Dexmedetomidine and Mortality From Sepsis Requiring Mechanical Ventilation: A Japanese Nationwide Retrospective Cohort Study.
Journal of intensive care medicine
BACKGROUND:Dexmedetomidine has a mild sedative effect and may reduce mortality in mechanically ventilated critically ill patients. However, few studies have examined the effects of dexmedetomidine in patients with sepsis who require mechanical ventilation. The aim of this study was to investigate the association between dexmedetomidine and mortality in patients with sepsis requiring mechanical ventilation, using a nationwide inpatient database in Japan. METHODS:Using the Diagnosis Procedure Combination database from July 1, 2010, to March 31, 2016, we identified adult patients with sepsis who required mechanical ventilation for more than 2 days. Patients were divided into those who received dexmedetomidine and those who received midazolam or propofol within 1 day after admission. Logistic regression analysis, propensity score-matched analysis, and instrumental variable analysis were performed to compare all-cause 28-day mortality and duration of mechanical ventilation between the groups. RESULTS:In total, 50 671 were eligible patients, including dexmedetomidine group (n = 13 759) and propofol or midazolam group (n = 36 912). The dexmedetomidine group had significantly lower all-cause 28-day mortality compared with the group receiving midazolam or propofol, as shown by the logistic regression analysis (odds ratio [OR]: 0.78; 95% confidence interval [CI]: 0.73-0.84), the propensity score-matched analysis (OR: 0.85; 95% CI: 0.80-0.91), and the instrumental variable analysis (OR: 0.64; 95% CI: 0.57-0.73). The duration of mechanical ventilation in the dexmedetomidine group was significantly shorter than that in the midazolam or propofol group. CONCLUSIONS:Dexmedetomidine was associated with a reduction in all-cause 28-day mortality and duration of mechanical ventilation.
10.1177/0885066620942154
Safety and efficacy of prolonged dexmedetomidine use in critically ill children with heart disease*.
Gupta Punkaj,Whiteside Wendy,Sabati Arash,Tesoro Tiffany M,Gossett Jeffrey M,Tobias Joseph D,Roth Stephen J
Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies
OBJECTIVES:To evaluate the safety and efficacy of prolonged dexmedetomidine administration (≥ 96 hrs) in critically ill children with heart disease. DESIGN:Retrospective observational study. SETTING:Cardiovascular intensive care unit in a single, tertiary care, academic children's hospital. INTERVENTIONS:None. SUBJECTS:We conducted a retrospective review of the charts of all critically ill infants and children (up to 18 yrs of age) with congenital or acquired heart disease who received dexmedetomidine for ≥ 96 hrs in our pediatric cardiovascular intensive care unit between January 2009 and March 2010. Patients were divided into two groups for study purposes: the dexmedetomidine group (n = 52) included patients who received a dexmedetomidine infusion along with other conventional sedation agents, and the control group (n = 42) included patients who received conventional sedation agents without the use of dexmedetomidine. Clinical outcomes evaluated in our study included days of mechanical ventilation, cardiovascular intensive care unit length of stay, hospital length of stay, and mortality. To evaluate the safety of dexmedetomidine, we collected physiologic data, including heart rate, mean arterial pressure, respiratory rate, systemic oxygen saturation by pulse oximetry, and inotrope score. To assess the efficacy of dexmedetomidine, we examined the amount and duration of concomitant sedation and analgesic infusions over a period of 24 hrs in both dexmedetomidine and control groups. We also examined the number of rescue boluses for each category prior to the initiation of sedative infusion, during the sedative infusion, and after the termination of the sedative infusion. The potential side effects evaluated in our study included nausea, vomiting, abdominal distension, dysrhythmias, neurological abnormalities, seizures, and signs and symptoms of withdrawal. MEASUREMENTS AND MAIN RESULTS:Patients' baseline characteristics were similar in the two groups. Patient complexity as measured by Risk-Adjusted Classification for Congenital Heart Surgery-1 score, ventricular ejection fraction, and proportion of patients receiving mechanical ventilatory support at the time of initiation of sedative infusion was also similar. The duration and amount of continuous midazolam and morphine infusions were significantly lower in the dexmedetomidine group when compared to the control group. During dexmedetomidine infusion, there was no statistical difference in the heart rate and blood pressure between the two groups. Inotrope score was significantly lower in the dexmedetomidine group as compared to the control group in the last 6 hrs prior to termination of dexmedetomidine infusion (p < .001), and at 1 hr (p < .001) and 6 hrs (p < .001) after termination of dexmedetomidine infusion. There was no difference in duration of mechanical ventilation (p = .77), cardiovascular intensive care unit length of stay (p = .29), or hospital length of stay (p = .43) in the two groups. One patient experienced junctional rhythm at 130 beats/min requiring temporary pacing. No other significant side effects were noted. A higher proportion of patients in the dexmedetomidine group were administered clonidine when compared to the control group after termination of dexmedetomidine (31% vs. 7%, p = .005). CONCLUSIONS:Prolonged dexmedetomidine administration in children with heart disease appears to be safe and is associated with decreased opioid and benzodiazepine requirement and decreased inotropic support.
10.1097/PCC.0b013e318253c7f1
Impact of Sedation Practices on Mortality in COVID-19-Associated Adult Respiratory Distress Syndrome Patients: A Multicenter Retrospective Descriptive Study.
