Role of Dexmedetomidine for the Prevention and Treatment of Delirium in Intensive Care Unit Patients

Dexmedetomidine for prevention of delirium in elderly patients after non-cardiac surgery: a randomised, double-blind, placebo-controlled trial

BACKGROUND

Delirium is a postoperative complication that occurs frequently in patients older than 65 years, and presages adverse outcomes. We investigated whether prophylactic low-dose dexmedetomidine, a highly selective α₂ adrenoceptor agonist, could safely decrease the incidence of delirium in elderly patients after non-cardiac surgery.

METHODS

We did this randomised, double-blind, placebo-controlled trial in two tertiary-care hospitals in Beijing, China. We enrolled patients aged 65 years or older, who were admitted to intensive care units after non-cardiac surgery, with informed consent. We used a computer-generated randomisation sequence (in a 1:1 ratio) to randomly assign patients to receive either intravenous dexmedetomidine (0·1 μg/kg per h, from intensive care unit admission on the day of surgery until 0800 h on postoperative day 1), or placebo (intravenous normal saline). Participants, care providers, and investigators were all masked to group assignment. The primary endpoint was the incidence of delirium, assessed twice daily with the Confusion Assessment Method for intensive care units during the first 7 postoperative days. Analyses were done by intention-to-treat and safety populations. This study is registered with Chinese Clinical Trial Registry, www.chictr.org.cn, number ChiCTR-TRC-10000802.

FINDINGS

Between Aug 17, 2011, and Nov 20, 2013, of 2016 patients assessed, 700 were randomly assigned to receive either placebo (n=350) or dexmedetomidine (n=350). The incidence of postoperative delirium was significantly lower in the dexmedetomidine group (32 [9%] of 350 patients) than in the placebo group (79 [23%] of 350 patients; odds ratio [OR] 0·35, 95% CI 0·22-0·54; p<0·0001). Regarding safety, the incidence of hypertension was higher with placebo (62 [18%] of 350 patients) than with dexmedetomidine (34 [10%] of 350 patients; 0·50, 0·32-0·78; p=0·002). Tachycardia was also higher in patients given placebo (48 [14%] of 350 patients) than in patients given dexmedetomidine (23 [7%] of 350 patients; 0·44, 0·26-0·75; p=0·002). Occurrence of hypotension and bradycardia did not differ between groups.

INTERPRETATION

For patients aged over 65 years who are admitted to the intensive care unit after non-cardiac surgery, prophylactic low-dose dexmedetomidine significantly decreases the occurrence of delirium during the first 7 days after surgery. The therapy is safe.

FUNDING

Braun Anaesthesia Scientific Research Fund and Wu Jieping Medical Foundation, Beijing, China. Study drugs were manufactured and supplied by Jiangsu Hengrui Medicine Co, Ltd, Jiangsu, China.

The Opioid-sparing Effect of Intraoperative Dexmedetomidine Infusion After Craniotomy

BACKGROUND

We conducted a randomized trial to evaluate the opioid-sparing effect of an intraoperative infusion of dexmedetomidine (DEX) after craniotomy.

METHODS

Sixty adult patients scheduled for craniotomy were divided randomly into group A (DEX infusion at 0.5 μg/kg/h for 10 min and then adjusted to 0.2 to 0.5 μg/kg/h from tracheal intubation to incision suturing) and group B (0.9% saline infusion). Additional intravenous injections and patient-controlled analgesia with morphine were used to control postoperative pain for verbal Numerical Rating Scale scores >4. Cumulative morphine consumption, Numerical Rating Scale pain score, and the Ramsay Sedation Scale score were evaluated at 1, 2, 4, 6, 8, 12, and 24 hours; the incidence of postoperative nausea and vomiting, agitation, and respiratory depression were recorded at 24 hours after surgery.

RESULTS

Postoperative pain scores within 12 hours and Ramsay Sedation Scale scores within 6 hours of surgery were both significantly lower in group A than in group B (P<0.001). Patients in group A required 54.4%, 43.3%, and 31.4% less cumulative morphine consumption during the first 4, 12, and 24 hours, respectively. No patient in group A and 5 patients in group B presented agitation within 1 hour after surgery. Three patients in group A and 9 patients in group B showed pruritus (P<0.001).

