In this article the authors describe their use of Precedex in the lab during ablation cases. By adding Precedex to their moderate sedation protocol for these extended cases, they have been able to increase patient comfort and significantly decrease the amount of midazolam and fentanyl used, reducing the risk of respiratory depression. Read more about their experience here.

Background
Many complex electrophysiology ablation procedures are long and require large doses of sedation. The historical moderate sedation medications our facility has used for ventricular tachycardia (VT) and atrial fibrillation (AF) ablations are intravenous midazolam and fentanyl combined, for providing conscious sedation. However, fentanyl and midazolam can cause respiratory depression, bradycardia, and hypotension. In our patient population, we have also found that we require quite large doses of fentanyl and midazolam for these complex ablation cases. However, despite high cumulative doses of sedation, patients continued to wake up and complain during the lengthy procedures. Our overall patient population at the VA consists of older patients with many comorbidities that increase their risk for complications during sedation, including high prevalence of cardiac disease, pulmonary disease and obesity. The high doses of opioids and benzodiazepines put these patients at risk for adverse outcomes from sedation. For these reasons, our lab chose to start using Precedex infusions on these patients. Precedex has long been used in our intensive care unit for intubated patients and has an excellent efficacy and safety profile.

Precedex (dexmedetomidine) is a short-acting, relatively selective alpha 2 adrenoreceptor agonist with sedative properties. Precedex was initially approved for IV sedation use on intubated patients in the ICU by the U.S. Food and Drug Administration (FDA) in 1999. In 2008, the FDA approved a new indication for Precedex, allowing its use in nonintubated patients requiring sedation before and/or during surgical and other procedures.

Precedex is an excellent drug for our sedation purposes because it does not cause respiratory depression. However, patients do need to be monitored closely for hypersensitivity effects. Precedex is not recommended for use in patients with advanced heart block and severe ventricular dysfunction. Doses also need to be modified for patients with impaired renal function, diabetes, chronic hypertension and the elderly.1 In addition, dose reduction should be considered in patients with impaired hepatic function because of the risk of decreased drug clearance.

Precedex is an ideal sedating agent for our use because it provides a rapid onset of effect, a rapid recovery, and low propensity to accumulate leaving no withdrawal effects. It has a half life of only six minutes. Precedex is easily titratable and possesses anxioytic, anesthetic, hypnotic and analgesic properties. Our patients are easily arousable, yet appear calm and comfortable during the procedures. When unstimulated, patients return to a hypnotic state.