Journal of intensive care medicine
Reduction in sedation exposure is an important metric in intensive care unit (ICU) patients. However, challenges arose during the coronavirus disease-2019 (COVID-19) pandemic in adhering to this practice, driven by concerns on transmission and disease severity issues. Accordingly, diverse sedation approaches emerged, although the effect on mortality has not been studied thoroughly. Retrospective cohort study in the medical ICU of seven hospitals within a major Health System in Northeast Ohio. We included all adult patients admitted with COVID-19 requiring invasive mechanical ventilation (IMV) from March 2020 to December 2021. Study included 2394 COVID-19 patients requiring IMV. Across waves, sample included 55-63% male subjects, with an average age of 61-68 years ( < 0.001), Acute Physiologic and Chronic Health Evaluation (APACHE)-III score 65.8-68.9 ( = 0.37), median IMV duration 8-10 days ( = 0.14), and median ICU duration 9.8-11.6 days ( = 0.084). Propofol remained the primary sedative (84-92%; = 0.089). Ketamine use increased from the first (9.7%) to fourth (19%) wave ( = 0.002). Midazolam use decreased from the first (27.4%) to third (9.4%) wave ( = 0.001). Dexmedetomidine use declined from 35% to 27-28% ( = 0.002) after the first wave. A multivariable regression analysis indicated clinical variables explained 34% of the variation in hospital mortality (R). Factors associated with higher mortality included age [aOR = 1.059 (95% CI 1.049-1.069); < 0.001], COVID-19 wave, especially fourth wave [aOR = 2.147, (95% CI 1.370-3.365); = 0.001], and higher number of vasopressors [aOR = 31.636, (95% CI 17.603-56.856); < 0.001]. Addition of sedative medications to a second model led to an increase in the R by only 1.6% to 35.6% [aOR = 1 (95% CI 1-1); > 0.05] for propofol, ketamine, and midazolam. Dexmedetomidine demonstrated a decrease in the odds of mortality [aOR = 0.96 (95% CI 0.94-0.97); < 0.001]. Mortality in critical COVID-19 patients was mostly driven by illness severity, and the choice of sedation might have minimal impact when other factors are controlled.
10.1177/08850666231224395
Addition of dexmedetomidine to standard sedation regimens after cardiac surgery: an outcomes analysis.
Dasta Joseph F,Jacobi Judith,Sesti Anne-Marie,McLaughlin Trent P
Pharmacotherapy
STUDY OBJECTIVE:To characterize inpatient use of intravenous sedatives in the real-world setting, and to evaluate clinical and economic outcomes when dexmedetomidine was used with midazolam and propofol for select cardiovascular procedures. DESIGN:12-month retrospective analysis. DATA SOURCE:An administrative claims database of operational data from a nationally representative sample of 250 medical and surgical hospitals. PATIENTS:Patients who received midazolam plus propofol (9996 patients) or dexmedetomidine, midazolam, plus propofol (356 patients) after cardiac valve or vessel surgery. MEASUREMENTS AND MAIN RESULTS:The source of patient demographics (e.g., age, sex, Charlson Comorbidity Index) and outcomes (e.g., charges, length of stay, mortality rate) was the hospital billing claim form. Patients in the dexmedetomidine-midazolam-propofol cohort tended to be younger and male and to have fewer comorbidities than those midazolam-propofol cohort. The primary outcomes for the three-drug cohort showed significant reductions in total charges/patient (approximately $18,000, p<0.05), total hospital length of stay (0.6 days, p<0.0001), days in the intensive care unit or cardiac care unit (3.87 days, p<0.0001), and mortality (2%, p=0.0142). Although pharmacy charges were higher (approximately $4000/patient), lower charges for the intensive care or cardiac care unit, operating room, room and board, and respiratory services were observed in the dexmedetomidinemidazolam-propofol cohort compared with the two-drug cohort. Also, mechanical ventilation was shorter by approximately 0.5 day in the three-drug cohort (p<0.01). CONCLUSION:These initial findings of a real-world assessment of dexmedetomidine use with other agents suggest favorable clinical and economic outcomes. Further research through randomized clinical trials of dexmedetomidine is warranted to better understand its optimum patient population, dosage, and the causality of the results, and to confirm the potential clinical and economic benefits observed in our patients.
10.1592/phco.26.6.798
ICU sedation with dexmedetomidine after severe traumatic brain injury.
Humble Stephen S,Wilson Laura D,Leath Taylor C,Marshall Matthew D,Sun Daniel Z,Pandharipande Pratik P,Patel Mayur B
Brain injury
OBJECTIVE:To comprehensively describe the use of dexmedetomidine in a single institutional series of adult ICU patients with severe TBI. This study describes the dexmedetomidine dosage and infusion times, as well as the physiological parameters, neurological status and daily narcotic requirements before, during and after dexmedetomidine infusion. METHODS:This study identified 85 adult patients with severe TBI who received dexmedetomidine infusions in the Trauma ICU at Vanderbilt University Medical Center between 2006-2010. Demographic, haemodynamic, narcotic use and sedative use data were systematically obtained from the medical record and analysed for changes associated with dexmedetomidine infusion. RESULTS:During infusion with dexmedetomidine, narcotic and sedative use decreased significantly (p < 0.001 and p < 0.05). Median MAP, SBP, DBP and HR also decreased significantly during infusion when compared to pre-infusion values (p < 0.001). Despite the use of dexmedetomidine, RASS and GCS scores improved from pre-infusion to infusion time periods. CONCLUSIONS:The findings demonstrate that initiation of dexmedetomidine infusion is not associated with a decline in neurological functioning in adults with severe TBI. Although there was an observed decrease in haemodynamic parameters during infusion with dexmedetomidine, the change was not clinically significant and the requirements for narcotics and additional sedatives were minimized.
10.1080/02699052.2016.1187289
Dexmedetomidine: a novel drug for the treatment of atrial and junctional tachyarrhythmias during the perioperative period for congenital cardiac surgery: a preliminary study.