CONCLUSIONS

An intraoperative infusion of DEX reduced cumulative morphine consumption and adverse effects after craniotomy.

Dexmedetomidine reduces postoperative delirium after joint replacement in elderly patients with mild cognitive impairment

BACKGROUND AND AIMS

Postoperative delirium (POD) is a common and serious surgical complication among the elderly, especially in those with amnestic mild cognitive impairment (aMCI). Dexmedetomidine (DEX) is neuroprotective for delirium. In this study, we determined the effect of intravenously administered DEX during general anesthesia on POD in elderly aMCI patients undergoing elective hip joint or knee joint or shoulder joint replacement surgery.

METHODS

This was a prospective, randomized parallel-group study of aMCI (n = 80) and normal elderly patients (n = 120). Prior to surgery, all subjects underwent neuropsychological assessment and were assigned to one of four groups: the aMCI DEX group (MD group, n = 40), the aMCI normal saline group (MN group, n = 40), the control DEX group (CD group, n = 60), and the control normal saline group (CN group, n = 60). The confusion assessment method was used to screen POD on postoperative days 1, 3, and 7.

RESULTS

We found patients age was positively correlated with POD incidence in the MN group (p < 0.05) but not in the CN group (p < 0.05). DEX treatment significantly decreased POD incidence in both control and aMCI groups relative to their respective placebo groups (all p < 0.05). The fraction of patients whose normal cognitive function was not restored by day 7 after surgery was significantly higher in the MN group than the MD and CN groups (all p < 0.05).

CONCLUSIONS

These findings suggested that DEX treatment during surgery significantly reduced POD incidence in both normal and aMCI elderly patients, suggesting that it may be an effective option for the prevention of POD.

Safety and short-term outcomes of endoscopic submucosal dissection for early gastric cancer in elderly patients

BACKGROUND AND STUDY AIMS

Endoscopic submucosal dissection (ESD) has become widely accepted as a minimally invasive treatment for early gastric cancer (EGC), and opportunities to use ESD to treat EGC in elderly patients are increasing. The objective of this study was to elucidate the safety and efficacy of ESD in elderly patients.

PATIENTS AND METHODS

Between April 2006 and March 2013, a total of 892 patients with EGC were prospectively recruited to undergo ESD according to definite inclusion criteria. The short-term outcomes and incidence of complications in 345 of these patients who were 75 years of age or older (elderly group) were compared with the short-term outcomes and incidence of complications in the remaining 547 patients (non-elderly group). Factors associated with the occurrence of pneumonia and delirium were also investigated.

RESULTS

The R0 resection rate did not differ between the two groups (96.2 % in the elderly group vs. 96.7 % in the non-elderly group; P = 0.65). The incidence of pneumonia (7.5 % vs. 1.8 %; P < 0.01) and incidence of delirium (10.1 % vs. 1.1 %; P < 0.01) were significantly higher in the elderly group. The incidence of post-ESD bleeding and incidence of perforation were similar in the two groups. No emergency surgery was required, but one patient in the non-elderly group died of aspiration pneumonia. On multivariate analysis, age 75 years or older, cerebrovascular disease, chronic obstructive pulmonary disease, delirium, and remnant stomach or gastric tube were independent risk factors for pneumonia, and age 75 years or older, diabetes, dementia, and pneumonia were independent risk factors for delirium.

CONCLUSION

ESD for EGC was feasible for elderly patients in good condition. However, pneumonia and delirium may develop more frequently after ESD in elderly patients with co-morbidities.

Neurologists as primary palliative care providers: Communication and practice approaches

PURPOSE OF REVIEW

To present current knowledge and recommendations regarding communication tasks and practice approaches for neurologists as they practice primary palliative care, including discussing serious news, managing symptoms, aligning treatment with patient preferences, introducing hospice/terminal care, and using the multiprofessional approach.

RECENT FINDINGS

Neurologists receive little formal palliative care training yet often need to discuss prognosis in serious illness, manage intractable symptoms in chronic progressive disease, and alleviate suffering for patients and their families. Because patients with neurologic disorders often have major cognitive impairment, physical impairment, or both, with an uncertain prognosis, their palliative care needs are particularly challenging and they remain largely uncharacterized and often unmanaged.

