Q: 54 year old male admitted to ICU for aspiration pneumonia after ETOH intoxication. Patient has been kept on Precedex (Dexmetomidine) for 10 days to counter Delirium-Tremens. Patient is successufully extubated now. All drip get discontinued. Patient went into acute psychosis with tachycardia and hypertension. Your diagnosis.

A) Unmasking of underlying Delirium Tremens

B) New ICU Psychosis

C) CVA

D) dexmedetomidine withdrawal syndrome

E) New onset sepsis

Answer:   D

Dexmedetomidine is an α(2)-adrenoreceptor agonist which is used in the ICU for various reasons due to its sedative, analgesic and anxiolytic properties. Lately, it has shown good profile for ETOH and drug withdrawal syndromes. Withdrawal of Dexmedetomidine after prolong infusion may produce a withdrawal syndrome of sympathetic over-activity, characterized by tachycardia, hypertension and agitation.

In such instances oral longer acting clonidine could be use to bridge the withdrawal. We utilized the principle of managing acute drug withdrawal with longer acting medications.

A is wrong as 14 days is a long time for re-emergence of DTs.

B is possible but unlikely as patient was getting better.

C is wrong as patient symptoms are not c/w CVA

E is wrong as there are no other signs of sepsis

References:

Kukoyi A, Coker S, Lewis L, Nierenberg D. - Two cases of acute dexmedetomidine withdrawal syndrome following prolonged infusion in the intensive care unit: Report of cases and review of the literature. - Hum Exp Toxicol. 2013 Jan;32(1):107-10.

Jamie L. Miller, PharmD, Christine Allen, MD, and Peter N. Johnson, PharmD - Neurologic Withdrawal Symptoms Following Abrupt Discontinuation of a Prolonged Dexmedetomidine Infusion in a Child - J Pediatr Pharmacol Ther. 2010 Jan-Mar; 15(1): 38–42.