Chrysostomou Constantinos,Beerman Lee,Shiderly Dana,Berry Donald,Morell Victor O,Munoz Ricardo
Anesthesia and analgesia
BACKGROUND:Atrial and junctional tachyarrhythmias occur frequently during the perioperative period for congenital cardiac surgery and can be a cause of increased morbidity and mortality. These rhythm disturbances that may be well tolerated in a normal heart can cause significant hemodynamic instability in patients with congenital heart defects, particularly during the postcardiopulmonary bypass period. Management of these arrhythmias presents more of a challenge, since currently available antiarrhythmic drugs can be ineffective and poorly tolerated. In this study, we examined the possible effect of dexmedetomidine, a primarily sedative drug, on atrial and junctional tachyarrhythmias. Though some animal data have shown that it can prevent certain types of ventricular tachycardia, its therapeutic role during these types of arrhythmias has not been studied. METHODS:This was a retrospective, nonrandomized, noncontrolled study. Fourteen patients admitted to the cardiac intensive care unit and who received dexmedetomidine for both, sedation/analgesia and for junctional ectopic tachycardia (JET), atrial ectopic tachycardia (AET), reentry type supraventricular tachycardia (Re-SVT), atrial flutter (AF) or junctional accelerated rhythm (JAR) were included. Dexmedetomidine was used as a primary drug or as a rescue if other antiarrhythmics had been used. Our primary end-points were (a) conversion to normal sinus rhythm (NSR) within 3 min for Re-SVT, and 2 h for all other arrhythmias or (b) heart rate (HR) reduction to improve hemodynamics; JET < or =170 bpm, AET > or =20%, AF < or =150 bpm and for JAR prevention of progression to JET. RESULTS:The mean age and weight were 2 +/- 3 mo and 4 +/- 1.5 kg, respectively. Most of the arrhythmias (79%) occurred during the postoperative period. Dexmedetomidine was used as a primary treatment in nine and as a rescue in five patients. Ten patients (71%) received an initial loading dose of 1.1 +/- 0.5 microg/kg. A continuous infusion, 0.9 +/- 0.3 microg x kg(-1) x h(-1) was administered in 12 patients. Thirteen patients' lungs were mechanically ventilated. Adverse effects were seen in four patients (28%). Three had hypotension that responded to fluid administration and one had a possible brief complete atrioventricular (AV) block. Nine of the 14 patients were transiently paced with atrial (seven) or AV sequential (two) pacing to improve AV synchrony. The primary outcome with rhythm and/or HR control was achieved in 13 patients (93%). JET rate decreased from 197 +/- 22 to 165 +/- 17 bpm within 67 +/- 75 min of dexmedetomidine administration. Five of these patients converted to NSR in 39 +/- 31 h and one remained in JAR. All four patients with Re-SVT had resolution of their tachyarrhythmia. Three converted to NSR and one to JAR. One patient with AET (220-270 bpm) responded well with decreasing HR to 120 bpm within 35 min and to NSR in 85 min. One patient with AF failed to respond. In two patients with JAR, neither progressed to JET and HR decreased from 158 +/- 11 to 129 +/- 1 bpm. CONCLUSION:This preliminary, observational report suggests that dexmedetomidine may have a potential therapeutic role in the acute phase of perioperative atrial and junctional tachyarrhythmias for either HR control or conversion to NSR.
10.1213/ane.0b013e318186499c
A comparison of severe hemodynamic disturbances between dexmedetomidine and propofol for sedation in neurocritical care patients.
Erdman Michael J,Doepker Bruce A,Gerlach Anthony T,Phillips Gary S,Elijovich Lucas,Jones G Morgan
Critical care medicine
OBJECTIVE:Dexmedetomidine and propofol are commonly used sedatives in neurocritical care as they allow for frequent neurologic examinations. However, both agents are associated with significant hemodynamic side effects. The primary objective of this study is to compare the prevalence of severe hemodynamic effects in neurocritical care patients receiving dexmedetomidine and propofol. DESIGN:Multicenter, retrospective, propensity-matched cohort study. SETTING:Neurocritical care units at two academic medical centers with dedicated neurocritical care teams and board-certified neurointensivists. PATIENTS:Neurocritical care patients admitted between July 2009 and September 2012 were evaluated and then matched 1:1 based on propensity scoring of baseline characteristics. INTERVENTIONS:Continuous sedation with dexmedetomidine or propofol. MEASUREMENTS AND MAIN RESULTS:A total of 342 patients (105 dexmedetomidine and 237 propofol) were included in the analysis, with 190 matched (95 in each group) by propensity score. The primary outcome of this study was a composite of severe hypotension (mean arterial pressure < 60 mm Hg) and bradycardia (heart rate < 50 beats/min) during sedative infusion. No difference in the primary composite outcome in both the unmatched (30% vs 30%, p = 0.94) or matched cohorts (28% vs 34%, p = 0.35) could be found. When analyzed separately, no differences could be found in the prevalence of severe hypotension or bradycardia in either the unmatched or matched cohorts. CONCLUSIONS:Severe hypotension and bradycardia occur at similar prevalence in neurocritical care patients who receive dexmedetomidine or propofol. Providers should similarly consider the likelihood of hypotension or bradycardia before starting either sedative.
10.1097/CCM.0000000000000328
Dexmedetomidine as an anesthetic adjunct is associated with reduced complications and cardiac intensive care unit length of stay after heart valve surgery.
BMC anesthesiology
BACKGROUND:We sought to explore the relationship between dexmedetomidine as an anesthetic adjuvant in cardiac surgery and postoperative complications and length of stay (LOS) in the cardiac intensive care unit (CICU). METHODS:We conducted a retrospective study of patients aged 18 years and older who underwent heart valve surgery between October 2020 and June 2022. The primary endpoint of the study was major postoperative complications (cardiac arrest, atrial fibrillation, myocardial injury/infarction, heart failure) and the secondary endpoint was prolonged CICU LOS (defined as LOS > 90th percentile). Multivariate logistic regression analysis was performed for variables that were significant in the univariate analysis. RESULTS:A total of 856 patients entered our study. The 283 patients who experienced the primary and secondary endpoints were included in the adverse outcomes group, and the remaining 573 were included in the prognostic control group. Multivariate logistic regression analysis revealed that age > 60 years (odds ratio [OR], 1.68; 95% confidence interval [CI], 1.23-2.31; p < 0.01), cardiopulmonary bypass (CPB) > 180 min (OR, 1.62; 95% CI, 1.03-2.55; p = 0.04) and postoperative mechanical ventilation time > 10 h (OR, 1.84; 95% CI, 1.35-2.52; p < 0.01) were independent risk factors for major postoperative complications; Age > 60 years (OR, 3.20; 95% CI, 1.65-6.20; p < 0.01), preoperative NYHA class 4 (OR, 4.03; 95% CI, 1.74-9.33; p < 0.01), diabetes mellitus (OR, 2.57; 95% CI, 1.22-5.41; p = 0.01), Intraoperative red blood cell (RBC) transfusion > 650 ml (OR, 2.04; 95% CI, 1.13-3.66; p = 0.02), Intraoperative bleeding > 1200 ml (OR, 2.69; 95% CI, 1.42-5.12; p < 0.01) were independent risk factors for prolonged CICU length of stay. Intraoperative use of dexmedetomidine as an anesthetic adjunct was a protective factor for major complications (odds ratio, 0.51; 95% confidence interval, 0.35-0.74; p < 0.01) and prolonged CICU stay. (odds ratio, 0.37; 95% confidence interval, 0.19-0.73; p < 0.01). CONCLUSIONS:In patients undergoing heart valve surgery, age, duration of cardiopulmonary bypass, and duration of mechanical ventilation are associated with major postoperative complication. Age, preoperative NYHA classification 4, diabetes mellitus, intraoperative bleeding, and RBC transfusion are associated with increased CICU length of stay. Intraoperative use of dexmedetomidine may improve such clinical outcomes.