SUMMARY

We provide an overview of neuropalliative care as a fundamental skill set for all neurologists.

Impact of Sedation on Cognitive Function in Mechanically Ventilated Patients

The practice of sedation dosing strategy in mechanically ventilated patient has a profound effect on cognitive function. We conducted a comprehensive review of outcome of sedation on mental health function in critically ill patients on mechanical ventilation in the intensive care unit (ICU). We specifically evaluated current sedative dosing strategy and the development of delirium, post-traumatic stress disorders (PTSDs) and agitation. Based on this review, heavy dosing sedation strategy with benzodiazepines contributes to cognitive dysfunction. However, outcome for mental health dysfunction is mixed in regard to newer sedatives agents such as dexmedetomidine and propofol. Moreover, studies that examine the impact of sedatives for persistence of PTSD/delirium and its long-term cognitive and functional outcomes for post-ICU patients are frequently underpowered. Most studies suffer from low sample sizes and methodological variations. Therefore, larger randomized controlled trials are needed to properly assess the impact of sedation dosing strategy on cognitive function.

Altered mental status in the neurocritical care unit

Altered mental status is a common pathological entity in critically ill patients and particularly in those with preexisting cerebral injury. In the neurological critical care unit, the prevalence of altered mental status is especially high because of the inherent nervous system disease of these patients. Altered mental status can be crudely divided into encephalopathy and delirium. Although often used interchangeably, the 2 pathological entities have subtle differences in etiology and presentation. This is a review of delirium and encephalopathy in the neurological critical care unit.

Delirium diagnosis, screening and management

Purpose of review

Our review focuses on recent developments across many settings regarding the diagnosis, screening and management of delirium, so as to inform these aspects in the context of palliative and supportive care.

Recent findings

Delirium diagnostic criteria have been updated in the long-awaited Diagnostic Statistical Manual of Mental Disorders, fifth edition. Studies suggest that poor recognition of delirium relates to its clinical characteristics, inadequate interprofessional communication and lack of systematic screening. Validation studies are published for cognitive and observational tools to screen for delirium. Formal guidelines for delirium screening and management have been rigorously developed for intensive care, and may serve as a model for other settings. Given that palliative sedation is often required for the management of refractory delirium at the end of life, a version of the Richmond Agitation-Sedation Scale, modified for palliative care, has undergone preliminary validation.

Summary

Although formal systematic delirium screening with brief but sensitive tools is strongly advocated for patients in palliative and supportive care, it requires critical evaluation in terms of clinical outcomes, including patient comfort. Randomized controlled trials are needed to inform the development of guidelines for the management of delirium in this setting.

Neurocognitive dysfunction risk alleviation with the use of dexmedetomidine in perioperative conditions or as ICU sedation: a meta-analysis

Many studies have reported the beneficial effects of dexmedetomidine on postoperative neurocognitive function but overall evidence is not as clear. We examined this conundrum by meta-analyzing studies that used dexmedetomidine in perioperative conditions or as intensive care unit (ICU) sedation and utilized reliable neurocognitive assessment tests. The literature search was undertaken across several electronic databases including EBSCO, Embase, Google Scholar, Ovid SP, PubMed, Scopus, and Web of Science. Literature search was carried out across several electronic databases and relevant studies were selected after following précised inclusion criteria. Meta-analysis of risk differences (RDs) was carried out and subgroup analyses were performed. Twenty studies were selected from which data of 2612 individuals were used. Initial dexmedetomidine dose was 0.68 ± 0.27 and maintenance dose was 0.54 ± 0.32 in the trials. Dexmedetomidine treatment was associated with significantly lower risk of postoperative/postanesthesia neurocognitive dysfunction both in comparison with saline-treated controls (RD [95% confidence interval, CI]: -0.17 (-0.30, -0.04); P = 0.008) and comparators (-0.16 [-0.28, -0.04]; P = 0.009). In the subgroups analyses, however, there was no significant differences between dexmedetomidine and controls/comparators when studies with confusion assessment method for ICU only (RD: -0.10 (-0.22, 0.02); P = 0.1) or midazolam as comparator only (RD: -0.26 (-0.60, 0.07); P = 0.12) were meta-analyzed. Dexmedetomidine use in the perioperative conditions or as ICU sedation is associated with lower risk of neurocognitive dysfunction. There can be some impact of neurocognitive assessment method, drug interactions, and clinical heterogeneity on the overall outcomes of this meta-analysis.

