They fall into two categories: “too low” of thyroid hormone (myxedema coma) and “too high” of thyroid hormone (thyroid storm). Thyroid emergencies are the extreme versions of these thyroid disorders. This is in contrast to the vast majority of thyroid cases that often present with minor symptoms (or found on routine labs), only requiring outpatient treatment and medications. They’re rare, but are an acute, life-threatening group of syndromes. There are some patients who will still be buck-wild on it, but for the patients in which Precedex is therapeutic, it's like dealing with a sleeping lion- they can become agitated when stimulated, but they go back to resting after a period of not being bothered.Thyroid emergencies are an interesting class of disorders. So in my experience, Precedex is really hit or miss. Precedex also doesn't have as much of a hypotensive effect on patients in comparison to drugs such as Propofol. Precedex is supposed to keep patients in a state where they are resting comfortably (RASS of -1), but they can wake up and follow commands when told to do so. Plus, if (and that is, only if) Precedex actually works for a particular patient (there's a good percentage of patients in which it does not work), then you can also do accurate neuro assessments on them while maintaining them at a comfortable RASS of -1. Precedex is good alternative to Propofol and Versed in the sense that it doesn't have the respiratory suppresant effect that Propofol and Versed do. In my unit, we usually use Precedex for intubated patients who are closer to being weaned off the vent (ie- going on PS trials), but still have some intolerance of the ETT and/or being on the vent itself. Well, evidence-based practice is all well and good, but sometimes they overlook the individual patient (as opposed to a population of patients in a study) when making decisions about which sedative to use. I think some docs just like to use new(er) drugs like Precedex because it's the latest and greatest new thing and they just read all sorts of literature about how well it works. Those docs are either very ignorant or just plain crazy- the outcome of that intubation attempt is definitely their fault and not yours. We just had an in-service on Precedex and I can tell you that facilitation of intubation is definitely NOT one of the labeled indications for this drug. I have learned to re-adjust my expectations on just how "down" i keep the patient because with the precedex, they DO wake up, but they should not be squirmy. There certainly have been times were we go back to propofol from the precedex - it isnt a magic drug for everyone but I don't hate it. With our protocols, we DO NOT wean precedex for vent weaning and do not remove analgesic drugs for weaning either, although sometimes we have to drop the narcotic a bit just to perk the patient up a little. Its not at all uncommon to add a versed gtt on top of that, with the goal to wean down the versed as much as possible and eventually just keep them on the dilaudid and precedex. 5-1mg.hr of dilaudid and up to 1.2 of dex. The special cocktail is usually a precedex gtt and a dilaudid gtt, and to keep a patient adequately down is usually. I have seen it as high as 2.5 for some patients. The general rule is to *try* to keep it less than 0.7mcgs/kg/hr, but 9x out of 10, you end up going up to the "max" dose of 1.2. This is not a drug to use to sedate people to intubate them. If they were using precedex as an RSI drug - thats just flat wrong. The big bonus to precedex is that you can use it on patients who are not intubated and you don't need to remove it to extubate others. I use precedex a lot and frankly, sometimes it works great - sometimes it doesn't.
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