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Taylor J, Wilcox ME. Physical and Cognitive Impairment in Acute Respiratory Failure. Crit Care Clin 2024; 40:429-450. [PMID: 38432704 DOI: 10.1016/j.ccc.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Recent research has brought renewed attention to the multifaceted physical and cognitive dysfunction that accompanies acute respiratory failure (ARF). This state-of-the-art review provides an overview of the evidence landscape encompassing ARF-associated neuromuscular and neurocognitive impairments. Risk factors, mechanisms, assessment tools, rehabilitation strategies, approaches to ventilator liberation, and interventions to minimize post-intensive care syndrome are emphasized. The complex interrelationship between physical disability, cognitive dysfunction, and long-term patient-centered outcomes is explored. This review highlights the need for comprehensive, multidisciplinary approaches to mitigate morbidity and accelerate recovery.
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Affiliation(s)
- Jonathan Taylor
- Division of Pulmonary, Critical Care and Sleep Medicine, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1232, New York, NY 10029, USA
| | - Mary Elizabeth Wilcox
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada.
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Wen J, Ding X, Liu C, Jiang W, Xu Y, Wei X, Liu X. A comparation of dexmedetomidine and midazolam for sedation in patients with mechanical ventilation in ICU: A systematic review and meta-analysis. PLoS One 2023; 18:e0294292. [PMID: 37963140 PMCID: PMC10645332 DOI: 10.1371/journal.pone.0294292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 10/28/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND The use of dexmedetomidine rather than midazolam may improve ICU outcomes. We summarized the available recent evidence to further verify this conclusion. METHODS An electronic search of PubMed, Medline, Embase, Cochrane Library, and Web of Science was conducted. Risk ratios (RR) were used for binary categorical variables, and for continuous variables, weighted mean differences (WMD) were calculated, the effect sizes are expressed as 95% confidence intervals (CI), and trial sequential analysis was performed. RESULTS 16 randomized controlled trials were enrolled 2035 patients in the study. Dexmedetomidine as opposed to midazolam achieved a shorter length of stay in ICU (MD = -2.25, 95%CI = -2.94, -1.57, p<0.0001), lower risk of delirium (RR = 0.63, 95%CI = 0.50, 0.81, p = 0.0002), and shorter duration of mechanical ventilation (MD = -0.83, 95%CI = -1.24, -0.43, p<0.0001). The association between dexmedetomidine and bradycardia was also found to be significant (RR 2.21, 95%CI 1.31, 3.73, p = 0.003). We found no difference in hypotension (RR = 1.44, 95%CI = 0.87, 2.38, P = 0.16), mortality (RR = 1.02, 95%CI = 0.83, 1.25, P = 0.87), neither in terms of adverse effects requiring intervention, hospital length of stay, or sedation effects. CONCLUSIONS Combined with recent evidence, compared with midazolam, dexmedetomidine decreased the risk of delirium, mechanical ventilation, length of stay in the ICU, as well as reduced patient costs. But dexmedetomidine could not reduce mortality and increased the risk of bradycardia.
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Affiliation(s)
- Jiaxuan Wen
- School of Nursing, Weifang Medical University, Weifang, P. R. China
| | - Xueying Ding
- School of Nursing, Weifang Medical University, Weifang, P. R. China
| | - Chen Liu
- School of Nursing, Weifang Medical University, Weifang, P. R. China
| | - Wenyu Jiang
- School of Public Health, Weifang Medical University, Weifang, P. R. China
| | - Yingrui Xu
- School of Nursing, Weifang Medical University, Weifang, P. R. China
| | - Xiuhong Wei
- School of Nursing, Weifang Medical University, Weifang, P. R. China
| | - Xin Liu
- Department of Neonatology, Weifang People’s Hospital, P. R. China
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3
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Liu Y, Peng Z, Liu S, Yu X, Zhu D, Zhang L, Wen J, An Y, Zhan L, Wang X, Kang Y, Pan A, Yan J, Zhang L, Liu F, Zeng J, Lin Q, Sun R, Yu J, Wang H, Yao L, Chen C, Liu N, Nie Y, Lyu J, Wu K, Wu J, Liu X, Guan X. Efficacy and Safety of Ciprofol Sedation in ICU Patients Undergoing Mechanical Ventilation: A Multicenter, Single-Blind, Randomized, Noninferiority Trial. Crit Care Med 2023; 51:1318-1327. [PMID: 37272947 PMCID: PMC10497206 DOI: 10.1097/ccm.0000000000005920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To determine the effectiveness and safety of ciprofol for sedating patients in ICUs who required mechanical ventilation (MV). DESIGN A multicenter, single-blind, randomized, noninferiority trial. SETTING Twenty-one centers across China from December 2020 to June 2021. PATIENTS A total of 135 ICU patients 18 to 80 years old with endotracheal intubation and undergoing MV, who were expected to require sedation for 6-24 hours. INTERVENTIONS One hundred thirty-five ICU patients were randomly allocated into ciprofol ( n = 90) and propofol ( n = 45) groups in a 2:1 ratio. Ciprofol or propofol were IV infused at loading doses of 0.1 mg/kg or 0.5 mg/kg, respectively, over 4 minutes ± 30 seconds depending on the physical condition of each patient. Ciprofol or propofol were then immediately administered at an initial maintenance dose of 0.3 mg/kg/hr or 1.5 mg/kg/hr, to achieve the target sedation range of Richmond Agitation-Sedation Scale (+1 to -2). Besides, continuous IV remifentanil analgesia was administered (loading dose: 0.5-1 μg/kg, maintenance dose: 0.02-0.15 μg/kg/min). MEASUREMENTS AND MAIN RESULTS Of the 135 patients enrolled, 129 completed the study. The primary endpoint-sedation success rates of ciprofol and propofol groups were 97.7% versus 97.8% in the full analysis set (FAS) and were both 100% in per-protocol set (PPS). The noninferiority margin was set as 8% and confirmed with a lower limit of two-sided 95% CI for the inter-group difference of -5.98% and -4.32% in the FAS and PPS groups. Patients who received ciprofol had a longer recovery time ( p = 0.003), but there were no differences in the remaining secondary endpoints (all p > 0.05). The occurrence rates of treatment-emergent adverse events (TEAEs) or drug-related TEAEs were not significantly different between the groups (all p > 0.05). CONCLUSIONS Ciprofol was well tolerated, with a noninferior sedation profile to propofol in Chinese ICU patients undergoing MV for a period of 6-24 hours.
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Affiliation(s)
- Yongjun Liu
- Department of Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhiyong Peng
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Songqiao Liu
- Department of Critical Care Medicine, Zhongda Hospital, Southeast University, Nanjing, China
| | - Xiangyou Yu
- Department of Critical Care Medicine, The First Affiliated Hospital of Xinjiang Medical University, Ulumuqi, China
| | - Duming Zhu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Linlin Zhang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jianli Wen
- Department of Critical Care Medicine, The First People's Hospital of Zunyi City, Zunyi, China
| | - Youzhong An
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | - Liying Zhan
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, China
| | - Xiaochuang Wang
- Department of Critical Care Medicine, The Second Affiliated Hospital of Xi'an Jiaotong University (Xibei Hospital), Xi'an, China
| | - Yan Kang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Aijun Pan
- Department of Critical Care Medicine, The First Affiliated Hospital of USTC, Anhui Provincial Hospital, Hefei, China
| | - Jing Yan
- Department of Critical Care Medicine, Zhejiang Hospital, Hangzhou, China
| | - Lina Zhang
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Fengming Liu
- Department of Critical Care Medicine, The First People's Hospital of Nanning, Nanning, China
| | - Jun Zeng
- Department of Critical Care Medicine, Guangzhou First People's Hospital, Guangzhou, China
| | - Qinhan Lin
- Department of Critical Care Medicine, Qingyuan People's Hospital, The Sixth Affiliated Hospital of Guangzhou Medical University, Qingyuan, China
| | - Renhua Sun
- Department of Critical Care Medicine, Zhejiang Provincial People's Hospital, Hangzhou, China
| | - Jiangquan Yu
- Department of Critical Care Medicine, Northern Jiangsu People's Hospital, Yangzhou, China
| | - Huaxue Wang
- Department of Critical Care Medicine, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Li Yao
- Department of Critical Care Medicine, The Second People's Hospital of Hefei, Hefei, China
| | - Chuanxi Chen
- Department of Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ning Liu
- Department of Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yao Nie
- Department of Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jie Lyu
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | - Kun Wu
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | - Jianfeng Wu
- Department of Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiao Liu
- Department of Medicine, Haisco Pharmaceutical Group Co., Ltd, Shanghai, China
| | - Xiangdong Guan
- Department of Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Heybati K, Zhou F, Ali S, Deng J, Mohananey D, Villablanca P, Ramakrishna H. Outcomes of dexmedetomidine versus propofol sedation in critically ill adults requiring mechanical ventilation: a systematic review and meta-analysis of randomised controlled trials. Br J Anaesth 2022; 129:515-526. [PMID: 35961815 DOI: 10.1016/j.bja.2022.06.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 06/02/2022] [Accepted: 06/19/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Guidelines have recommended the use of dexmedetomidine or propofol for sedation after cardiac surgery, and propofol monotherapy for other patients. Further outcome data are required for these drugs. METHODS This systematic review and meta-analysis was prospectively registered on PROSPERO. The primary outcome was ICU length of stay. Secondary outcomes included duration of mechanical ventilation, ICU delirium, all-cause mortality, and haemodynamic effects. Intensive care patients were analysed separately as cardiac surgical, medical/noncardiac surgical, those with sepsis, and patients in neurocritical care. Subgroup analyses based on age and dosage were conducted. RESULTS Forty-one trials (N=3948) were included. Dexmedetomidine did not significantly affect ICU length of stay across any ICU patient subtype when compared with propofol, but it reduced the duration of mechanical ventilation (mean difference -0.67 h; 95% confidence interval: -1.31 to -0.03 h; P=0.041; low certainty) and the risk of ICU delirium (risk ratio 0.49; 95% confidence interval: 0.29-0.87; P=0.019; high certainty) across cardiac surgical patients. Dexmedetomidine was also associated with a greater risk of bradycardia across a variety of ICU patients. Subgroup analyses revealed that age might affect the incidence of haemodynamic side-effects and mortality among cardiac surgical and medical/other surgical patients. CONCLUSION Dexmedetomidine did not significantly impact ICU length of stay compared with propofol, but it significantly reduced the duration of mechanical ventilation and the risk of delirium in cardiac surgical patients. It also significantly increased the risk of bradycardia across ICU patient subsets.
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Affiliation(s)
- Kiyan Heybati
- Mayo Clinic Alix School of Medicine, Mayo Clinic - Rochester, Rochester, MN, USA
| | - Fangwen Zhou
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Saif Ali
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada; Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jiawen Deng
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada; Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | | | | | - Harish Ramakrishna
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic - Rochester, Rochester, MN, USA
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5
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Lewis K, Alshamsi F, Carayannopoulos KL, Granholm A, Piticaru J, Al Duhailib Z, Chaudhuri D, Spatafora L, Yuan Y, Centofanti J, Spence J, Rochwerg B, Perri D, Needham DM, Holbrook A, Devlin JW, Nishida O, Honarmand K, Ergan B, Khorochkov E, Pandharipande P, Alshahrani M, Karachi T, Soth M, Shehabi Y, Møller MH, Alhazzani W. Dexmedetomidine vs other sedatives in critically ill mechanically ventilated adults: a systematic review and meta-analysis of randomized trials. Intensive Care Med 2022; 48:811-840. [PMID: 35648198 DOI: 10.1007/s00134-022-06712-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 04/18/2022] [Indexed: 12/17/2022]
Abstract
Conventional gabaminergic sedatives such as benzodiazepines and propofol are commonly used in mechanically ventilated patients in the intensive care unit (ICU). Dexmedetomidine is an alternative sedative that may achieve lighter sedation, reduce delirium, and provide analgesia. Our objective was to perform a comprehensive systematic review summarizing the large body of evidence, determining if dexmedetomidine reduces delirium compared to conventional sedatives. We searched MEDLINE, EMBASE, CENTRAL, ClinicalTrials.gov and the WHO ICTRP from inception to October 2021. Independent pairs of reviewers identified randomized clinical trials comparing dexmedetomidine to other sedatives for mechanically ventilated adults in the ICU. We conducted meta-analyses using random-effects models. The results were reported as relative risks (RRs) for binary outcomes and mean differences (MDs) for continuous outcomes, with corresponding 95% confidence intervals (CIs). In total, 77 randomized trials (n = 11,997) were included. Compared to other sedatives, dexmedetomidine reduced the risk of delirium (RR 0.67, 95% CI 0.55 to 0.81; moderate certainty), the duration of mechanical ventilation (MD - 1.8 h, 95% CI - 2.89 to - 0.71; low certainty), and ICU length of stay (MD - 0.32 days, 95% CI - 0.42 to - 0.22; low certainty). Dexmedetomidine use increased the risk of bradycardia (RR 2.39, 95% CI 1.82 to 3.13; moderate certainty) and hypotension (RR 1.32, 95% CI 1.07 to 1.63; low certainty). In mechanically ventilated adults, the use of dexmedetomidine compared to other sedatives, resulted in a lower risk of delirium, and a modest reduction in duration of mechanical ventilation and ICU stay, but increased the risks of bradycardia and hypotension.