A case report of dexmedetomidine used to treat intractable pain and delirium in a tertiary palliative care unit

BACKGROUND

This case report describes an end-stage cancer patient with intractable neuropathic pain and delirium who was successfully managed during the last 3 weeks of her life with a continuous subcutaneous infusion of dexmedetomidine.

CASE PRESENTATION

A 55-year-old woman with locally advanced cervical cancer and uncontrolled pelvic pain was admitted to a tertiary palliative care unit for pain management. As her disease progressed, the patient's pelvic pain intensified despite treatment with methadone, gabapentin, ketamine, and hydromorphone administered by continuous subcutaneous infusion plus frequent breakthrough doses of hydromorphone and sufentanil.

CASE MANAGEMENT

A continuous subcutaneous infusion of dexmedetomidine was started and titrated to achieve pain relief.

CASE OUTCOME

The patient's pain and delirium cleared. The treatment was successful in fulfilling the patient's goal of care: not to be deeply and continuously sedated, but to be rousable and of clear mind while still having good pain control.

CONCLUSION

Dexmedetomidine is a potentially useful medication for the targeted treatment of intractable pain and delirium in the tertiary palliative care environment. Future research is required to compare dexmedetomidine infusion to standard treatment with midazolam infusion for treatment of intractable symptoms in the palliative care environment.

The protocol of the Oslo Study of Clonidine in Elderly Patients with Delirium; LUCID: a randomised placebo-controlled trial

Background

Delirium affects 15% of hospitalised patients and is linked with poor outcomes, yet few pharmacological treatment options exist. One hypothesis is that delirium may in part result from exaggerated and/or prolonged stress responses. Dexmedetomidine, a parenterally-administered alpha2-adrenergic receptor agonist which attenuates sympathetic nervous system activity, shows promise as treatment in ICU delirium. Clonidine exhibits similar pharmacodynamic properties and can be administered orally. We therefore wish to explore possible effects of clonidine upon the duration and severity of delirium in general medical inpatients.

Methods/Design

The Oslo Study of Clonidine in Elderly Patients with Delirium (LUCID) is a randomised, placebo-controlled, double-blinded, parallel group study with 4-month prospective follow-up. We will recruit 100 older medical inpatients with delirium or subsyndromal delirium in the acute geriatric ward. Participants will be randomised to oral clonidine or placebo until delirium free for 2 days (Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria), or after a maximum of 7 days treatment. Assessment of haemodynamics (blood pressure, heart rate and electrocardiogram) and delirium will be performed daily until discharge or a maximum of 7 days after end of treatment. The primary endpoint is the trajectory of delirium over time (measured by Memorial Delirium Assessment Scale). Secondary endpoints include the duration of delirium, use of rescue medication for delirium, pharmacokinetics and pharmacodynamics of clonidine, cognitive function after 4 months, length of hospital stay and need for institutionalisation.

Discussion

LUCID will explore the efficacy and safety of clonidine for delirium in older medical inpatients.

Trial registration

ClinicalTrials.gov NCT01956604. EudraCT Number: 2013-000815-26

Is it prime time for alpha2-adrenocepter agonists in the treatment of withdrawal syndromes?

The need to treat withdrawal syndromes is a common occurrence in outpatient, inpatient ward, and intensive care unit (ICU) settings. A PubMed and Google Scholar search using alpha2-adrenoreceptor agonist (A2AA), specific A2AA agents, withdrawal syndrome and nicotine, and alcohol and opioid withdrawal terms was performed. A2AA agents appear to be able to modulate many of the signs and symptoms of significant withdrawal syndromes but are also capable of significant side effects, which can limit clinical use. Non-opioid oral A2AA agent use for opioid withdrawal has been well established. Pharmacologic combination therapy that utilizes A2AA agents for withdrawal syndromes appears promising but requires further formal testing to better define which other agents, under what condition(s), and at what A2AA doses are needed. The A2AA dexmedetomidine may be useful as an adjunctive agent in treating severe alcohol withdrawal syndromes in the ICU. In general, the current data does not support the routine use of A2AA as the primary or sole agent to treat ethanol/alcohol or nicotine withdrawal syndromes. Specific A2AA agents such as lofexidine has been shown to have a primary role in non-opioid-based treatment of opioid withdrawal syndrome and dexmedetomidine in combination with benzodiazepines has been shown to have potential in the treatment of severe ICU-based alcohol withdrawal syndrome.

