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How should dexmedetomidine and clonidine be prescribed in the critical care setting?

Cardiac, ventilatory and kidney management in the critical care setting has been optimized over the past decades. Cognition and sedation represent one of the last remaning challenges. As conventional sedation is suboptimal and as the sedation evoked by alpha-2 adrenergic agonists (“cooperative” seda...

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Autores principales: Longrois, Dan, Petitjeans, Fabrice, Simonet, Olivier, de Kock, Marc, Belliveau, Marc, Pichot, Cyrille, Lieutaud, Thomas, Ghignone, Marco, Quintin, Luc
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Associação de Medicina Intensiva Brasileira - AMIB 2021
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8889603/
https://www.ncbi.nlm.nih.gov/pubmed/35081245
http://dx.doi.org/10.5935/0103-507X.20210087
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author Longrois, Dan
Petitjeans, Fabrice
Simonet, Olivier
de Kock, Marc
Belliveau, Marc
Pichot, Cyrille
Lieutaud, Thomas
Ghignone, Marco
Quintin, Luc
author_facet Longrois, Dan
Petitjeans, Fabrice
Simonet, Olivier
de Kock, Marc
Belliveau, Marc
Pichot, Cyrille
Lieutaud, Thomas
Ghignone, Marco
Quintin, Luc
author_sort Longrois, Dan
collection PubMed
description Cardiac, ventilatory and kidney management in the critical care setting has been optimized over the past decades. Cognition and sedation represent one of the last remaning challenges. As conventional sedation is suboptimal and as the sedation evoked by alpha-2 adrenergic agonists (“cooperative” sedation with dexmedetomidine, clonidine or guanfacine) represents a valuable alternative, this manuscript covers three practical topics for which evidence-based medicine is lacking: a) Switching from conventional to cooperative sedation (“switching”): the short answer is the abrupt withdrawal of conventional sedation, immediate implementation of alpha-2 agonist infusion and the use of “rescue sedation” (midazolam bolus[es]) or “breakthrough sedation” (haloperidol bolus[es]) to stabilize cooperative sedation. b) Switching from conventional to cooperative sedation in unstable patients (e.g., refractory delirium tremens, septic shock, acute respiratory distress syndrome, etc.): to avoid hypotension and bradycardia evoked by sympathetic deactivation, the short answer is to maintain the stroke volume through volume loading, vasopressors and inotropes. c) To avoid these switches and associated difficulties, alpha-2 agonists should be considered first-line sedatives. The short answer is to administer alpha-2 agonists slowly from admission or endotracheal intubation up to stabilized cooperative sedation. The “take home” message is as follows: a) alpha-2 agonists are jointly sympathetic deactivators and sedative agents; b) sympathetic deactivation implies maintaining the stroke volume and iterative assessment of volemia. Evidence-based medicine should document our propositions.
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spelling pubmed-88896032022-03-09 How should dexmedetomidine and clonidine be prescribed in the critical care setting? Longrois, Dan Petitjeans, Fabrice Simonet, Olivier de Kock, Marc Belliveau, Marc Pichot, Cyrille Lieutaud, Thomas Ghignone, Marco Quintin, Luc Rev Bras Ter Intensiva Review Article Cardiac, ventilatory and kidney management in the critical care setting has been optimized over the past decades. Cognition and sedation represent one of the last remaning challenges. As conventional sedation is suboptimal and as the sedation evoked by alpha-2 adrenergic agonists (“cooperative” sedation with dexmedetomidine, clonidine or guanfacine) represents a valuable alternative, this manuscript covers three practical topics for which evidence-based medicine is lacking: a) Switching from conventional to cooperative sedation (“switching”): the short answer is the abrupt withdrawal of conventional sedation, immediate implementation of alpha-2 agonist infusion and the use of “rescue sedation” (midazolam bolus[es]) or “breakthrough sedation” (haloperidol bolus[es]) to stabilize cooperative sedation. b) Switching from conventional to cooperative sedation in unstable patients (e.g., refractory delirium tremens, septic shock, acute respiratory distress syndrome, etc.): to avoid hypotension and bradycardia evoked by sympathetic deactivation, the short answer is to maintain the stroke volume through volume loading, vasopressors and inotropes. c) To avoid these switches and associated difficulties, alpha-2 agonists should be considered first-line sedatives. The short answer is to administer alpha-2 agonists slowly from admission or endotracheal intubation up to stabilized cooperative sedation. The “take home” message is as follows: a) alpha-2 agonists are jointly sympathetic deactivators and sedative agents; b) sympathetic deactivation implies maintaining the stroke volume and iterative assessment of volemia. Evidence-based medicine should document our propositions. Associação de Medicina Intensiva Brasileira - AMIB 2021 /pmc/articles/PMC8889603/ /pubmed/35081245 http://dx.doi.org/10.5935/0103-507X.20210087 Text en https://creativecommons.org/licenses/by/4.0/This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
spellingShingle Review Article
Longrois, Dan
Petitjeans, Fabrice
Simonet, Olivier
de Kock, Marc
Belliveau, Marc
Pichot, Cyrille
Lieutaud, Thomas
Ghignone, Marco
Quintin, Luc
How should dexmedetomidine and clonidine be prescribed in the critical care setting?
title How should dexmedetomidine and clonidine be prescribed in the critical care setting?
title_full How should dexmedetomidine and clonidine be prescribed in the critical care setting?
title_fullStr How should dexmedetomidine and clonidine be prescribed in the critical care setting?
title_full_unstemmed How should dexmedetomidine and clonidine be prescribed in the critical care setting?
title_short How should dexmedetomidine and clonidine be prescribed in the critical care setting?
title_sort how should dexmedetomidine and clonidine be prescribed in the critical care setting?
topic Review Article
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8889603/
https://www.ncbi.nlm.nih.gov/pubmed/35081245
http://dx.doi.org/10.5935/0103-507X.20210087
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