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Affiliation(s)
- Kimberley Lewis
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada. .,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada.
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Alain, United Arab Emirates
| | - Kallirroi Laiya Carayannopoulos
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada
| | - Anders Granholm
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Joshua Piticaru
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada
| | - Zainab Al Duhailib
- Department of Critical Care Medicine, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Dipayan Chaudhuri
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Laura Spatafora
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada
| | - Yuhong Yuan
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Canada
| | - John Centofanti
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada.,Department of Anesthesia, McMaster University, Hamilton, Canada
| | - Jessica Spence
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada.,Department of Anesthesia, McMaster University, Hamilton, Canada.,Population Health Research Institute, McMaster University, Hamilton, Canada
| | - Bram Rochwerg
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Dan Perri
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada.,Division of Clinical Pharmacology and Toxicology, McMaster University, Hamilton, Canada
| | - Dale M Needham
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, USA.,Armstrong Institute for Patient Safety and Quality, John Hopkins University, Baltimore, USA.,Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, USA.,Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Anne Holbrook
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada.,Division of Clinical Pharmacology and Toxicology, McMaster University, Hamilton, Canada
| | - John W Devlin
- School of Pharmacy, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Northeastern University, Boston, MA, USA
| | - Osamu Nishida
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Aichi, Japan
| | - Kimia Honarmand
- Division of Critical Care Medicine, Department of Medicine, Western University, London, Canada
| | - Begüm Ergan
- Department of Pulmonary and Critical Care, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Eugenia Khorochkov
- Department of Medical Imaging, Memorial University of Newfoundland, St. John's, Canada
| | - Pratik Pandharipande
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, USA
| | - Mohammed Alshahrani
- Department of Emergency and Critical Care, College of Medicine, Imam Abdulrahman Ben Faisal University, Al Khobar, Kingdom of Saudi Arabia
| | - Tim Karachi
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada
| | - Mark Soth
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada
| | - Yahya Shehabi
- Department of Intensive Care, Monash Health School of Clinical Sciences, The School of Clinical Medicine, University of New South Wales, Clayton, VIC 3168, Randwick, 2031, Australia
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Waleed Alhazzani
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
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Zhou Y, Yang J, Wang B, Wang P, Wang Z, Yang Y, Liang G, Jing X, Jin X, Zhang Z, Deng Y, Hu C, Liao X, Yin W, Tang Z, Tian Y, Tao L, Kang Y. Sequential use of midazolam and dexmedetomidine for long-term sedation may reduce weaning time in selected critically ill, mechanically ventilated patients: a randomized controlled study. Crit Care 2022; 26:122. [PMID: 35505432 PMCID: PMC9066885 DOI: 10.1186/s13054-022-03967-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 03/28/2022] [Indexed: 02/08/2023] Open
Abstract
Background Current sedatives have different side effects in long-term sedation. The sequential use of midazolam and dexmedetomidine for prolonged sedation may have distinct advantages. We aimed to evaluate the efficacy and safety of the sequential use of midazolam and either dexmedetomidine or propofol, and the use of midazolam alone in selected critically ill, mechanically ventilated patients. Methods This single-center, randomized controlled study was conducted in medical and surgical ICUs in a tertiary, academic medical center. Patients enrolled in this study were critically ill, mechanically ventilated adult patients receiving midazolam, with anticipated mechanical ventilation for ≥ 72 h. They passed the spontaneous breathing trial (SBT) safety screen, underwent a 30-min-SBT without indication for extubation and continued to require sedation. Patients were randomized into group M-D (midazolam was switched to dexmedetomidine), group M-P (midazolam was switched to propofol), and group M (sedation with midazolam alone), and sedatives were titrated to achieve the targeted sedation range (RASS − 2 to 0). Results Total 252 patients were enrolled. Patients in group M-D had an earlier recovery, faster extubation, and more percentage of time at the target sedation level than those in group M-P and group M (all P < 0.001). They also experienced less weaning time (25.0 h vs. 49.0 h; HR1.47, 95% CI 1.05 to 2.06; P = 0.025), and a lower incidence of delirium (19.5% vs. 43.8%, P = 0.002) than patients in group M. Recovery (P < 0.001), extubation (P < 0.001), and weaning time (P = 0.048) in group M-P were shorter than in group M, while the acquisition cost of sedative drug was more expensive than other groups (both P < 0.001). There was no significant difference in adverse events among these groups (all P > 0.05). Conclusions The sequential use of midazolam and dexmedetomidine was an effective and safe sedation strategy for long-term sedation and could provide clinically relevant benefits for selected critically ill, mechanically ventilated patients. Trial registration NCT02528513. Registered August 19, 2015.
Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03967-5.
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Affiliation(s)
- Yongfang Zhou
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Jie Yang
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Bo Wang
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Peng Wang
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Zhen Wang
- Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan, China
| | - Yunqin Yang
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Guopeng Liang
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Xiaorong Jing
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Xiaodong Jin
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Zhongwei Zhang
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Yiyun Deng
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Chenggong Hu
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Xuelian Liao
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Wanhong Yin
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Zhihong Tang
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Yongming Tian
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Liyuan Tao
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, 100191, China
| | - Yan Kang
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, 610041, Sichuan, China.
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7
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Oxlund J, Toft P, Sörberg M, Knudsen T, Jørgen Jennum P. Dexmedetomidine and sleep quality in mechanically ventilated critically ill patients: study protocol for a randomised placebo-controlled trial. BMJ Open 2022; 12:e050282. [PMID: 35351693 PMCID: PMC8961120 DOI: 10.1136/bmjopen-2021-050282] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 03/03/2022] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Sleep deprivation, which is a common complication in the intensive care unit (ICU), is associated with delirium and increased mortality. Sedation with gamma-aminobutyric acid agonists (propofol, benzodiazepine) results in significant disturbance of the sleep architecture. Dexmedetomidine is a lipophilic imidazole with an affinity for α2-adrenoceptors and it has sedative and analgesic properties. It has been reported to enhance sleep efficiency, thus sedate while preserving sleep architecture. METHODS AND ANALYSIS Thirty consecutive patients are planned to be included, at the Department of Anesthesia and Intensive Care at the Hospital of Southwest Jutland, Denmark. The study is a double-blinded, randomised, controlled trial with two parallel groups (2:1 allocation ratio). Screening and inclusion will be done on day 1 from 8:00 to 16:00. Two 16 hours PSG (polysomnography) recording will be done starting at 16:00 on day 1 and day 2. Randomisation is performed if the first recording is of acceptable quality, otherwise the patient is excluded before randomisation. Dexmedetomidine/placebo will be administered during the second recording from 18:00 on day 2 to 6:00 on day 3. PRIMARY ENDPOINT Improvement of total sleep time and sleep quality of clinical significance determined by PSG. SECONDARY ENDPOINTS Sleep phases determined by PSG. Daytime function and delirium determined by Confusion Assessment Method-ICU. Alertness and wakefulness determined by Richmonde Agitation Sedation Scale. The objective is to compare the effect of dexmedetomidine versus placebo on sleep quality in critical ill mechanically ventilated patients. ETHICS AND DISSEMINATION The trial investigate the potential benefit of dexmedetomidine on clinically relevant endpoints. If a beneficial effect is shown, this would have a large impact on future treatment of mechanically ventilated critically ill patients. Publication in peer-reviewed journal are plannedand the study has been approved by the National Committee on Health Research Ethics (ID:S-20180214). TRIAL REGISTRATION NUMBER EudraCT (2017-001612-11DK) and Danish National Committee on Health Research Ethics (ID:S-20180214). The study related to pre-results.
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Affiliation(s)
- Jakob Oxlund
- Anaesthesia and Intensive Care, Hospital of South West Jutland, Esbjerg, Denmark
| | - Palle Toft
- Anaesthesia and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Mikael Sörberg
- Departments of Infectious Diseases, Karolinska University Hospital, Solna, Sweden
| | - Torben Knudsen
- Gastroenterology, Hospital South West Jutland, Esbjerg, Denmark
| | - Poul Jørgen Jennum
- Danish Center for Sleep Medicine. Department of Clinical Neurophysiology, Rigshospital - Glostrup Hostpital, Copenhagen, Denmark
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Song X, Wang F, Dong R, Zhu K, Wang C. Efficacy and Safety of Remimazolam Tosilate Combined With Esketamine for Analgesic Sedation in Mechanically Ventilated ICU Patients: A Single-Arm Clinical Study Protocol. Front Med (Lausanne) 2022; 9:832105. [PMID: 35372406 PMCID: PMC8968316 DOI: 10.3389/fmed.2022.832105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 02/23/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionPatients in the intensive care unit (ICU) frequently experience increased heart rate, blood pressure, and respiration rate as a product of anxiety and restlessness about their condition and treatments. Analgesia and sedation commonly involve benzodiazepines or opioids that lead to respiratory suppression and other adverse reactions. Remimazolam tosilate is a short-acting GABAA receptor agonist with reduced cardiovascular and respiratory inhibition compared to other commonly used benzodiazepines. Esketamine is a non-competitive N-methyl-D-aspartic acid (NMDA) receptor inhibitor that inhibits hyperalgesia and prolongs postoperative analgesia. It also reduces postoperative pain, delirium, and the use and acute tolerance of opioids. This study aims to assess the efficacy and safety of remimazolam tosilate combined with esketamine and sufentanil for sedation and analgesia in mechanically ventilated ICU patients.Methods and AnalysisThis prospective, single-arm, single-center, open-label clinical trial will be conducted from January 2022 to December 2023. The study will include 200 adult patients (≥ 18 years) from Shandong Provincial Hospital (affiliated with Shandong First Medical University) who are mechanically ventilated and admitted to the ICU between 24 and 72 h from the time of ventilation and who are administered analgesia and sedatives. Patients will undergo arterial blood gas analysis before administration. Remimazolam tosilate (0.2 mg/kg) will be injected intravenously within 30 s, followed by continuous infusion at a rate of 0.1 to 0.3 mg/kg/h via micropump. Esketamine (0.25 mg/kg) will be injected intravenously and maintained at 0.15 mg/kg/h, while sufentanil will be maintained at the rate of 0.1 to 0.2 μg/kg/h. The primary study outcome is the overall time required to maintain sedation. Secondary outcomes will include the total dosage used to reach the target sedation level, total mechanical ventilation time, awakening time, length of hospital stay, and incidence of cardiorespiratory-related adverse events and delirium. Adverse events (AEs) will be reported regardless of their relationship to the experimental drugs. AEs associated with adverse drug reactions will be classified as “affirmative correlation,” “possible relevance,” and “unable to determine.” A paired t-test or Wilcoxon signed-rank test will be used to compare the changes of observed indexes before and after treatment. A P < 0.05 will be considered statistically significant.Ethics and DisseminationThis study was approved by the local ethics committee at Shandong Provincial Hospital affiliatied to Shandong First Medical University. The results of this trial will be disseminated in peer-reviewed journals and at scientific conferences.Trial RegistrationThe trial is registered at the Chinese Clinical Trial Registry: ChiCTR2100053106; date of registration: 2021-11-10.