10.1186/s12871-023-02227-5
Dexmedetomidine for Refractory Intracranial Hypertension.
Schomer Kendra J,Sebat Christian M,Adams Jason Y,Duby Jeremiah J,Shahlaie Kiarash,Louie Erin L
Journal of intensive care medicine
Dexmedetomidine (DEX) is a selective α adrenergic agonist that is commonly used for sedation in the intensive care unit (ICU). The role of DEX for adjunctive treatment of refractory intracranial hypertension is poorly defined. The primary objective of this study was to determine the effect of DEX on the need for rescue therapy (ie, hyperosmolar boluses, extraventricular drain [EVD] drainages) for refractory intracranial hypertension. Secondary objectives included the number of intracranial pressure (ICP) excursions, bradycardic, hypotensive, and compromised cerebral perfusion pressure episodes. This retrospective cohort study evaluated patients admitted to the neurosurgical ICU from August 1, 2009, to July 29, 2015, and who received DEX for refractory intracranial hypertension. The objectives were compared between the 2 time periods-before (pre-DEX) and during therapy (DEX). Twenty-three patients with 26 episodes of refractory intracranial hypertension met the inclusion criteria. The number of hyperosmolar boluses was decreased after DEX therapy was initiated. Mannitol boluses required were statistically reduced (1 vs 0.5, P = .03); however, reduction in hypertonic boluses was not statistically significant (1.3 vs 0.9, P = .2). The mean number of EVD drainages per 24 hours was not significantly different between the time periods (15.7 vs 14.0, P = .35). The rate of ICP excursions did not differ between the 2 groups (24.3 vs 22.5, P = .62). When compared to pre-DEX data, there was no difference in the median number of hypotensive (0 vs 0), bradycardic (0 vs 0), or compromised cerebral perfusion pressure episodes (0.5 vs 1.0). Dexmedetomidine may avoid increases in the need for rescue therapy when used as an adjunctive treatment of refractory intracranial hypertension without compromising hemodynamics.
10.1177/0885066616689555
DEXmedetomidine compared to PROpofol in NEurocritical Care [DEXPRONE]: A multicenter retrospective evaluation of clinical utility and safety.
Owusu Kent A,Kurczewski Lisa,Armahizer Michael J,Zichichi Albert,Maciel Carolina B,Heavner Mojdeh S
Journal of critical care
PURPOSE:Although guidelines recommend dexmedetomidine (DEX) or propofol (PRO) as preferred sedatives in critically ill adults, comparisons in neurocritical care (NCC) are limited. We aimed to evaluate the clinical utility and safety of DEX compared with PRO in NCC setting. MATERIALS AND METHODS:This retrospective, multicenter, observational cohort study conducted at three tertiary academic hospitals with Level 1 Trauma Center and Comprehensive Stroke Center designations, compared the clinical indication and safety of DEX vs PRO in patients in NCC setting. RESULTS:179 patients were included (94 DEX and 85 PRO), median age of 58, 49% were male (DEX) and 58% were male (PRO). PRO was more commonly used to manage agitation. DEX was more commonly used for facilitating extubation, alcohol withdrawal, and sedation during frequent neurologic assessments. Mean Glasgow Coma Scale scores were higher in DEX group (11 vs. 9; p = .04). The duration of either infusions, mechanical ventilation, and lengths of stay were similar. No difference was observed in hypotension or bradycardia rates. Death was significantly higher with PRO (DEX 10% vs. PRO 22%; p = .02). CONCLUSIONS:DEX and PRO were used for distinct indications in our cohort. Adverse effect profiles and clinical outcome, in the cohorts are largely similar.
10.1016/j.jcrc.2020.07.021
Exploring the impact of dexmedetomidine on short-term outcomes in critically ill sepsis-associated encephalopathy patients.
European review for medical and pharmacological sciences
OBJECTIVE:Dexmedetomidine has demonstrated potential in preclinical medical research as a protective agent against inflammatory injuries and a provider of neuroprotective benefits. However, its effect on the short-term prognosis of patients with sepsis-associated encephalopathy remains unclear. This study aims to explore the underlying value of dexmedetomidine in these patients. PATIENTS AND METHODS:This study enrolled patients with sepsis-associated encephalopathy from the Medical Information Mart for Intensive Care (MIMIC)-IV database, and they were divided into two groups based on dexmedetomidine therapy during hospitalization. Propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) were utilized to balance the inter-group baseline differences. Kaplan-Meier (KM) curves with log-rank test and subgroup analysis were also employed. The primary outcome was 28-day mortality, and the secondary outcomes were in-hospital mortality, intensive care unit (ICU) stay time, hospital stay time, and the incidence of ventilator-associated pneumonia (VAP). RESULTS:After PSM, 1,075 pairs of patients were matched. In contrast to the non-dexmedetomidine cohort, the dexmedetomidine cohort did not exhibit a shortened ICU [4.65 (3.16, 8.55) vs. 6.14 (3.66, 11.04), p<0.001] and hospital stay duration [10.04 (6.55, 15.93) vs. 12.76 (7.92, 19.95), p<0.001], and there was an elevated incidence of VAP [90 (8.4%) vs. 135 (12.6%), p=0.002]. The log-rank test for the KM curves of dexmedetomidine use and 28-day mortality was statistically significant (p<0.001). The results showed that dexmedetomidine was associated with improved 28-day mortality [hazard ratio (HR) 0.46, 95% confidence interval (CI) 0.35-0.61, p<0.001] and in-hospital mortality (HR 0.50, 95% CI 0.37-0.67, p<0.001) after adjusting for various confounders. In the following subgroup analysis, dexmedetomidine infusion was associated with decreased 28-day mortality in most subgroups. CONCLUSIONS:Dexmedetomidine administration was significantly associated with reduced short-term mortality among patients with sepsis-associated encephalopathy in the ICU. However, it also prolonged ICU and hospital stays and increased the incidence of VAP.
