Objectives: Prolonged use of dexmedetomidine has become increasingly common due to its favorable sedative and anxiolytic properties. Hypersympathetic withdrawal symptoms have been reported with abrupt discontinuation of prolonged dexmedetomidine infusions. Clonidine has been used to transition patients off dexmedetomidine infusions for ICU sedation. The objective of this study was to compare the occurrence of dexmedetomidine withdrawal symptoms in ICU patients transitioning to a clonidine taper versus those weaned off dexmedetomidine alone after prolonged dexmedetomidine infusion. Design: This was a single-center, prospective, double cohort observational study conducted from November 2017 to December 2018. Setting: Medical-surgical, cardiothoracic, and neurosurgical ICUs in a tertiary care hospital. Patients: We included adult ICU patients being weaned off dexmedetomidine after receiving continuous infusions for at least 3 days. Interventions: Patients were either weaned off dexmedetomidine alone or with a clonidine taper at the discretion of the providers. Measurements and Main Results: The primary outcome was the incidence of at least two dexmedetomidine withdrawal symptoms during a single assessment within 24 hours of dexmedetomidine discontinuation. Time on dexmedetomidine after wean initiation and difference in medication cost were also evaluated. Forty-two patients were included in this study: 15 received clonidine (Group C) and 27 weaned off dexmedetomidine alone (Group D). There was no significant difference in the incidence of two or more withdrawal symptoms between groups (73% in Group C vs 59% in Group D; p = 0.51). Patients in Group C spent less time on dexmedetomidine after wean initiation compared with patients in Group D (19 vs 42 hr; p = 0.02). An average cost savings of $1,553.47 per patient who received clonidine was observed. No adverse effects were noted. Conclusions: Our study demonstrated that patients receiving clonidine were able to wean off dexmedetomidine more rapidly, with a considerable cost savings and no difference in dexmedetomidine withdrawal symptoms, compared with patients weaned off dexmedetomidine alone. Clonidine may be a safe, effective, and practical option to transition patients off prolonged dexmedetomidine infusions.

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(J Clin Anesth. 2017;37:77–81) The generally accepted mechanism of postdural puncture headache (PDPH) is leakage of cerebrospinal fluid (CSF) from a dural defect, resulting in decreased CSF volume. However, while pushing during the second stage of labor and increased body mass index (BMI) may affect CSF leakage, and thus the incidence of PDPH, studies have reported conflicting results. The authors of the present study explored how pushing during labor and BMI affect the development of PDPH in parturients who experienced dural puncture with a Tuohy epidural needle.

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This case examines perioperative suspension of a do-notresuscitate (DNR) order during surgery. The commentary considers the appropriateness of DNR orders; types of DNR order suspension in the context of alternative anesthesia techniques; and what is required from a surgeon, anesthesiologist, and patient or surrogate to reach a decision expressing the patient's best interest. It concludes by offering communication recommendations based on joint discussion and decision sharing. Case A 76-year-old woman with dementia, Ms B, is brought to the emergency department after she fell at her nursing home. An X-ray reveals a left femoral neck fracture, and she is seen by an orthopedic consultant, Dr S, who recommends surgical repair.

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