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Affiliation(s)
- Xuan Song
- Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Feng Wang
- Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Ranran Dong
- Dong E Hospital Affiliated to Shandong First Medical University, Liaocheng, China
| | - Kehan Zhu
- Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Chunting Wang
- Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- *Correspondence: Chunting Wang
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Xiao Z, He T, Jiang X, Xie F, Xia L, Zhou H. Effect of dexmedetomidine and propofol sedation on the prognosis of children with severe respiratory failure: a systematic review and meta-analysis. Transl Pediatr 2022; 11:260-269. [PMID: 35282029 PMCID: PMC8905109 DOI: 10.21037/tp-22-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 02/16/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND During treatment of acute respiratory failure (ARF) in children, sedation can reduce pain, improve tolerance, and reduce the incidence of adverse events, so selecting an appropriate sedation strategy is very important for improving prognosis and quality of life. Both dexmedetomidine and propofol have good sedative effects, so we investigated the application of these drugs in critically ill children with ARF by literature search and meta-analysis. METHODS We searched Embase, The Cochrane Library, PubMed, Ovid, Clinicaltrials.org, and Google Scholar for randomized controlled trials (RCTs) preferentially but not exclusively, and used RevMan 5.4 to analyze the screened literature. RESULTS Seven studies were included in the quantitative meta-analysis, with a total of 1,188 patients. There was no significant difference in the effect of dexmedetomidine and propofol on the duration of tracheal intubation in children with ARF [mean difference (MD) =-0.05; 95% confidence interval (CI): (-0.42, 0.32); Z=0.26; P=0.79], but dexmedetomidine sedation could reduce the intensive care unit (ICU) stay in children with ARF [MD =-0.62; 95% CI: (-1.08, -0.16); Z=2.65; P=0.008], and shorten the total hospital stay [MD =-1.94; 95% CI: (-2.63, -1.25); Z=5.48; P<0.00001]. There was no significant effect on mortality between the two groups [odds ratio (OR) =0.48; 95% CI: (0.19, 1.25); Z=1.50; P=0.13]. The incidence rate of bradycardia with dexmedetomidine sedation was higher than with propofol [OR =12.30; 95% CI: (2.28, 66.47); Z=2.92; P=0.004], and the incidence of hypotension was also higher [OR =6.99, 95% CI: (1.22, 39.86); Z=2.19; P=0.03]. DISCUSSION Compared with propofol, dexmedetomidine can significantly reduce the ICU stay and hospital stay. However, bradycardia and hypotension may occur during the use of dexmedetomidine, which requires close attention and timely intervention.
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Affiliation(s)
- Zizhen Xiao
- Department of Anesthesiology, The Central Hospital of Loudi, Loudi, China
| | - Tao He
- Department of Anesthesiology, The Central Hospital of Loudi, Loudi, China
| | - Xinping Jiang
- Department of Pediatrics, The Central Hospital of Loudi, Loudi, China
| | - Fengyong Xie
- Department of Anesthesiology, The Central Hospital of Loudi, Loudi, China
| | - Lihua Xia
- Department of Anesthesiology, The Central Hospital of Loudi, Loudi, China
| | - Huiming Zhou
- Department of Pediatrics, The Central Hospital of Loudi, Loudi, China
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Jiang X, Yan M. Comparing the impact on the prognosis of acute myocardial infarction critical patients of using midazolam, propofol, and dexmedetomidine for sedation. BMC Cardiovasc Disord 2021; 21:584. [PMID: 34876027 PMCID: PMC8650377 DOI: 10.1186/s12872-021-02385-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 11/04/2021] [Indexed: 11/10/2022] Open
Abstract
Background There are less studies focusing on the sedative therapy of acute myocardial infarction (AMI) critical patients. This study aim to compare the impact on the prognosis of AMI critical patients of using midazolam, propofol and dexmedetomidine. Methods We collected clinical data from the Medical Information Mart for Intensive Care III (MIMIC III) database. Data on 427 AMI patients with sedatives using were recruited from in Coronary Heart Disease Intensive Care unit (CCU). Results There were 143 patients in midazolam using, 272 in propofol using and 28 in dexmedetomidine using. The rate of 28-days mortality was 23.9% in overall patients. Through logistic regression analysis, only midazolam using was significant association with increased 28-days mortality when compared with propofol or dexmedetomidine using. In the subgroup analysis of age, gender, body mass index (BMI), white blood cell (WBC), beta-block, and revascularization, the association between midazolam using and increased 28-days mortality remained significantly. Through propensity score matching, 140 patients using midazolam and 192 using non-midazolam were successfully matched, the midazolam using presented with higher rate of CCU mortality, hospital mortality and 28-days mortality, longer of mechanical ventilation time and CCU duration. E-value analysis suggested robustness to unmeasured confounding. Conclusion Propofol or dexmedetomidine are preferred to be used in AMI critical patients for sedative therapy.
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Affiliation(s)
- Xiaowei Jiang
- Cardiology Department, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital Central South University, Changsha, Hunan, China
| | - Min Yan
- Internal Medicine Department, Changsha Medical University, Changsha, Hunan, China.
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Dexmedetomidine and paralytic exposure after damage control laparotomy: risk factors for delirium? Results from the EAST SLEEP-TIME multicenter trial. Eur J Trauma Emerg Surg 2021; 48:2097-2105. [PMID: 34807273 DOI: 10.1007/s00068-021-01813-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 10/25/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE To evaluate factors associated with ICU delirium in patients who underwent damage control laparotomy (DCL), with the hypothesis that benzodiazepines and paralytic infusions would be associated with increased delirium risk. We also sought to evaluate the differences in sedation practices between trauma (T) and non-trauma (NT) patients. METHODS We reviewed retrospective data from 15 centers in the EAST SLEEP-TIME registry admitted from January 1, 2017 to December 31, 2018. We included all adults undergoing DCL, regardless of diagnosis, who had completed daily Richmond Agitation Sedation Score (RASS) and Confusion Assessment Method-ICU (CAM-ICU). We excluded patients younger than 18 years, pregnant women, prisoners and patients who died before the first re-laparotomy. Data collected included age, number of re-laparotomies after DCL, duration of paralytic infusion, duration and type of sedative and opioid infusions as well as daily CAM-ICU and RASS scores to analyze risk factors associated with the proportion of delirium-free/coma-free ICU days during the first 30 days (DF/CF-ICU-30) using multivariate linear regression. RESULTS A 353 patient subset (73.2% trauma) from the overall 567-patient cohort had complete daily RASS and CAM-ICU data. NT patients were older (58.9 ± 16.0 years vs 40.5 ± 17.0 years [p < 0.001]). Mean DF/CF-ICU-30 days was 73.7 ± 96.4% for the NT and 51.3 ± 38.7% in the T patients (p = 0.030). More T patients were exposed to Midazolam, 41.3% vs 20.3% (p = 0.002). More T patients were exposed to Propofol, 91.0% vs 71.9% (p < 0.001) with longer infusion times in T compared to NT (71.2 ± 85.9 vs 48.9 ± 69.8 h [p = 0.017]). Paralytic infusions were also used more in T compared to NT, 34.8% vs 18.2% (p < 0.001). Using linear regression, dexmedetomidine infusion and paralytic infusions were associated with decreases in DF/CF-ICU-30, (- 2.78 (95%CI [- 5.54, - 0.024], p = 0.040) and (- 7.08 ([- 13.0, - 1.10], p = 0.020) respectively. CONCLUSIONS Although the relationship between paralytic use and delirium is well-established, the observation that dexmedetomidine exposure is independently associated with increased delirium and coma is novel and bears further study.
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Petitjeans F, Geloen A, Pichot C, Leroy S, Ghignone M, Quintin L. Is the Sympathetic System Detrimental in the Setting of Septic Shock, with Antihypertensive Agents as a Counterintuitive Approach? A Clinical Proposition. J Clin Med 2021; 10:4569. [PMID: 34640590 PMCID: PMC8509206 DOI: 10.3390/jcm10194569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 08/05/2021] [Accepted: 09/07/2021] [Indexed: 12/14/2022] Open
Abstract
Mortality in the setting of septic shock varies between 20% and 100%. Refractory septic shock leads to early circulatory failure and carries the worst prognosis. The pathophysiology is poorly understood despite studies of the microcirculatory defects and the immuno-paralysis. The acute circulatory distress is treated with volume expansion, administration of vasopressors (usually noradrenaline: NA), and inotropes. Ventilation and anti-infectious strategy shall not be discussed here. When circulation is considered, the literature is segregated between interventions directed to the systemic circulation vs. interventions directed to the micro-circulation. Our thesis is that, after stabilization of the acute cardioventilatory distress, the prolonged sympathetic hyperactivity is detrimental in the setting of septic shock. Our hypothesis is that the sympathetic hyperactivity observed in septic shock being normalized towards baseline activity will improve the microcirculation by recoupling the capillaries and the systemic circulation. Therefore, counterintuitively, antihypertensive agents such as beta-blockers or alpha-2 adrenergic agonists (clonidine, dexmedetomidine) are useful. They would reduce the noradrenaline requirements. Adjuncts (vitamins, steroids, NO donors/inhibitors, etc.) proposed to normalize the sepsis-evoked vasodilation are not reviewed. This itemized approach (systemic vs. microcirculation) requires physiological and epidemiological studies to look for reduced mortality.
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Affiliation(s)
- Fabrice Petitjeans
- Critical Care, Hôpital d’Instruction des Armées Desgenettes, 69003 Lyon, France;
| | - Alain Geloen
- UMR Ecologie Microbienne Lyon (LEM), University of Lyon, 69100 Villeurbanne, France;
| | - Cyrille Pichot
- Critical Care, Hôpital Louis Pasteur, 39108 Dole, France;
| | | | - Marco Ghignone
- Critical Care, JF Kennedy Hospital North Campus, West Palm Beach, FL 33407, USA;
| | - Luc Quintin
- Critical Care, Hôpital d’Instruction des Armées Desgenettes, 69003 Lyon, France;
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Abstract
Delirium, a form of acute brain dysfunction, is very common in the critically ill adult patient population. Although its pathophysiology is poorly understood, multiple factors associated with delirium have been identified, many of which are coincident with critical illness. To date, no drug or non-drug treatments have been shown to improve outcomes in patients with delirium. Clinical trials have provided a limited understanding of the contributions of multiple triggers and processes of intensive care unit (ICU) acquired delirium, making identification of therapies difficult. Delirium is independently associated with poor long term outcomes, including persistent cognitive impairment. A longer duration of delirium is associated with worse long term cognition after adjustment for age, education, pre-existing cognitive function, severity of illness, and exposure to sedatives. Interestingly, differences in prevalence are seen between ICU survivor populations, with survivors of acute respiratory distress syndrome experiencing higher rates of cognitive impairment at early follow-up compared with mixed ICU survivor populations. Although cognitive performance improves over time for some ICU survivors, impairment is persistent in others. Studies have so far been unable to identify patients at higher risk of long term cognitive impairment; this is an active area of scientific investigation.
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Affiliation(s)
- M Elizabeth Wilcox
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, ON, Canada
| | - Timothy D Girard
- Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Catherine L Hough
- Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University, Portland, OR, USA
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Dexmedetomidine versus midazolam for sedation during endobronchial ultrasound-guided transbronchial needle aspiration: A randomised controlled trial. Eur J Anaesthesiol 2021; 38:534-540. [PMID: 33122573 DOI: 10.1097/eja.0000000000001370] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Desaturation is a common complication of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). Dexmedetomidine (DEX), a commonly used sedative in intensive care, is associated with less respiratory depression compared with other sedatives. OBJECTIVE We compared DEX with midazolam (MDZ) when used as a sedative during EBUS-TBNA. DESIGN A randomised, parallel, double-blinded trial. SETTING A university-affiliated teaching hospital between June 2014 and July 2015. PATIENTS A total of 102 patients who underwent EBUS-TBNA were randomly allocated to two groups (48 DEX group, 54 MDZ group). INTERVENTIONS DEX group received 0.25 to 0.75 μg kg-1 h-1 (start with 0.5 μg kg-1 h-1, modulated in three steps from 0.25 to 0.75 μg kg-1 h-1) of DEX after a loading dose of 0.25 μg kg-1 h-1 for 10 min to maintain a Ramsay Sedation Scale (RSS) of 3 to 5. If the patient was agitated, 1 mg of MDZ bolus was used as a rescue drug. Patients in the MDZ group initially received 0.05 mg kg-1 of MDZ as a bolus. For maintenance and rescue, 1 mg of MDZ bolus was used. MAIN OUTCOME MEASURES The primary outcome was the presence of oxygen desaturation. Secondary outcomes were level of sedation (Ramsay Sedation Scale score), cough score, sedation and procedure satisfaction score. RESULTS The baseline characteristics of the patients, duration of EBUS-TBNA procedures and the use of rescue MDZ were not different between the groups. There was no significant difference in desaturation events between the DEX and MDZ groups (56.3 and 68.5%, respectively; P = 0.20). The level of sedation and the sedation satisfaction scores were similar between the two groups. However, cough score was significantly lower in the DEX group (41.9 vs. 53.4; P = 0.02). CONCLUSION The use of DEX during EBUS-TBNA was not superior to MDZ in terms of oxygen desaturation. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT02157818.