10.26355/eurrev_202404_35901
Adjunctive dexmedetomidine therapy in the intensive care unit: a retrospective assessment of impact on sedative and analgesic requirements, levels of sedation and analgesia, and ventilatory and hemodynamic parameters.
MacLaren Robert,Forrest Laurel K,Kiser Tyree H
Pharmacotherapy
STUDY OBJECTIVE:To determine if adjunctive dexmedetomidine therapy in intensive care patients alters requirements for and levels of sedation and analgesia, and to describe hemodynamic and ventilatory parameters. DESIGN:Retrospective, noncontrolled, descriptive study of clinical practice. SETTING:Four intensive care units (ICUs; medical, surgical, neurosurgical, or burn) in a university-affiliated medical center. PATIENTS:Forty patients who were already receiving sustained use of propofol, lorazepam, or fentanyl when dexmedetomidine was started. MEASUREMENTS AND MAIN RESULTS:Medical records were identified by searching the pharmacy database for patients who had received continuous-infusion dexmedetomidine from January 2000-January 2003 while in one of the four ICUs. Primary end points were discontinuation or dosage reduction of other sedatives or fentanyl from the hour before to 6 hours after starting dexmedetomidine. Other outcomes included levels of sedation and analgesia before and after dexmedetomidine and description of ventilatory and hemodynamic parameters. The initial dexmedetomidine rate of 0.4 +/- 0.25 microg/kg/hour changed minimally through 47.4 +/- 61.1 infusion hours. At 6 hours, 11 of 13 patients receiving propofol, 14 of 23 receiving lorazepam, and 4 of 30 receiving fentanyl had the respective agent discontinued. With dexmedetomidine, the hourly rates and cumulative daily doses were reduced only for propofol. Adequate sedation occurred at rates of 64.6% and 47.9% during the 24-hour periods before and after dexmedetomidine was started, respectively (p=0.001). Four and 12 patients had severe agitation before and after, respectively (p=0.05). One and 12 patients had severe pain before and after, respectively (p=0.02). Nine patients experienced hypotension or bradycardia. Twenty-two patients were successfully extubated within 24 hours of starting dexmedetomidine. CONCLUSIONS:Adjunctive dexmedetomidine reduces sedative requirements but does not alter analgesic requirements. However, dexmedetomidine was associated with enhanced agitation, severe pain, and hemodynamic compromise. Transitioning to dexmedetomidine from other sedatives and analgesics may not provide optimal sedation and analgesia. Future studies are needed to evaluate dexmedetomidine as a bridge to extubation.
10.1592/phco.27.3.351
Dexmedetomidine Is Associated With Lower Incidence of Acute Kidney Injury After Congenital Heart Surgery.
Kwiatkowski David M,Axelrod David M,Sutherland Scott M,Tesoro Tiffany M,Krawczeski Catherine D
Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies
OBJECTIVES:Recent data have suggested an association between the use of dexmedetomidine and a decreased incidence of acute kidney injury in adult patients after cardiopulmonary bypass. However, no study has focused on this association among pediatric populations where the incidence of acute kidney injury is particularly high and of critical significance. The primary objective of this study was to assess the relationship between the use of postoperative dexmedetomidine and the incidence of acute kidney injury in pediatric patients undergoing cardiopulmonary bypass. The secondary objective was to determine whether there was an association between dexmedetomidine use and duration of mechanical ventilation or cardiovascular ICU stay. DESIGN:Single-center retrospective matched cohort study. SETTING:A 20-bed quaternary cardiovascular ICU in a university-based pediatric hospital in California. PATIENTS:Children less than 18 years old admitted after cardiac surgery with cardiopulmonary bypass between January 1, 2012, and May 31, 2014. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:Data from a cohort of 102 patients receiving dexmedetomidine during the first postoperative day after cardiac surgery were compared to an age- and procedure-matched cohort not receiving dexmedetomidine. Cohorts had similar baseline and demographic characteristics. Patients receiving dexmedetomidine were less likely to develop acute kidney injury (24% vs 36%; odds ratio, 0.54; 95% CI, 0.29-0.99; p = 0.046). After adjusting for age, bypass time, nephrotoxin use, and vasoactive inotropic score, the use of dexmedetomidine was associated with a lower incidence of acute kidney injury with adjusted odds ratio of 0.43 (95% CI, 0.27-0.98; p = 0.048). There was no difference between the cohorts with respect to the duration of mechanical duration (1 d each; p = 0.98) or cardiovascular ICU stays (5 vs 6 d; p = 0.91). CONCLUSIONS:The use of a dexmedetomidine infusion in pediatric patients after congenital heart surgery was associated with a decreased incidence of acute kidney injury; however, it was not associated with changes in clinical outcomes. Further prospective study is necessary to validate these findings.
10.1097/PCC.0000000000000611
Dexmedetomidine in the care of critically ill patients from 2001 to 2007: an observational cohort study.
