracheal intubation, such as fiberoptic bronchoscopy, dental procedures, and ophthalmological procedures 5
  • Pediatric patients undergoing procedures such as cardiac catheterization and magnetic resonance imaging 5
• The drug has been shown to be effective for sedation in these settings, with a low risk of respiratory depression and other adverse effects 2, 3, 4, 5, 6.