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Chen YT, Sun CK, Wu KY, Chang YJ, Chiang MH, Chen IW, Liao SW, Hung KC. The Use of Propofol versus Dexmedetomidine for Patients Receiving Drug-Induced Sleep Endoscopy: A Meta-Analysis of Randomized Controlled Trials. J Clin Med 2021; 10:1585. [PMID: 33918644 PMCID: PMC8070183 DOI: 10.3390/jcm10081585] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 03/31/2021] [Accepted: 04/06/2021] [Indexed: 11/16/2022] Open
Abstract
The sedation outcomes associated with dexmedetomidine compared with those of propofol during drug-induced sleep endoscopy (DISE) remains unclear. Electronic databases (i.e., the Cochrane controlled trials register, Embase, Medline, and Scopus) were searched from inception to 25 December 2020 for randomized controlled trials (RCTs) that evaluated the sedation outcomes with dexmedetomidine or propofol in adult patients diagnosed with obstructive sleep apnea (OSA) receiving DISE. The primary outcome was the difference in minimum oxygen saturation (mSaO2). Five RCTs (270 participants) published between 2015 and 2020 were included for analysis. Compared with dexmedetomidine, propofol was associated with lower levels of mSaO2 (mean difference (MD) = -7.24, 95% confidence interval (CI) -12.04 to -2.44; 230 participants) and satisfaction among endoscopic performers (standardized MD = -2.43, 95% CI -3.61 to -1.26; 128 participants) as well as a higher risk of hypoxemia (relative ratios = 1.82, 95% CI 1.2 to 2.76; 82 participants). However, propofol provided a shorter time to fall asleep and a lower risk of failed sedation compared with dexmedetomidine. No significant difference was found in other outcomes. Compared with propofol, dexmedetomidine exhibited fewer adverse effects on respiratory function and provided a higher level of satisfaction among endoscopic performers but was associated with an elevated risk of failed sedation.
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Affiliation(s)
- Yi-Ting Chen
- Department of Anesthesiology, Chia-Yi Chang Gung Memorial Hospital, Chia-Yi 61363, Taiwan;
| | - Cheuk-Kwan Sun
- Department of Emergency Medicine, E-Da Hospital, Kaohsiung 83301, Taiwan;
- College of Medicine, I-Shou University, Kaohsiung 84001, Taiwan
| | - Kuan-Yu Wu
- Department of Urology, National Cheng Kung University Hospital, Tainan 70101, Taiwan;
- College of Medicine, National Cheng Kung University, Tainan 70101, Taiwan
| | - Ying-Jen Chang
- Department of Anesthesiology, Chi Mei Medical Center, No.901, ChungHwa Road, YungKung Dist, Tainan 71004, Taiwan; (Y.-J.C.); (I.-W.C.); (S.-W.L.)
- College of Health Sciences, Chang Jung Christian University, Tainan 71101, Taiwan
| | - Min-Hsien Chiang
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan;
| | - I-Wen Chen
- Department of Anesthesiology, Chi Mei Medical Center, No.901, ChungHwa Road, YungKung Dist, Tainan 71004, Taiwan; (Y.-J.C.); (I.-W.C.); (S.-W.L.)
| | - Shu-Wei Liao
- Department of Anesthesiology, Chi Mei Medical Center, No.901, ChungHwa Road, YungKung Dist, Tainan 71004, Taiwan; (Y.-J.C.); (I.-W.C.); (S.-W.L.)
| | - Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, No.901, ChungHwa Road, YungKung Dist, Tainan 71004, Taiwan; (Y.-J.C.); (I.-W.C.); (S.-W.L.)
- Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan 71710, Taiwan
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Garcia R, Salluh JIF, Andrade TR, Farah D, da Silva PSL, Bastos DF, Fonseca MCM. A systematic review and meta-analysis of propofol versus midazolam sedation in adult intensive care (ICU) patients. J Crit Care 2021; 64:91-99. [PMID: 33838522 DOI: 10.1016/j.jcrc.2021.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/31/2021] [Accepted: 04/01/2021] [Indexed: 12/29/2022]
Abstract
PURPOSE Compare outcomes of adult patients admitted to ICU- length of ICU stay, length of mechanical ventilation (MV), and time until extubation- according to the use of propofol versus midazolam. METHODS We searched MEDLINE, EMBASE, LILACS, and Cochrane databases to retrieve RCTs that compared propofol and midazolam used as sedatives in adult ICU patients. We applied a random-effects, meta-analytic model in all calculations. We applied the Cochrane collaboration tool and GRADE. We separated patients into two groups: acute surgical patients (hospitalization up to 24 h) and critically-ill patients (hospitalization over 24 h and whose articles mostly mix surgical, medical and trauma patients). RESULTS Globally, propofol was associated with a reduced MV time of 4.46 h (MD: -4.46 [95% CI -7.51 to -1.42] p = 0.004, I2 = 63%, 6 studies) and extubation time of 7.95 h (MD: -7.95 [95% CI -9.86 to -6.03] p < 0.00001, I2 = 98%, 16 studies). Acute surgical patients sedation with propofol compared to midazolam was associated with a reduced ICU stay of 5.07 h (MD: -5.07 [95% CI -8.68 to -1.45] p = 0.006, I2 = 41%, 5 studies), MV time of 4.28 h (MD: -4.28; [95% CI -4.62 to -3.94] p < 0.0001, I2 = 0%, 3 studies), extubation time of 1.92 h (MD: -1.92; [95% CI -2.71 to -1.13] p = 0.00001, I2 = 89%, 9 studies). In critically-ill patients sedation with propofol compared to midazolam was associated with a reduced extubation time of 32.68 h (MD: -32.68 [95% CI -48.37 to -16.98] p = 0.0001, I2 = 97%, 9 studies). GRADE was very low for all outcomes. CONCLUSIONS Sedation with propofol compared to midazolam is associated with improved clinical outcomes in ICU, with reduced ICU stay MV time and extubation time in acute surgical patients and reduced extubation time in critically-ill patients.
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Affiliation(s)
- Raphaela Garcia
- AxiaBio Life Sciences International ltda, São Paulo, Brazil; Health Technologies Assessment Center - Department of Gynecology, Escola Paulista de Medicina - Federal University of Sao Paulo, Brazil
| | | | - Teresa Raquel Andrade
- AxiaBio Life Sciences International ltda, São Paulo, Brazil; Health Technologies Assessment Center - Department of Gynecology, Escola Paulista de Medicina - Federal University of Sao Paulo, Brazil
| | - Daniela Farah
- AxiaBio Life Sciences International ltda, São Paulo, Brazil; Health Technologies Assessment Center - Department of Gynecology, Escola Paulista de Medicina - Federal University of Sao Paulo, Brazil
| | - Paulo S L da Silva
- Pediatric Intensive Care Unit, Department of Pediatrics, Hospital do Servidor Público Municipal, São Paulo, Brazil
| | | | - Marcelo C M Fonseca
- AxiaBio Life Sciences International ltda, São Paulo, Brazil; Health Technologies Assessment Center - Department of Gynecology, Escola Paulista de Medicina - Federal University of Sao Paulo, Brazil.
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Bailly P, Egreteau PY, Ehrmann S, Thille AW, Guitton C, Grillet G, Reizine F, Huet O, Jaber S, Nowak E, L'her E. Inased (inhaled sedation in ICU) trial protocol: a multicentre randomised open-label trial. BMJ Open 2021; 11:e042284. [PMID: 33608400 PMCID: PMC7896597 DOI: 10.1136/bmjopen-2020-042284] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION The use of sedation in intensive care units (ICUs) is necessary and ubiquitous. The impact of sedation strategy on outcome, particularly when delivered early after initiation of mechanical ventilation, is unknown. Evidence is increasing that volatile anaesthetic agents could be associated with better outcome. Their use in delirium prevention is unknown. METHODS AND ANALYSIS This study is an investigator-initiated, prospective, multicentre, two-arm, randomised, control, open-trial comparing inhaled sedation strategy versus intravenous sedation strategy in mechanically ventilated patients in ICU. Two hundred and fifty patients will be randomly assigned to the intravenous sedation group or inhaled sedation group, with a 1:1 ratio in two groups according to the sedation strategy. The primary outcome is the occurrence of delirium assessed using two times a day confusion assessment method for the ICU (CAM-ICU). Secondary outcomes include cognitive and functional outcomes at 3 and 12 months. ETHICS AND DISSEMINATION The study has been approved by the Regional Ethics Committee (CPP Ouest) and national authorities (ANSM). The results will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04341350.
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Affiliation(s)
- Pierre Bailly
- Médecine Intensive et Réanimation, CHRU de Brest, Brest, Bretagne, France
| | - Pierre-Yves Egreteau
- Réanimation polyvalente, Centre Hospitalier des Pays de Morlaix, Morlaix, France
| | - Stephan Ehrmann
- Médecine Intensive et Réanimation, Centre Hospitalier Régional Universitaire de Tours, Tours, Centre, France
| | - Arnaud W Thille
- Médecine Intensive et Réanimation, CHU de Poitiers, Poitiers, France
- INSERM CIC 1402 Alive Research Group, Université de Poitiers, Poitiers, Poitou-Charentes, France
| | - Christophe Guitton
- Service de Réanimation Médico- Chirurgicale & USC, Centre Hospitalier de Mans, Le Mans, France
| | - Guillaume Grillet
- Réanimation polyvalente, Centre Hospitalier de Lorient, Lorient, Bretagne, France
| | - Florian Reizine
- Médecine Intensive et Réanimation, Centre Hospitalier Universitaire de Rennes, Rennes, Bretagne, France
| | - Olivier Huet
- Réanimation chirurgicale, Centre Hospitalier Régional et Universitaire de Brest, Brest, Bretagne, France
| | - S Jaber
- Anesthesia and Critical Care, Montpellier Univ Hosp, Montpellier, France
| | | | - Erwan L'her
- Médecine Intensive et Réanimation, CHRU de Brest, Brest, NA, France
- LATIM INSERM UMR 1101, Université de Bretagne Occidentale, Brest, NA, France
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Burry LD, Cheng W, Williamson DR, Adhikari NK, Egerod I, Kanji S, Martin CM, Hutton B, Rose L. Pharmacological and non-pharmacological interventions to prevent delirium in critically ill patients: a systematic review and network meta-analysis. Intensive Care Med 2021; 47:943-960. [PMID: 34379152 PMCID: PMC8356549 DOI: 10.1007/s00134-021-06490-3] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 07/19/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE To compare the effects of prevention interventions on delirium occurrence in critically ill adults. METHODS MEDLINE, Embase, PsychINFO, CINAHL, Web of Science, Cochrane Library, Prospero, and WHO international clinical trial registry were searched from inception to April 8, 2021. Randomized controlled trials of pharmacological, sedation, non-pharmacological, and multi-component interventions enrolling adult critically ill patients were included. We performed conventional pairwise meta-analyses, NMA within Bayesian random effects modeling, and determined surface under the cumulative ranking curve values and mean rank. Reviewer pairs independently extracted data, assessed bias using Cochrane Risk of Bias tool and evidence certainty with GRADE. The primary outcome was delirium occurrence; secondary outcomes were durations of delirium and mechanical ventilation, length of stay, mortality, and adverse effects. RESULTS Eighty trials met eligibility criteria: 67.5% pharmacological, 31.3% non-pharmacological and 1.2% mixed pharmacological and non-pharmacological interventions. For delirium occurrence, 11 pharmacological interventions (38 trials, N = 11,993) connected to the evidence network. Compared to placebo, only dexmedetomidine (21/22 alpha2 agonist trials were dexmedetomidine) probably reduces delirium occurrence (odds ratio (OR) 0.43, 95% Credible Interval (CrI) 0.21-0.85; moderate certainty). Compared to benzodiazepines, dexmedetomidine (OR 0.21, 95% CrI 0.08-0.51; low certainty), sedation interruption (OR 0.21, 95% CrI 0.06-0.69; very low certainty), opioid plus benzodiazepine (OR 0.27, 95% CrI 0.10-0.76; very low certainty), and protocolized sedation (OR 0.27, 95% CrI 0.09-0.80; very low certainty) may reduce delirium occurrence but the evidence is very uncertain. Dexmedetomidine probably reduces ICU length of stay compared to placebo (Ratio of Means (RoM) 0.78, CrI 0.64-0.95; moderate certainty) and compared to antipsychotics (RoM 0.76, CrI 0.61-0.98; low certainty). Sedative interruption, protocolized sedation and opioids may reduce hospital length of stay compared to placebo, but the evidence is very uncertain. No intervention influenced mechanical ventilation duration, mortality, or arrhythmia. Single and multi-component non-pharmacological interventions did not connect to any evidence networks to allow for ranking and comparisons as planned; pairwise comparisons did not detect differences compared to standard care. CONCLUSION Compared to placebo and benzodiazepines, we found dexmedetomidine likely reduced the occurrence of delirium in critically ill adults. Compared to benzodiazepines, sedation-minimization strategies may also reduce delirium occurrence, but the evidence is uncertain.