Wunsch Hannah,Kahn Jeremy M,Kramer Andrew A,Wagener Gebhard,Li Guohua,Sladen Robert N,Rubenfeld Gordon D
Anesthesiology
BACKGROUND:Dexmedetomidine is a novel sedative agent that causes anxiolysis without respiratory depression in critically ill patients. We sought to examine patient and hospital variation in dexmedetomidine use and adoption patterns of dexmedetomidine over time. METHODS:We performed a retrospective cohort study of all patients who received intravenous infusion sedation in 174 intensive care units contributing data to Project IMPACT from 2001 through 2007. Sedation use was defined as having received an intravenous sedative infusion (dexmedetomidine, midazolam, lorazepam, or propofol) for any period during the intensive care stay. The primary outcome was use of dexmedetomidine in the intensive care unit. RESULTS:Of 58,391 patients who received intravenous infusion sedation, 2,535 (4.3%, 95% confidence interval [CI], 4.2-4.5) received dexmedetomidine. Overall use was highest in cardiac surgery patients (11.7%, 10.8-12.7) and was similar in other surgical patients (4.3%, 4.0-4.6) and medical patients (3.4%, 3.2-3.6, P < 0.001). Use of dexmedetomidine increased from 2.0% (1.6-2.4) of patients receiving intravenous infusion sedation in 2001 to 7.2% (6.6-7.9) in 2007 (P < 0.001), primarily because of an increase in use in cardiac surgery patients (1.4%, 0.0-2.8, in 2001 vs. 20.2%, 17.6-22.8 in 2007, P < 0.001). Of the patients who received dexmedetomidine, 31.5% (29.6-33.3) received the infusion for more than 1 day, and 10.9% were not mechanically ventilated. CONCLUSION:Use of dexmedetomidine in critically ill patients has increased over time, primarily as a result of an increase in use among cardiac surgery patients. A substantial portion of dexmedetomidine was administered outside of the regulatory approval guidelines at the time.
10.1097/ALN.0b013e3181e74116
Use of dexmedetomidine for the treatment of alcohol withdrawal syndrome in critically ill patients: a retrospective case series.
DeMuro Jonas P,Botros David G,Wirkowski Ela,Hanna Adel F
Journal of anesthesia
Alcohol withdrawal syndrome (AWS) continues to be a challenge to manage in the ICU setting, and the ideal pharmacological treatment continues to evolve. Dexmedetomidine is a newer agent approved for short-term sedation in the ICU, but its use in the treatment of AWS has been limited. We report a retrospective case series of ten patients who were identified as receiving dexmedetomidine for AWS as designated by electronic pharmacy records. All subjects were male, with a mean age of 53.6 years, and a mean ICU length of stay of 9.3 days. They were all diagnosed with AWS by DSM-IV criteria. All the study patients received dexmedetomidine during their hospital course as a treatment for AWS. Studied variables included demographic data, dose and duration of dexmedetomidine, other pharmaceutical agents, and hemodynamics. Dexmedetomidine was safe to use in all patients, although mechanical ventilation was still required in three patients. With dexmedetomidine, the autonomic hyperactivity was blunted, with a mean 12.8% reduction in rate pressure product observed. Consideration should be given to the combined use of dexmedetomidine with benzodiazepines in the treatment of AWS.
10.1007/s00540-012-1381-y
Hemodynamic Effects of Dexmedetomidine in Adults With Reduced Ejection Fraction Heart Failure.
Journal of intensive care medicine
BACKGROUND:Dexmedetomidine (DEX) can cause hypotension complicating its use in critically ill patients with labile hemodynamics secondary to an underlying disease state such as heart failure. The aim of this study was to determine the effect of DEX on mean arterial pressure (MAP) in nonsurgical patients with heart failure and reduced ejection fraction (HFrEF). METHODS:This retrospective single-center cohort study evaluated patients who received DEX in the cardiac care and medical intensive care units at a large academic hospital. The primary end point was the change in MAP within 6 hours following DEX initiation. RESULTS:Sixty-five patients with HFrEF diagnosis were compared 1:1 to a control group without HFrEF. Both groups experienced a decrease in MAP over the study period. Patients with HFrEF had a greater absolute percentage reduction in MAP 1 hour following DEX initiation compared to the control group (-9.6% vs -5.2%; < .01). When accounting for the combined effect of DEX initiation and HFrEF diagnosis on the primary end point, patients with HFrEF did not have a significant difference in MAP compared to the control group over the study period. CONCLUSIONS:Within 6 hours following DEX initiation, both groups experienced a decrease in MAP. The effect of DEX on MAP over the composite time period was not found to be significantly different in the HFrEF group compared to the non-HFrEF group. However, patients with HFrEF experienced a greater reduction in MAP in the first hour following DEX initiation compared to the non-HFrEF group. Prospective studies are needed to evaluate the effect of DEX on patients with acute decompensated HFrEF compared to patients with compensated HFrEF.
10.1177/0885066620934416
Predictors of a response to dexmedetomidine in intubated, critically ill adult patients.
DiCesare Michael A,Rech Megan A,DeMott Joshua M
Pharmacotherapy
BACKGROUND:Dexmedetomidine is a centrally acting α-2 receptor agonist used to maintain light analgosedation in mechanically ventilated adults. This study was conducted to determine factors predictive of successful maintenance of light sedation (Richmond Agitation-Sedation Scale (RASS) 0 to -2) for ≥60% of the first 48 h of mechanical ventilation with dexmedetomidine. METHODS:This was a single-center, retrospective, cohort study of critically ill adult patients receiving dexmedetomidine and admitted to an intensive care unit (ICU) between January 1, 2013, and August 31, 2019. A multivariable logistic regression analysis was performed in patients receiving dexmedetomidine for sedation to assess patient and clinical characteristics associated with a positive clinical response to dexmedetomidine. RESULTS:Of 1065 patients reviewed for study inclusion, 158 patients were included. Sixty-two percent of patients initiated on dexmedetomidine to maintain light sedation were able to remain within this sedation target ≥60% of the time during the first 48 hours of therapy. Patients maintained within the target RASS score ≥60% of the time had a higher percentage of ventilator-free days at 14 days (p = 0.044). The odds of having a mean time within goal RASS score ≥60% in the first 48 hours of mechanical ventilation after intubation were decreased by 9% for every point increase in sequential organ failure assessment score (odds ratio: 0.91, 95% confidence interval: 0.82-0.99). CONCLUSION:Patients were less likely to maintain light sedation with dexmedetomidine as their degree of critical illness increased. The duration of time maintained within goal sedation after dexmedetomidine initiation and the impact on patient outcomes remain a research priority.