Dexmedetomidine reduces the risk of delirium, agitation and confusion in critically Ill patients: a meta-analysis of randomized controlled trials

OBJECTIVES

Delirium frequently is observed in critically ill patients in the intensive care unit (ICU) and is associated strongly with a poor outcome. Dexmedetomidine seems to reduce time to extubation and ICU stay without detrimental effects on mortality. The objective of the authors' study was to evaluate the effect of this drug on delirium, agitation, and confusion in the ICU setting.

DESIGN

Meta-analysis of all the randomized clinical trials ever performed on dexmedetomidine versus any comparator in the ICU setting.

SETTING

Intensive care units.

PARTICIPANTS

Critically ill patients.

INTERVENTIONS

None

MEASUREMENTS AND MAIN RESULTS

Pertinent studies were independently searched in BioMedCentral, PubMed, Embase, and the Cochrane Central Register of clinical trials. Primary endpoint was the rate of delirium, including the adverse events, agitation and confusion. The 13 included manuscripts (14 trials) randomized 3,029 patients. Overall analysis showed that the use of dexmedetomidine was associated with significant reductions in the incidence of delirium, agitation and confusion (298/1,565 [19%] in the dexmedetomidine group v 337/1,464 [23%] in the control group, RR = 0.68 [0.49 to 0.96], p = 0.03). Results were confirmed in subanalyses performed on patients undergoing noninvasive ventilation (1/53 [2%] in the dexmedetomidine group v 7/49 [14%] in the control group, RR=0.18 [0.03 to 1.01], p = 0.05), receiving midazolam as a comparator (268/1,164 [23%] in the dexmedetomidine group v 277/1,025 [27%] in the control group, RR = 0.68 [0.47 to 1.00], p = 0.05) and in general ICU setting patients (204/688 [30%] in the dexmedetomidine group v 204/560 [36%] in the control group, RR = 0.68 [0.45 to 0.81], p < 0.01).

CONCLUSIONS

This meta-analysis of randomized controlled studies suggests that dexmedetomidine could help to reduce delirium in critically ill patients.

Early Pharmacological Treatment of Delirium May Reduce Physical Restraint Use

Introduction: Evidence surrounding pharmacological treatment of delirium is limited. The negative impact of physical restraints on patient outcomes in the intensive care unit (ICU), however, is well published. The objective of this study was to evaluate whether initiating pharmacologic delirium treatment within 24 hours of a positive screen reduces the number of days in physical restraints and improves patient outcomes compared with delayed or no treatment. Methods: Patients from a mixed ICU with a documented positive delirium score using the Intensive Care Delirium Screening Checklist were retrospectively grouped based on having received pharmacologic treatment within 24 hours of the first positive screen or not. Primary end points were number of days spent in physical restraints and time to extubation after delirium onset. Secondary end points included hospital and ICU length of stay (LOS) and survival to discharge. Results: Two hundred intubated patients were either pharmacologically treated (n = 98) or not treated (n = 102) within 24 hours of the first positive delirium score. Patients receiving treatment spent a shorter median time in restraints compared with patients who were not treated (3 vs 6 days; P < .001), and had a shorter median time to extubation (3 vs 6.5 days; P < .001). The treatment group also experienced a shorter ICU LOS (9.5 vs 16 days; P < .001) and hospital LOS (14.5 vs 22 days; P < .001) compared with the no-treatment group. Conclusions: Delirious patients who received pharmacological treatment within 24 hours of the first positive screen spent fewer days in physical restraints and less time receiving mechanical ventilation compared with those who did not. Although delirium management is multifactorial, early pharmacological therapy may benefit patients diagnosed with delirium.