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Affiliation(s)
- Lisa D. Burry
- grid.416166.20000 0004 0473 9881Department of Pharmacy, Mount Sinai Hospital, Room 18-377, 600 University Avenue, Toronto, ON M5G 1X5 Canada ,grid.416166.20000 0004 0473 9881Department Medicine, Mount Sinai Hospital, Toronto, Canada ,grid.17063.330000 0001 2157 2938Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Wei Cheng
- grid.47100.320000000419368710Department of Biostatistics, Yale School of Public Health, New Haven, CT USA
| | - David R. Williamson
- grid.14848.310000 0001 2292 3357Pharmacy Department, Université de Montréal, Montréal, Canada ,grid.414056.20000 0001 2160 7387Pharmacy Department and Research Centre, CIUSSS-NIM Hôpital du Sacré-Cœur de Montréal, Montréal, Canada
| | - Neill K. Adhikari
- grid.413104.30000 0000 9743 1587Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada ,grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada
| | - Ingrid Egerod
- grid.475435.4Intensive Care Unit 4131, Rigshospitalet, University of Copenhagen, Copenhagen Ø, Denmark
| | - Salmaan Kanji
- grid.412687.e0000 0000 9606 5108Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada ,grid.412687.e0000 0000 9606 5108Department of Pharmacy, The Ottawa Hospital, Ottawa, Canada
| | - Claudio M. Martin
- grid.412745.10000 0000 9132 1600Division of Critical Care, London Health Sciences Centre, London, Canada ,grid.39381.300000 0004 1936 8884Department of Medicine, The University of Western Ontario, London, Canada
| | - Brian Hutton
- grid.412687.e0000 0000 9606 5108Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada ,grid.28046.380000 0001 2182 2255School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Louise Rose
- grid.13097.3c0000 0001 2322 6764Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King’s College London, London, UK
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Wang S, Hong Y, Li S, Kuriyama A, Zhao Y, Hu J, Luo A, Sun R. Effect of dexmedetomidine on delirium during sedation in adult patients in intensive care units: A systematic review and meta-analysis. J Clin Anesth 2020; 69:110157. [PMID: 33296787 DOI: 10.1016/j.jclinane.2020.110157] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 11/10/2020] [Accepted: 11/21/2020] [Indexed: 12/29/2022]
Abstract
STUDY OBJECTIVE To compare the effect of sedation protocols with and without dexmedetomidine on delirium risk and duration in adult patients in intensive care units (ICUs). DESIGN A meta-analysis of randomized controlled trials. REVIEW METHODS We searched the Cochrane Central Register of Controlled Trials, PubMed, EMBASE, and ISI Web of Science from inception to September 3, 2020. We included studies comparing the effect of dexmedetomidine-based sedation on delirium risk with non-dexmedetomidine-based sedation in adult patients in ICUs. We pooled the data using a random-effects model using Review Manager 5.2, and assessed publication bias using Stata 11.0. The quality of evidence was rated using the Grading of Recommendations, Assessment, Development and Evaluation system. MAIN RESULTS We included 36 studies involving 9623 participants. The use of dexmedetomidine was associated with reduced risk of delirium (risk ratio [RR], 0.63; 95% confidence interval [CI], 0.54-0.75; very low-quality evidence), but higher incidences of hypotension and bradycardia during hospital stay. Dexmedetomidine was also associated with shorter durations of ICU stay, hospital stay and mechanical ventilation. Dexmedetomidine did not affect ICU mortality (RR, 1.01; 95% CI, 0.89-1.14; low-quality evidence), hospital mortality (RR, 1.01; 95% CI, 0.91-1.12; very low-quality evidence), or 30-day mortality (RR, 0.77; 95% CI, 0.58-1.01; moderate-quality evidence), or duration of delirium (mean difference, -0.74 days; 95% CI, -1.83 to 0.36 days; very low-quality evidence). We identified publication bias for risk and duration of delirium, length of ICU stay, and hospital stay. CONCLUSIONS Low- or very low-quality evidence suggests that dexmedetomidine was associated with a clinically-small reduction of delirium risk, ICU/hospital stay and mechanical ventilation duration, but were not associated with improved mortality or shorter delirium duration in ICU patients. These findings were inconclusive because of publication bias, heterogeneity, and limited sample size. Significant adverse effects of dexmedetomidine include hypotension and bradycardia. PROSPERO registration number: CRD42018095358.
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Affiliation(s)
- Shuo Wang
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Yishun Hong
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Shiyong Li
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Akira Kuriyama
- Emergency and Critical Care Center, Kurashiki Central Hospital, Kurashiki, Okayama 710-8602, Japan
| | - Yilin Zhao
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Jinqian Hu
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Ailin Luo
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Rao Sun
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China.
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Dong Q, Li C, Xiao F, Xie Y. Efficacy and safety of dexmedetomidine in patients receiving mechanical ventilation: Evidence from randomized controlled trials. Pharmacol Res Perspect 2020; 8:e00658. [PMID: 33179456 PMCID: PMC7658106 DOI: 10.1002/prp2.658] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 08/20/2020] [Accepted: 08/23/2020] [Indexed: 11/05/2022] Open
Abstract
At present, the efficacy and safety of dexmedetomidine in patients receiving mechanical ventilation (MV) is still controversial. Therefore, the purpose of this research was to assess the efficacy and safety of dexmedetomidine in MV patients by reviewing the results of randomized controlled trials (RCT). RCTs evaluating the efficacy of dexmedetomidine in the treatment of MV patients were obtained by searching relevant online databases, including PubMed, EMbase, Web of Science, the Cochrane Library, Medline, OVID, and ClinicalTrials.gov. Literature meeting the inclusion criteria were selected and evaluated by two researchers independently. Risk ratio (RR)/standardized mean difference (SMD) and 95% confidence interval (CI) were used to express the differences between groups. Seven RCTs were included in our study, with 986 participants in the dexmedetomidine group and 862 participants in the control group. Summary analysis results displayed no reduction in 30-day mortality (RR = 0.77, 95% CI: 0.59 to 1.02), delirium (RR = 0.77, 95% CI: 0.57 to 1.03), and adverse events (RR = 1.06, 95% CI: 0.22 to 5.08) in the dexmedetomidine group compared with the control group. As the length of stay in the intensive care unit (ICU) were presented as median and interquartile range (IQR)/standard deviation (SD), descriptive analysis of the results were performed. Generally, for 99.65% (953/986) of patients, dexmedetomidine was not better than the control group in reducing ICU length of stay. Our results demonstrate that for patients requiring MV, dexmedetomidine was not superior to the control group. However, analysis of more RCTs is required to confirm this conclusion.
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Affiliation(s)
- Qinghua Dong
- Department of AnesthesiologyThe First Affiliated Hospital of Guangxi Medical UniversityNanningChina
| | - Chunlai Li
- Department of AnesthesiologyThe First Affiliated Hospital of Guangxi Medical UniversityNanningChina
| | - Fei Xiao
- Department of AnesthesiologyThe First Affiliated Hospital of Guangxi Medical UniversityNanningChina
| | - Yubo Xie
- Department of AnesthesiologyThe First Affiliated Hospital of Guangxi Medical UniversityNanningChina
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Longrois D, Petitjeans F, Simonet O, de Kock M, Belliveau M, Pichot C, Lieutaud T, Ghignone M, Quintin L. Clinical Practice: Should we Radically Alter our Sedation of Critical Care Patients, Especially Given the COVID-19 Pandemics? Rom J Anaesth Intensive Care 2020; 27:43-76. [PMID: 34056133 PMCID: PMC8158317 DOI: 10.2478/rjaic-2020-0018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The high number of patients infected with the SARS-CoV-2 virus requiring care for ARDS puts sedation in the critical care unit (CCU) to the edge. Depth of sedation has evolved over the last 40 years (no-sedation, deep sedation, daily emergence, minimal sedation, etc.). Most guidelines now recommend determining the depth of sedation and minimizing the use of benzodiazepines and opioids. The broader use of alpha-2 adrenergic agonists ('alpha-2 agonists') led to sedation regimens beginning at admission to the CCU that contrast with hypnotics+opioids ("conventional" sedation), with major consequences for cognition, ventilation and circulatory performance. The same doses of alpha-2 agonists used for 'cooperative' sedation (ataraxia, analgognosia) elicit no respiratory depression but modify the autonomic nervous system (cardiac parasympathetic activation, attenuation of excessive cardiac and vasomotor sympathetic activity). Alpha-2 agonists should be selected only in patients who benefit from their effects ('personalized' indications, as opposed to a 'one size fits all' approach). Then, titration to effect is required, especially in the setting of systemic hypotension and/or hypovolemia. Since no general guidelines exist for the use of alpha-2 agonists for CCU sedation, our clinical experience is summarized for the benefit of physicians in clinical situations in which a recommendation might never exist (refractory delirium tremens; unstable, hypovolemic, hypotensive patients, etc.). Because the physiology of alpha-2 receptors and the pharmacology of alpha-2 agonists lead to personalized indications, some details are offered. Since interactions between conventional sedatives and alpha-2 agonists have received little attention, these interactions are addressed. Within the existing guidelines for CCU sedation, this article could facilitate the use of alpha-2 agonists as effective and safe sedation while awaiting large, multicentre trials and more evidence-based medicine.
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Affiliation(s)
- D Longrois
- Départements d’Anesthésie-Réanimation, Université Paris-Diderot and Paris VII Sorbonne-Paris-Cité, Hôpital Bichat-Claude Bernard, Assistance Publique-Hôpitaux de Paris and UMR 5698, Paris, France
| | - F Petitjeans
- Hôpital d’Instruction des Armées Desgenettes, Lyon, France
| | - O Simonet
- Centre Hospitalier de Wallonie Picarde, Tournai, Belgium
| | - M de Kock
- Centre Hospitalier de Wallonie Picarde, Tournai, Belgium
| | - M Belliveau
- Hôpital de St Jerome, St Jérôme, Québec, Canada
| | - C Pichot
- Hôpital Louis Pasteur, Dole, France
| | - Th Lieutaud
- Hôpital de Bourg en BresseBourg-en-BresseFrance
- Centre de Recherche en Neurosciences(TIGER,UMR CRNS 5192-INSERM 1098), Lyon-Bron, France
| | - M Ghignone
- J.F. Kennedy Hospital North Campus, West Palm Beach, Florida, USA
| | - L Quintin
- Hôpital d’Instruction des Armées Desgenettes, Lyon, France
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Abstract
PURPOSES OF REVIEW Critically ill patients frequently require mechanical ventilation as part of their care. Administration of analgesia and sedation to ensure patient comfort and facilitate mechanical ventilation must be balanced against the known negative consequences of excessive sedation. The present review focuses on the current evidence for sedation management during mechanical ventilation, including choice of sedatives, sedation strategies, and special considerations for acute respiratory distress syndrome (ARDS). RECENT FINDINGS The Society of Critical Care Medicine recently published their updated clinical practice guidelines for analgesia, agitation, sedation, delirium, immobility, and sleep in adult patients in the ICU. Deep sedation, especially early in the course of mechanical ventilation, is associated with prolonged time to liberation from mechanical ventilation, longer ICU stays, longer hospital stays, and increased mortality. Dexmedetomidine may prevent ICU delirium when administered nocturnally at low doses; however, it was not shown to improve mortality when used as the primary sedative early in the course of mechanical ventilation, though the majority of patients in the informing study failed to achieve the prescribed light level of sedation. In a follow up to the ACURASYS trial, deep sedation with neuromuscular blockade did not result in improved mortality compared to light sedation in patients with severe ARDS. SUMMARY Light sedation should be targeted early in the course of mechanical ventilation utilizing daily interruptions of sedation and/or nursing protocol-based algorithms, even in severe ARDS.