10.1002/phar.2501
Association of Early Dexmedetomidine Utilization With Clinical and Functional Outcomes Following Moderate-Severe Traumatic Brain Injury: A Transforming Clinical Research and Knowledge in Traumatic Brain Injury Study.
Critical care medicine
OBJECTIVE:To examine early sedation patterns, as well as the association of dexmedetomidine exposure, with clinical and functional outcomes among mechanically ventilated patients with moderate-severe traumatic brain injury (msTBI). DESIGN:Retrospective cohort study with prospectively collected data. SETTING:Eighteen Level-1 Trauma Centers, United States. PATIENTS:Adult (age > 17) patients with msTBI (as defined by Glasgow Coma Scale < 13) who required mechanical ventilation from the Transforming Clinical Research and Knowledge in TBI (TRACK-TBI) study. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:Using propensity-weighted models, we examined the association of early dexmedetomidine exposure (within the first 5 d of ICU admission) with the primary outcome of 6-month Glasgow Outcomes Scale Extended (GOS-E) and the following secondary outcomes: length of hospital stay, hospital mortality, 6-month Disability Rating Scale (DRS), and 6-month mortality. The study population included 352 subjects who required mechanical ventilation within 24 hours of admission. The initial sedative medication was propofol for 240 patients (68%), midazolam for 59 patients (17%), ketamine for 6 patients (2%), dexmedetomidine for 3 patients (1%), and 43 patients (12%) never received continuous sedation. Early dexmedetomidine was administered in 77 of the patients (22%), usually as a second-line agent. Compared with unexposed patients, early dexmedetomidine exposure was not associated with better 6-month GOS-E (weighted odds ratio [OR] = 1.48; 95% CI, 0.98-2.25). Early dexmedetomidine exposure was associated with lower DRS (weighted OR = -3.04; 95% CI, -5.88 to -0.21). In patients requiring ICP monitoring within the first 24 hours of admission, early dexmedetomidine exposure was associated with higher 6-month GOS-E score (OR 2.17; 95% CI, 1.24-3.80), lower DRS score (adjusted mean difference, -5.81; 95% CI, -9.38 to 2.25), and reduced length of hospital stay (hazard ratio = 1.50; 95% CI, 1.02-2.20). CONCLUSION:Variation exists in early sedation choice among mechanically ventilated patients with msTBI. Early dexmedetomidine exposure was not associated with improved 6-month functional outcomes in the entire population, although may have clinical benefit in patients with indications for ICP monitoring.
10.1097/CCM.0000000000006106
Safety of dexmedetomidine for the control of agitation in critically ill traumatic brain injury patients: a descriptive study.
Bilodeau Véronique,Saavedra-Mitjans Mar,Frenette Anne Julie,Burry Lisa,Albert Martin,Bernard Francis,Williamson David R
Journal of clinical pharmacy and therapeutics
BACKGROUND:Behavioural disturbances such as agitation are common following traumatic brain injury and can interfere with treatments, cause self-harm and delay rehabilitation. As there is a lack of evidence on the optimal approach to manage agitation in recovering TBI patients, various pharmacological agents are used including antipsychotics, anticonvulsants and sedative agents. Among sedatives, the safety and efficacy of dexmedetomidine to control agitation in traumatic brain injury patients is not well documented. OBJECTIVE:To describe the safety, use and efficacy of dexmedetomidine for the management of agitation following traumatic brain injury in the intensive care unit. METHODS:Medical records of all patients admitted to the intensive care unit of the Hôpital Sacré-Coeur de Montréal for a traumatic brain injury who received dexmedetomidine for agitation between 1 January 2017 and 31 December 2017 were reviewed. Patients who received dexmedetomidine for indications other than agitation were excluded. Data on dexmedetomidine prescription practices and safety were extracted. Frequency of agitation and concomitant psychoactive medication use was explored over a period starting two days prior to the initiation of dexmedetomidine to six days after or discontinuation, whichever came first. RESULTS:We identified 41 patients in whom dexmedetomidine was initiated. Dexmedetomidine was started on median ICU day 3 (25 -75 percentiles: 2-7) and had a median treatment duration of 3 days (25 -75 percentiles: 3-6) and a mean average rate of 0.62 mcg/kg/h (SD 0.25). Although hypotension (76%) and bradycardia (54%) were common, only one patient required intervention. The proportion of patients with at least one episode of agitation decreased from 100% on day 0, to 88%, 69% and 63% on days 1, 2 and 3 of dexmedetomidine, respectively. The decrease was statistically significant difference between days 0 and 2 as well as between days 0 and 3. Concomitant use of propofol and benzodiazepines also decreased over the course of dexmedetomidine treatment. CONCLUSION:Dexmedetomidine use was safe and associated with a reduction in agitation in traumatic brain injury patients in the 96 hours following its initiation.
10.1111/jcpt.13389
Safety of dexmedetomidine in the cardiac intensive care unit.
Adie Sarah K,Farina Nicholas,Abdul-Aziz Ahmad A,Lee Ran,Thomas Michael P,Konerman Matthew C
European heart journal. Acute cardiovascular care
AIMS:Dexmedetomidine is one of the sedative agents recommended by the Society of Critical Care Medicine as a preferred option over benzodiazepines in critically ill, mechanically ventilated patients. Little data exists describing sedation in the cardiac intensive care unit (CICU). The purpose of this study was to determine the prevalence of adverse events in CICU patients treated with dexmedetomidine. METHODS AND RESULTS:This was a retrospective cohort analysis of patients >18 years old admitted to the University of Michigan CICU from June 2014 to October 2019 who received dexmedetomidine therapy. The primary outcome was the composite of adverse events including bradycardia, hypotension, increasing vasopressor/inotrope requirements, and asystole. Secondary outcomes included individual components of the primary outcome. Patients that experienced adverse events were compared to those that did not experience adverse events to identify risk factors for adverse events. A total of 197 patients were included. There were 116 adverse events in 106 patients. Hypotension was the most common adverse event, making up 60.3% of adverse events reported. Increased vasopressor requirement and bradycardia both occurred in 22 patients (18.9%). Asystole occurred in two patients. B-type natriuretic peptide (BNP) levels were significantly higher in those experiencing an adverse event (848 pg/mL vs. 431 pg/mL; P = 0.03). CONCLUSIONS:Patients admitted to the CICU experienced a high rate of adverse events with dexmedetomidine use. Those experiencing adverse events were more likely to have a higher BNP. Future studies should explore the safety of alternative sedative agents to ascertain safe pharmacological options for patients admitted to the CICU.
10.1093/ehjacc/zuaa009
Impact of dexmedetomidine on mortality in critically ill patients with acute kidney injury: a retrospective propensity score matching analysis.
BMJ open
OBJECTIVES:This study sought to estimate the effect of dexmedetomidine (DEX) administration on mortality in critically ill patients with acute kidney injury (AKI). DESIGN:A retrospective cohort study. SETTING:The study sourced its data from the Multiparameter Intelligent Monitoring in Intensive Care Database IV (MIMIC-IV), a comprehensive database of intensive care unit patients. PARTICIPANTS:A total of 15 754 critically ill patients with AKI were enrolled from the MIMIC-IV database. PRIMARY AND SECONDARY OUTCOME:Primary outcome was in-hospital mortality and secondary outcome was 180-day mortality. RESULTS:15 754 critically ill AKI patients were included in our analysis. We found that DEX use decreased in-hospital mortality risk by 38% (HR 0.62, 95% CI 0.55 to 0.70) and 180-day mortality risk by 23% (HR 0.77, 95% CI 0.69 to 0.85). After adjusting for confounding factors, DEX can reduce all three stages of AKI in in-hospital mortality. CONCLUSIONS:Our retrospective cohort study suggests that DEX significantly correlates with decreased risk-adjusted in-hospital and 180-day mortality in critically ill AKI patients. Nonetheless, future randomised controlled trials are warranted to validate our findings.
10.1136/bmjopen-2023-073675
The Use of Dexmedetomidine in the Emergency Department: A Cohort Study.
The western journal of emergency medicine
INTRODUCTION:Management of sedation, analgesia, and anxiolysis are cornerstone therapies in the emergency department (ED). Dexmedetomidine (DEX), a central alpha-2 agonist, is increasingly being used, and intensive care unit (ICU) data demonstrate improved outcomes in patients with respiratory failure. However, there is a lack of ED-based data. We therefore sought to: 1) characterize ED DEX use; 2) describe the incidence of adverse events; and 3) explore factors associated with adverse events among patients receiving DEX in the ED. METHODS:This was a single-center, retrospective, cohort study of consecutive ED patients administered DEX (January 1, 2017-July 1, 2019) at an academic, tertiary care ED with an annual census of ~90,000 patient visits. All included patients (n= 103) were analyzed for characterization of DEX use in the ED. The primary outcome was a composite of adverse events, bradycardia and hypotension. Secondary clinical outcomes included ventilator-, ICU-, and hospital-free days, and hospital mortality. To examine for variables associated with adverse events, we used a multivariable logistic regression model. RESULTS:We report on 103 patients. Dexmedetomidine was most commonly given for acute respiratory failure, including sedation for mechanical ventilation (28.9%) and facilitation of non-invasive ventilation (17.4%). Fifty-four (52.4%) patients experienced the composite adverse event, with hypotension occurring in 41 patients (39.8%) and bradycardia occurring in 18 patients (17.5%). Dexmedetomidine was stopped secondary to an adverse event in eight patients (7.8%). Duration of DEX use in the ED was associated with an increase adverse event risk (adjusted odds ratio, 1.004; 95% confidence interval, 1.001, 1.008). CONCLUSION:Dexmedetomidine is most commonly administered in the ED for patients with acute respiratory failure. Adverse events are relatively common, yet DEX is discontinued comparatively infrequently due to adverse events. Our results suggest that DEX could be a viable option for analgesia, anxiolysis, and sedation in ED patients.
10.5811/westjem.2021.4.50917
Association between dexmedetomidine administration and outcomes in critically ill patients with sepsis-associated acute kidney injury.
Journal of clinical anesthesia
STUDY OBJECTIVE:To investigate the association between dexmedetomidine administration and outcomes in critically ill patients with sepsis-associated acute kidney injury (SA-AKI). DESIGN:A single-center, retrospective, cohort study. SETTING:Intensive care unit (ICU). PATIENTS:A total of 2192 critically ill patients with SA-AKI were included in the analysis, which identified from the Medical Information Mart for Intensive Care (MIMIC-IV) database between 2008 and 2019. INTERVENTIONS:Intravenous infusion of dexmedetomidine. MEASUREMENTS:The primary outcome was recovery of renal function. In-hospital mortality, vasopressor requirements, length of ICU and hospital stay were considered secondary outcomes. The Cox proportional hazards, logistic regression, and linear regression models were used to assess the association between dexmedetomidine and outcomes. Propensity score matching (PSM) analysis was used to match patients receiving dexmedetomidine to those without treatment. MAIN RESULTS:After PSM, 719 matched patient pairs were derived from patients who received dexmedetomidine and those who did not. The administration of dexmedetomidine was associated with a higher rate of renal recovery [61.8% vs. 55.8%, hazard ratio (HR) 1.35; P = 0.01], reduced in-hospital mortality [28.3% vs. 41.3%, HR 0.56; P < 0.001], and prolonged intensive care unit (ICU) stay [15.8d vs 12.6d, HR 2.34; P < 0.001] and hospital stay [23.7d vs 19.7d, HR 4.47; P < 0.001]. No significant difference was found in vasopressor requirements in patients with SA-AKI. Nevertheless, results illustrated that dose receiving between 0.30 and 1.00 μg/kg/h and duration using under 48 h of dexmedetomidine was associated with improvements in renal function recovery in SA-AKI patients. CONCLUSION:Dexmedetomidine administration was associated with improvements in renal function recovery and in-hospital survival in critically ill patients with SA-AKI. The results need to be verified in further randomized controlled trials.
10.1016/j.jclinane.2022.110960