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Pavone KJ, Jablonski J, Cacchione PZ, Polomano RC, Compton P. Evaluating Pain, Opioids, and Delirium in Critically Ill Older Adults. Clin Nurs Res 2020; 30:455-463. [PMID: 33215518 DOI: 10.1177/1054773820973123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Untreated pain and pain management with opioids are independent precipitating factors for delirium. This retrospective study evaluated the relationships among pain severity, its management with opioids, and the onset of delirium in older adult patients admitted to the surgical intensive care unit (SICU). Consecutive patients aged 65 or greater admitted to the SICU over a 5-month period were examined (n = 172). When assessed using a multivariable general estimating equation model, opioids (chi-square [χ2], 12.34, p = .0004), but not pain (χ2, 3.31, p = .0688) were significant in predicting next-day delirium status. Controlling for pain, patients exposed to opioids were 2.5 times more likely to develop delirium than patients not exposed (95% Confidence Interval: 1.44-4.36). Our data shows that opioid administration predicted the onset of next-day delirium. In an effort to prevent delirium, future research should focus on opioid-sparing pain management approaches to mitigate pain and delirium.
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Affiliation(s)
| | | | - Pamela Z Cacchione
- University of Pennsylvania, Philadelphia, USA.,Penn Presbyterian Medical Center, Philadelphia, PA, USA
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A Centrally Acting Antihypertensive, Clonidine, Sedates Patients Presenting With Acute Respiratory Distress Syndrome Evoked by Severe Acute Respiratory Syndrome-Coronavirus 2. Crit Care Med 2020; 48:e991-e993. [PMID: 32618691 PMCID: PMC7328439 DOI: 10.1097/ccm.0000000000004503] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Schuler BR, Kovacevic MP, Dube KM, Szumita PM, DeGrado JR. Evaluation of Sedation Outcomes Following Increased Dexmedetomidine Use in the ICU. Crit Care Explor 2020; 2:e0100. [PMID: 32426742 PMCID: PMC7188421 DOI: 10.1097/cce.0000000000000100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
To evaluate sedation practices following a dexmedetomidine guideline update in the ICU. Design Single-center, retrospective chart review. Setting Tertiary academic medical center. Patients Patients were included in this analysis if they were admitted to the ICU and were ordered for continuous infusion sedatives or opioids from September to November 2016 (PRE) and from September to November 2017 (POST). Patients were excluded from this analysis if they met any of the following criteria: mechanical ventilation less than 12 hours, admitted with acute neurologic injury, burn of greater than 20% total body surface area, chronic tracheostomy, admitted to the neuroscience or cardiac surgery ICU, on extracorporeal membrane oxygenation support, or received an infusion of neuromuscular blockers. Interventions Patients admitted during a restricted dexmedetomidine prescribing guideline were compared with patients admitted during an expanded prescribing guideline. Measurements and Main Results Of the 1,426 patients evaluated for inclusion, 427 patients met the criteria in this analysis. Of these, 217 patients were in the PRE and 210 patients in the POST. A majority of patients were excluded for admission to neuroscience or cardiac surgery ICU. Dexmedetomidine was used in 13.8% of encounters in the PRE and 51.9% of encounters in the POST (p < 0.001). The median duration of mechanical ventilation was 49 hours (24-110 hr) in the PRE and 47.5 hours (26-98 hr) in the POST (p = 0.8). ICU length of stay was a median of 136 and 121 hours in the PRE and POST, respectively (p = 0.2). The median hospital length of stay was 296 and 326 hours in the PRE and POST, respectively (p = 0.35). After controlling for possible confounders, ventilation time remained unchanged between the PRE and POST (p = 0.98). Conclusions The expansion of a hospital dexmedetomidine prescribing guideline resulted in an increased use of dexmedetomidine but was not associated with a difference in length of mechanical ventilation.
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Affiliation(s)
- Brian R Schuler
- All authors: Department of Pharmacy, Brigham and Women's Hospital, Boston, MA
| | - Mary P Kovacevic
- All authors: Department of Pharmacy, Brigham and Women's Hospital, Boston, MA
| | - Kevin M Dube
- All authors: Department of Pharmacy, Brigham and Women's Hospital, Boston, MA
| | - Paul M Szumita
- All authors: Department of Pharmacy, Brigham and Women's Hospital, Boston, MA
| | - Jeremy R DeGrado
- All authors: Department of Pharmacy, Brigham and Women's Hospital, Boston, MA
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The Effectiveness of α2 Agonists As Sedatives in Pediatric Critical Care: A Propensity Score-Matched Cohort Study. Crit Care Med 2020; 47:e580-e586. [PMID: 31033500 DOI: 10.1097/ccm.0000000000003789] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES There is limited evidence supporting the widespread use of α2 agonists (clonidine and dexmedetomidine) in pediatric critical care sedation. This study sought to test the association between the use of α2 agonists and enhanced sedation. DESIGN A retrospective observational cohort study was conducted. Noninferiority of time adequately sedated (COMFORT Behavior Score 11-16) while mechanically ventilated was assessed. Secondarily, dosing of opioids and benzodiazepines was examined. SETTING Two tertiary PICUs. PATIENTS Children were classified into an exposed group, who received an α2 agonist as part of their sedation regimen, and an unexposed group. Groups were matched using propensity score analysis. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS One-thousand eighty-five patients were included. The exposed group were adequately sedated 74% (95% CI, 72-75%) of the study time compared with the unexposed group at 70% (95% CI, 67-72%) giving a ratio of 1.06 (95% CI, 1.02-1.10) and a noninferior time adequately sedated. A decrease in time oversedated was observed with 8.1% (95% CI, 4.3-11.9%) less time classified as oversedated in the exposed group. Reduction in morphine use of 0.25 μg/kg/hr (95% CI, -0.68 to 1.18 μg/kg/hr) was not statistically significant. Midazolam use did not decrease and was statistically higher. CONCLUSIONS Use of α2 agonists was associated with similar time adequately sedated as a matched unexposed group although no reduction in morphine or benzodiazepine coadministration was observed. There was a shift toward lighter sedation with α2 agonist use.
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O'Brien DW, Cotta MO, Choo L, Fowler S, Downey M, Fisquet S, Tan I, Roberts JA. Dexmedetomidine prescribing in Australian intensive care units: an observational study. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2019. [DOI: 10.1002/jppr.1529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | - Menino O. Cotta
- School of Pharmacy Centre for Translational Anti‐infective Pharmacodynamics The University of Queensland Brisbane Australia
- Faculty of Medicine University of Queensland Centre for Clinical Research The University of Queensland Brisbane Australia
| | - Lyn Choo
- Department of Intensive Care Medicine John Hunter Hospital Newcastle Australia
| | - Stephen Fowler
- Pharmacy Department Royal Darwin Hospital Darwin Australia
| | - Maria Downey
- Pharmacy Department Royal Hobart Hospital Hobart Australia
| | | | - Ivy Tan
- Pharmacy Department Royal Victorian Eye and Ear Hospital Melbourne Australia
| | - Jason A. Roberts
- School of Pharmacy Centre for Translational Anti‐infective Pharmacodynamics The University of Queensland Brisbane Australia
- Faculty of Medicine University of Queensland Centre for Clinical Research The University of Queensland Brisbane Australia
- Department of Intensive Care Medicine Royal Brisbane and Women's Hospital Brisbane Australia
- Pharmacy Department Royal Brisbane and Women's Hospital Brisbane Australia
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Hayden JC, Bardol M, Doherty DR, Dawkins I, Healy M, Breatnach CV, Gallagher PJ, Cousins G, Standing JF. Optimizing clonidine dosage for sedation in mechanically ventilated children: A pharmacokinetic simulation study. Paediatr Anaesth 2019; 29:1002-1010. [PMID: 31373752 DOI: 10.1111/pan.13715] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 06/28/2019] [Accepted: 07/29/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Clonidine is in widespread off-label use as a sedative in mechanically ventilated children, despite limited evidence of efficacy. A variety of dosage regimens have been utilized in clinical practice and in research studies. Within these studies, clonidine has inconsistently shown useful sedation properties. One of the reasons attributed to the inconsistent signs of efficacy is suboptimal clonidine dosing. AIMS This study aims to propose a target plasma concentration and simulate clonidine pharmacokinetics (PK) in a cohort of mechanically ventilated children to evaluate the adequacy of clonidine dosage regimens used in clinical practice and research studies. METHODS A literature search was undertaken to identify a clonidine pharmaockinetic-pharmacodynamics (PKPD) model, from which a target concentration for sedation was defined. Using a previously published PK model, the projected plasma concentrations of 692 mechanically ventilated children (demographics taken from a recent study) were generated. Doses from recently published clinical studies were investigated. Adequacy of each regimen to attain therapeutic clonidine plasma concentrations was assessed. RESULTS A target plasma concentration of above 2 µg/L was proposed. Nine dosage regimens (four intravenous boluses, four intravenous infusions, and one nasogastric route boluses) were evaluated ranging from 1 µg/kg eight hourly intravenous boluses to a regimen up to 3 µg/kg/hr continuous intravenous infusion. Regimens with a loading dose of 2 µg/kg followed by variable continuous infusion of up to 2 µg/kg/hr titrated according to sedation score appear most suitable. Doses should be halved in neonates. CONCLUSION The variety of dosage regimens in the previous studies of clonidine along with difficulties in the conduct of interventional studies may have contributed to the lack of efficacy data to support its use. Simulations of clonidine plasma concentrations based on known population pharmacokinetic parameters suggest a loading dose followed by higher than current practice maintenance dose infusion is required to achieve adequate steady-state concentrations early in treatment. Further PKPD studies will aid in the determination of the optimal clonidine dosage regimen.
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Affiliation(s)
- John C Hayden
- School of Pharmacy, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Maddlie Bardol
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Dermot R Doherty
- Paediatric Intensive Care Unit, Our Lady's Children's Hospital, Dublin, Ireland.,Intensive Care Unit, Children's University Hospital, Dublin, Ireland
| | - Ian Dawkins
- Paediatric Intensive Care Unit, Our Lady's Children's Hospital, Dublin, Ireland.,Intensive Care Unit, Children's University Hospital, Dublin, Ireland
| | - Martina Healy
- Paediatric Intensive Care Unit, Our Lady's Children's Hospital, Dublin, Ireland
| | - Cormac V Breatnach
- Paediatric Intensive Care Unit, Our Lady's Children's Hospital, Dublin, Ireland
| | - Paul J Gallagher
- School of Pharmacy, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Gráinne Cousins
- School of Pharmacy, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Joseph F Standing
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK
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Flieller LA, Alaniz C, Pleva MR, Miller JT. Incidence of Rebound Hypertension after Discontinuation of Dexmedetomidine. Pharmacotherapy 2019; 39:970-974. [PMID: 31463963 DOI: 10.1002/phar.2323] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION To date, no studies have evaluated the incidence of rebound hypertension occurring with the discontinuation of long-term (> 72 hrs) dexmedetomidine infusions. Rebound hypertension has been documented in the literature with clonidine, a structurally and pharmacologically similar medication. OBJECTIVES To compare the incidence of rebound hypertension associated with cessation of dexmedetomidine infusion with other sedative medications. METHODS This retrospective, matched cohort study evaluated the incidence of rebound hypertension in intensive care unit patients receiving continuous infusions of at least 72 hours in duration of dexmedetomidine, propofol, or midazolam. RESULTS The study population consisted of 216 patients: 54 treated with dexmedetomidine and 162 treated with propofol or midazolam. Rebound hypertension occurred significantly more often in patients with a history of hypertension (71.1%) than in patients with no prior hypertension (28.9%; p<0.001).There was no difference in incidence of rebound hypertension in the dexmedetomidine or propofol and midazolam arms (16.7% vs 17.9%, p=0.837). The titration timeframe for the dexmedetomidine infusion, defined as the time from peak infusion rate until discontinuation, was significantly shorter in patients with rebound hypertension (median duration, 4 hrs) compared with patients who did not have rebound hypertension (median duration, 17 hrs; p=0.011). CONCLUSION There was no difference in the incidence of rebound hypertension observed with dexmedetomidine discontinuation compared with propofol or midazolam. Instead, history of hypertension and a shorter weaning duration appear to be associated with increased risk of rebound hypertension regardless of the sedative used.
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Affiliation(s)
- Lauren A Flieller
- Department of Pharmacy, Michigan Medicine, Ann Arbor, Michigan.,Department of Pharmacotherapy and Pharmacy Services, University Health System, San Antonio, Texas
| | - Cesar Alaniz
- Department of Pharmacy, Michigan Medicine, Ann Arbor, Michigan.,University of Michigan College of Pharmacy, Ann Arbor, Michigan
| | - Melissa R Pleva
- Department of Pharmacy, Michigan Medicine, Ann Arbor, Michigan
| | - James T Miller
- Department of Pharmacy, Michigan Medicine, Ann Arbor, Michigan
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30
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Rojo Del Moral O, Mena-Arceo RG, García-García AE, Ñamendys-Silva SA. Organ Function Assessment, Prevention, and Outcomes in Critically Ill Patients with Sepsis. Am J Respir Crit Care Med 2019; 198:1444-1446. [PMID: 30192644 DOI: 10.1164/rccm.201705-0982rr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Oscar Rojo Del Moral
- Department of Critical Care Medicine, Medica Sur Clinic & Foundation, Mexico City, Mexico
| | - Roger G Mena-Arceo
- Department of Critical Care Medicine, Medica Sur Clinic & Foundation, Mexico City, Mexico
| | - Alan E García-García
- Department of Critical Care Medicine, Medica Sur Clinic & Foundation, Mexico City, Mexico
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31
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Song Y, Gao S, Tan W, Qiu Z, Zhou H, Zhao Y. Dexmedetomidine versus midazolam and propofol for sedation in critically ill patients: Mining the Medical Information Mart for Intensive Care data. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:197. [PMID: 31205915 DOI: 10.21037/atm.2019.04.14] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The benefits of dexmedetomidine on reducing mortality and length of intensive care unit (ICU) stay are still controversial. We aimed to evaluate the superiority of dexmedetomidine by comparing it with midazolam and propofol. Methods Subjects who were given dexmedetomidine, midazolam and propofol exclusively as sedatives in the Beth Israel Deaconess Medical Center between 2001 and 2012 were identified from the Medical Information Mart for Intensive Care (MIMIC) III database. Univariate, multivariate and stratified analysis was performed to compare the mortality and length of ICU stay between the dexmedetomidine, midazolam and propofol groups. To compare the depth of sedation between the midazolam and propofol group, we used propensity score matching (PSM) to create comparable units and their Richmond Agitation Sedation Score (RASS) were analyzed. Results A total of 1,542 unique ICU records were identified in the MIMIC-III database, among which 163 belonged to the dexmedetomidine group and 531 belonged to the midazolam group and 848 belonged to the propofol group. Mortality was decreased in dexmedetomidine group compared with midazolam group (OR 15.25; 95% CI, 5.29-64.80, P<0.001) and propofol group (OR 5.51; 95% CI, 1.91-23.45, P=0.006). In patients with high Simplified Acute Physiologic Score (SAPS) II (>52), midazolam was related to a higher mortality (~50%). But competing risk analysis revealed that dexmedetomidine was associated with longer ICU stay (P<0.001). There was no significant difference in the RASS between propofol and midazolam group (P=0.300). Conclusions Dexmedetomidine was significantly related to lower mortality when compared with midazolam and propofol. Midazolam had a comparably higher mortality than propofol and dexmedetomidine in patients with high SAPS II. Propofol and midazolam were equivalent in sedative efficacy. Further evaluation is needed.
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Affiliation(s)
- Yiyan Song
- Department of Anesthesia, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China.,Department of General Surgery, Guangdong Second Provincial General Hospital, Guangzhou 510310, China
| | - Shaowei Gao
- Department of Anesthesia, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Wulin Tan
- Department of Anesthesia, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Zeting Qiu
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou 510080, China
| | - Huaqiang Zhou
- Department of Medical Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
| | - Yue Zhao
- Department of General Surgery, Guangdong Second Provincial General Hospital, Guangzhou 510310, China
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32
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Wang H, Wang C, Wang Y, Tong H, Feng Y, Li M, Jia L, Yu K. Sedative drugs used for mechanically ventilated patients in intensive care units: a systematic review and network meta-analysis. Curr Med Res Opin 2019; 35:435-446. [PMID: 30086671 DOI: 10.1080/03007995.2018.1509573] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The effects of different sedative drugs on all-cause mortality rate, duration of ICU stay, and risk of delirium in mechanically ventilated ICU patients are unclear. This meta-analysis aimed to compare the effectiveness and safety of individual sedative drugs and drug combinations in mechanically ventilated ICU patients. MATERIALS AND METHODS Medline, Embase, Cochrane, EBSCOhost, and ISI Web of Science databases were searched for studies that assessed sedation in ICU mechanically ventilated patients. A Bayesian random-effects model was used to combine the direct comparisons and indirect evidence. RESULTS Thirty-one randomized, controlled trials were included, which consisted of 4491 patients who received one of seven sedative drugs or a combination of drugs. There were no significant differences regarding the all-cause mortality rate. Compared to propofol, inhalation anesthetics (hazard ratio [HR] 0.121; 95% credible interval [CrI] -7.58 to 7.62), alpha agonists (HR 2.2; 95% CrI 0.776 to 5.22), propofol with benzodiazepines (HR 0.306; 95% CrI -6.97 to 7.65), ketamine with benzodiazepines (HR 6.57; 95% CrI -6.05 to 19.1) and placebo (HR 2.4; 95% CrI -5.37 to 10.3), benzodiazepines (HR 3.62; 95% CrI 0.834 to 6.2) may increase the duration of ICU stay. Compared to alpha agonists, propofol (HR 2.4; 95% CrI 0.304 to 21.1) and placebo (HR 6.12; 95% CrI 0.745 to 54.6), benzodiazepines (HR 2.59; 95% CrI 1.08 to 7.4) were associated with incremental risks of delirium. CONCLUSION Compared to propofol, benzodiazepines may increase the duration of ICU stay. Compared to alpha agonists, benzodiazepines were associated with an increased risk of delirium.
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Affiliation(s)
- Hongliang Wang
- a Department of Critical Care Medicine , the Second Affiliated Hospital of Harbin Medical University , Harbin , China
| | - Changsong Wang
- b Department of Critical Care Medicine , Harbin Medical University Cancer Hospital , Harbin , China
| | - Yue Wang
- b Department of Critical Care Medicine , Harbin Medical University Cancer Hospital , Harbin , China
- c Department of Anesthesiology , the Fifth Affiliated Hospital of Sun Yat-Sen University , Zhuhai , China
| | - Hongshuang Tong
- b Department of Critical Care Medicine , Harbin Medical University Cancer Hospital , Harbin , China
- d Department of Anesthesiology , Shenzhen Hospital (Futian) of Guangzhou University of Chinese Medicine , Shenzhen , China
| | - Yue Feng
- b Department of Critical Care Medicine , Harbin Medical University Cancer Hospital , Harbin , China
- e Department of Anesthesiology , TEDA International Cardiovascular Hospital , Tianjin , China
| | - Ming Li
- a Department of Critical Care Medicine , the Second Affiliated Hospital of Harbin Medical University , Harbin , China
| | - Liu Jia
- a Department of Critical Care Medicine , the Second Affiliated Hospital of Harbin Medical University , Harbin , China
| | - Kaijiang Yu
- b Department of Critical Care Medicine , Harbin Medical University Cancer Hospital , Harbin , China
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Barbateskovic M, Krauss SR, Collet MO, Larsen LK, Jakobsen JC, Perner A, Wetterslev J. Pharmacological interventions for prevention and management of delirium in intensive care patients: a systematic overview of reviews and meta-analyses. BMJ Open 2019; 9:e024562. [PMID: 30782910 PMCID: PMC6377549 DOI: 10.1136/bmjopen-2018-024562] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES We assessed the evidence from reviews and meta-analyses of randomised clinical trials on the effects of pharmacological prevention and management of delirium in intensive care unit (ICU) patients. METHODS We searched for reviews in July 2017 in: Cochrane Library, MEDLINE, Embase, Science Citation Index, BIOSIS Previews, CINAHL and LILACS. We assessed whether reviews were systematic according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and assessed the methodological quality using ROBIS. OUTCOME MEASURES Primary outcomes: all-cause mortality, serious adverse events, prevention of delirium and management of delirium. SECONDARY OUTCOMES quality of life; non-serious adverse events and cognitive function. RESULTS We included 378 reviews: 369 narrative reviews, eight semisystematic reviews which failed on a maximum of two arbitrary PRISMA criteria and one systematic review fulfilling all 27 PRISMA criteria. For the prevention of delirium, we identified the one systematic review and eight semisystematic reviews all assessing the effects of alpha-2-agonists. None found evidence of a reduction of mortality (systematic review RR 0.99, 95% CI 0.79 to 1.24). The systematic review and three semisystematic reviews found no evidence of an effect for the prevention of delirium (systematic review RR 0.85, 0.63 to 1.14). Conversely, four semisystematic reviews found a beneficial effect. Serious adverse events, quality of life, non-serious adverse events and cognitive function were not assessed. We did not identify any systematic or semisystematic reviews addressing other pharmacological interventions for the prevention of delirium. For the management of manifest delirium, we did not identify any systematic or semisystematic review assessing any pharmacological agents. CONCLUSION Based on systematic reviews, the evidence for the use of pharmacological interventions for prevention or management of delirium is poor or sparse. A systematic review with low risk of bias assessing the effects of pharmacological prevention of delirium and management of manifest delirium in ICU patients is urgently needed. PROSPERO REGISTRATION NUMBER CRD42016046628.
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Affiliation(s)
- Marija Barbateskovic
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Sara Russo Krauss
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Marie Oxenboell Collet
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Laura Krone Larsen
- Department of of Neuroanaesthesiology, Rigshospitalet, Copenhagen University hospital, Copenhagen, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Cardiology, Holbaek Hospital, Holbaek, Denmark
| | - Anders Perner
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jørn Wetterslev
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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34
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Recognition, Assessment, and Pharmacotherapeutic Treatment of Alcohol Withdrawal Syndrome in the Intensive Care Unit. Crit Care Nurs Q 2019; 42:12-29. [DOI: 10.1097/cnq.0000000000000233] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Pavone KJ, Cacchione PZ, Polomano RC, Winner L, Compton P. Evaluating the use of dexmedetomidine for the reduction of delirium: An integrative review. Heart Lung 2018; 47:591-601. [PMID: 30266265 DOI: 10.1016/j.hrtlng.2018.08.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 08/14/2018] [Accepted: 08/19/2018] [Indexed: 12/29/2022]
Abstract
Delirium, an acute change in cognition and attention not secondary to a pre-existing condition or dementia, affects nearly 40,000 hospitalized older adults in the United States every day. Delirium is associated with increased healthcare costs of $16,303 to $64,421 per patient. To date, no single pharmacological intervention is effective in preventing or treating delirium in critically ill patients. Evidence suggests the alpha-2 agonist, dexmedetomidine, may reduce or prevent delirium. An integrative review examined whether dexmedetomidine was associated with a lower incidence of delirium compared to other analgesic and sedation strategies. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guided this review and 16 publications met quality criteria for inclusion. These studies support that postoperative administration of dexmedetomidine may reduce delirium in patients, particularly following cardiac surgery. Further research is needed to determine the benefits of dexmedetomidine in patients on mechanical ventilation and optimal timing and duration of administration.
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Affiliation(s)
- Kara J Pavone
- University of Pennsylvania, School of Nursing, 418 Curie Blvd, Philadelphia, PA 19104, United States.
| | - Pamela Z Cacchione
- University of Pennsylvania, School of Nursing, 418 Curie Blvd, Philadelphia, PA 19104, United States
| | - Rosemary C Polomano
- University of Pennsylvania, School of Nursing, 418 Curie Blvd, Philadelphia, PA 19104, United States
| | - LoriAnn Winner
- University of Pennsylvania, School of Nursing, 418 Curie Blvd, Philadelphia, PA 19104, United States
| | - Peggy Compton
- University of Pennsylvania, School of Nursing, 418 Curie Blvd, Philadelphia, PA 19104, United States
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Flükiger J, Hollinger A, Speich B, Meier V, Tontsch J, Zehnder T, Siegemund M. Dexmedetomidine in prevention and treatment of postoperative and intensive care unit delirium: a systematic review and meta-analysis. Ann Intensive Care 2018; 8:92. [PMID: 30238227 PMCID: PMC6148680 DOI: 10.1186/s13613-018-0437-z] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Accepted: 09/06/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND To determine the preventive and therapeutic effect of dexmedetomidine on intensive care unit (ICU) delirium. METHODS The literature search using PubMed and the Cochrane Central Register of Controlled Trials was performed (August 1, 2018) to detect all randomized controlled trials (RCTs) of adult ICU patients receiving dexmedetomidine. Articles were included if they assessed the influence of dexmedetomidine compared to a sedative agent on incidence of ICU delirium or treatment of this syndrome. Accordingly, relevant articles were allocated to the following two groups: (1) articles that assessed the delirium incidence (incidence comparison) or articles that assessed the treatment of delirium (treatment comparison). Incidence of delirium and delirium resolution were the primary outcomes. We combined treatment effects comparing dexmedetomidine versus (1) placebo, (2) standard sedatives, and (3) opioids in random-effects meta-analyses. Risk of bias for each included RCT was assessed following Cochrane standards. RESULTS The literature search resulted in 28 articles (25 articles/4975 patients for the incidence comparison and three articles/166 patients for the treatment comparison). In the incidence comparison, heterogeneity was present in different subgroups. Administration of dexmedetomidine was associated with significantly lower overall incidence of delirium when compared to placebo (RR 0.52; 95% CI 0.39-0.70; I2 = 37%), standard sedatives (RR 0.63; 95% CI 0.46-0.86; I2 = 69%), as well as to opioids (RR 0.61; 95% CI 0.44-0.83; I2 = 0%). Use of dexmedetomidine significantly increased the risks of bradycardia and hypotension. Limited data were available on circulatory insufficiency and mortality. In the treatment comparison, the comparison drugs in the three RCTs were placebo, midazolam, and haloperidol. The resolution of delirium was measured differently in each study. Two out of the three studies indicated clear favorable effects for dexmedetomidine (i.e., compared to placebo and midazolam). The study comparing dexmedetomidine with haloperidol was a pilot study (n = 20) with high variability in the results. CONCLUSION Findings suggest that dexmedetomidine reduces incidence and duration of ICU delirium. Furthermore, our systematic searches show that there is limited evidence if a delirium shall be treated with dexmedetomidine.
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Affiliation(s)
- Julian Flükiger
- Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Alexa Hollinger
- Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland. .,Department of Anaesthesiology, Burn and Critical Care Medicine, AP-HP, Saint Louis and Lariboisière University Hospitals, 2 rue Ambroise Paré, 75010, Paris, France. .,Inserm 942 Paris, Biomarqueurs et maladies cardiaques, Hôpital Lariboisière - Bâtiment Viggo Petersen, 41, boulevard de la Chapelle, 75475, Paris Cedex 10, France.
| | - Benjamin Speich
- Department of Clinical Research, Basel Institute for Clinical Epidemiology and Biostatistics, University of Basel and University Hospital Basel, Basel, Switzerland.,Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Vera Meier
- Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Janna Tontsch
- Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Tatjana Zehnder
- Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Martin Siegemund
- Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
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Abstract
BACKGROUND Intensive care unit patients undergoing mechanical ventilation have traditionally been sedated to make them comfortable and to avoid pain and anxiety. However, this may lead to prolonged mechanical ventilation and a longer length of stay. OBJECTIVE The aim of this retrospective study was to explore whether different sedation regimens influence the course and duration of the weaning process. PATIENTS AND METHODS Intubated adult patients (n = 152) from 15 general intensive care units in Sweden were mechanically ventilated for ≥ 24 h. Patients were divided into three groups according to the sedative(s) received during the weaning period (i.e. from being assessed as 'fit for weaning' until extubation): dexmedetomidine alone (DEX group, n = 32); standard of care with midazolam and/or propofol (SOC group, n = 67); or SOC plus dexmedetomidine (SOCDEX group, n = 53). RESULTS Patients receiving dexmedetomidine alone were weaned more rapidly than those in the other groups despite spending longer time on mechanical ventilation prior to weaning. Anxiety during weaning was present in 0, 9 and 24% patients in the DEX, SOC and SOCDEX groups, respectively. Anxiety after extubation was present in 41, 20 and 34% in the DEX, SOC and SOCDEX groups, respectively. Delirium during weaning was present in 1, 2 and 1 patient in the DEX, SOC and SOCDEX groups, respectively. Delirium at ICU discharge was present in 1, 0 and 3 patients in the DEX, SOC and SOCDEX groups, respectively. Few patients fulfilled criteria for post-traumatic stress disorder. CONCLUSION Dexmedetomidine, used as a single sedative, may have contributed to a shorter weaning period than SOC or SOCDEX. Patients who received dexmedetomidine-only sedation tended to report better health-related quality of life than those receiving other forms of sedation.
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Chang YF, Chao A, Shih PY, Hsu YC, Lee CT, Tien YW, Yeh YC, Chen LW. Comparison of dexmedetomidine versus propofol on hemodynamics in surgical critically ill patients. J Surg Res 2018; 228:194-200. [DOI: 10.1016/j.jss.2018.03.040] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 03/06/2018] [Accepted: 03/15/2018] [Indexed: 12/30/2022]
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Newsome AS, Chastain DB, Watkins P, Hawkins WA. Complications and Pharmacologic Interventions of Invasive Positive Pressure Ventilation During Critical Illness. J Pharm Technol 2018; 34:153-170. [PMID: 34860978 DOI: 10.1177/8755122518766594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: To review the fundamentals of invasive positive pressure ventilation (IPPV) and the common complications and associated pharmacotherapeutic management in order to provide opportunities for pharmacists to improve patient outcomes. Data Sources: A MEDLINE literature search (1950-December 2017) was performed using the key search terms invasive positive pressure ventilation, mechanical ventilation, pharmacist, respiratory failure, ventilator associated organ dysfunction, ventilator associated pneumonia, ventilator bundles, and ventilator liberation. Additional references were identified from a review of literature citations. Study Selection and Data Extraction: All English-language original research and review reports were evaluated. Data Synthesis: IPPV is a common supportive care measure for critically ill patients. While lifesaving, IPPV is associated with significant complications including ventilator-associated pneumonia, sinusitis, organ dysfunction, and hemodynamic alterations. Optimization of pain and sedation management provides an opportunity for pharmacists to directly affect IPPV exposure. A number of pharmacotherapeutic interventions are related directly to prophylaxis against IPPV-associated adverse events or aimed at reduction of duration of IPPV. Conclusions: Enhanced knowledge of the common complications, associated pharmacotherapy, and monitoring strategies facilitate the pharmacist's ability to provide increased pharmacotherapeutic insight in a multidisciplinary intensive care unit setting.
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Affiliation(s)
- Andrea Sikora Newsome
- The University of Georgia, Augusta, GA, USA.,Augusta University Medical Center, Augusta, GA, USA
| | | | | | - W Anthony Hawkins
- The University of Georgia, Augusta, GA, USA.,The University of Georgia-Albany, GA, USA
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Petitjeans F, Leroy S, Pichot C, Geloen A, Ghignone M, Quintin L. Hypothesis: Fever control, a niche for alpha-2 agonists in the setting of septic shock and severe acute respiratory distress syndrome? Temperature (Austin) 2018; 5:224-256. [PMID: 30393754 PMCID: PMC6209424 DOI: 10.1080/23328940.2018.1453771] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 03/11/2018] [Indexed: 12/12/2022] Open
Abstract
During severe septic shock and/or severe acute respiratory distress syndrome (ARDS) patients present with a limited cardio-ventilatory reserve (low cardiac output and blood pressure, low mixed venous saturation, increased lactate, low PaO2/FiO2 ratio, etc.), especially when elderly patients or co-morbidities are considered. Rescue therapies (low dose steroids, adding vasopressin to noradrenaline, proning, almitrine, NO, extracorporeal membrane oxygenation, etc.) are complex. Fever, above 38.5-39.5°C, increases both the ventilatory (high respiratory drive: large tidal volume, high respiratory rate) and the metabolic (increased O2 consumption) demands, further limiting the cardio-ventilatory reserve. Some data (case reports, uncontrolled trial, small randomized prospective trials) suggest that control of elevated body temperature ("fever control") leading to normothermia (35.5-37°C) will lower both the ventilatory and metabolic demands: fever control should simplify critical care management when limited cardio-ventilatory reserve is at stake. Usually fever control is generated by a combination of general anesthesia ("analgo-sedation", light total intravenous anesthesia), antipyretics and cooling. However general anesthesia suppresses spontaneous ventilation, making the management more complex. At variance, alpha-2 agonists (clonidine, dexmedetomidine) administered immediately following tracheal intubation and controlled mandatory ventilation, with prior optimization of volemia and atrio-ventricular conduction, will reduce metabolic demand and facilitate normothermia. Furthermore, after a rigorous control of systemic acidosis, alpha-2 agonists will allow for accelerated emergence without delirium, early spontaneous ventilation, improved cardiac output and micro-circulation, lowered vasopressor requirements and inflammation. Rigorous prospective randomized trials are needed in subsets of patients with a high fever and spiraling toward refractory septic shock and/or presenting with severe ARDS.
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Affiliation(s)
- F. Petitjeans
- Critical Care, Hôpital d'Instruction des Armées Desgenettes, Lyon, France
| | - S. Leroy
- Pediatric Emergency Medicine, Hôpital Avicenne, Paris-Bobigny, France
| | - C. Pichot
- Critical Care, Hôpital d'Instruction des Armées Desgenettes, Lyon, France
| | - A. Geloen
- Physiology, INSA de Lyon (CARMeN, INSERM U 1060), Lyon-Villeurbanne, France
| | - M. Ghignone
- Critical Care, JF Kennedy Hospital North Campus, WPalm Beach, Fl, USA
| | - L. Quintin
- Critical Care, Hôpital d'Instruction des Armées Desgenettes, Lyon, France
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Guo F, Ding Y, Yu X, Cai X. Effect of dexmedetomidine, midazolam, and propofol on lipopolysaccharide-stimulated dendritic cells. Exp Ther Med 2018; 15:5487-5494. [PMID: 29904429 DOI: 10.3892/etm.2018.6094] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 03/09/2018] [Indexed: 12/17/2022] Open
Abstract
Dexmedetomidine, midazolam and propofol are common sedative drugs used in the intensive care unit. Lipopolysaccharides (LPS) are a potent inducer of human dendritic cells (DCs) maturation and survival, which induces cytokine production. The present study aimed to investigate the effect and mechanisms of sedative drugs on LPS-induced cytokine production in DCs. The mouse bone marrow-derived dendritic DC2.4 cell line was used in the present study. The Cell Counting Kit-8 assay was used to measure the viability of cells. Tumor necrosis factor (TNF)-α, interleukin (IL)-1β, IL-6, and IL-10 mRNA expression levels and contents were measured using reverse transcription-quantitative polymerase chain reaction and ELISA, respectively. The expression levels of proteins associated with nuclear factor-κB (NF-κB) and mitogen activated protein kinase signaling pathways were assessed by western blotting. The three sedatives had different roles on TNF-α, IL-1β, IL-6, and IL-10 mRNA expression levels and content in DCs. Dexmedetomidine promoted inflammatory cytokine production at high clinical concentrations (10, 1 and 0.1 µM), however suppressed them at the lowest clinical concentration (0.001 µM), which was associated with NF-κB and c-Jun N-terminal kinase (JNK)-mitogen-activated protein kinase (MAPK) signaling. Midazolam inhibited inflammatory cytokine production via suppression of the NF-κB and JNK signaling pathways. Propofol partly inhibited inflammatory cytokine production, including IL-1β and IL-6, and the anti-inflammatory effect may result from inhibition of JNK-MAPK, and enhanced NF-κB and extracellular signal-regulated kinase-MAPK signaling at clinical concentrations. The present study helped to elucidate the function of sedatives in LPS-induced cytokine production in DCs, which will facilitate rational implementation of these sedatives in patients undergoing tracheal intubation with sepsis or multiple organ dysfunction syndrome.
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Affiliation(s)
- Feng Guo
- Department of Intensive Care Unit, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, P.R. China
| | - Ying Ding
- Department of Intensive Care Unit, Sir Run Run Shaw Hospital Xiasha Campus, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, P.R. China
| | - Xue Yu
- Department of Medicine, Tengzhou Central People's Hospital, Zaozhuang, Shandong 277500, P.R. China
| | - Xiujun Cai
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, P.R. China
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Efficacy and safety of etomidate-based sedation compared with propofol-based sedation during ERCP in low-risk patients: a double-blind, randomized, noninferiority trial. Gastrointest Endosc 2018; 87:174-184. [PMID: 28610897 DOI: 10.1016/j.gie.2017.05.050] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 05/25/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Etomidate is a short-acting intravenous hypnotic with a safety profile that is superior to alternative drugs such as propofol. However, there is a lack of evidence on the safety of etomidate in ERCP. The objective of this study was to compare efficacy and safety profiles of etomidate and propofol for endoscopic sedation. METHODS This single-center, randomized, double-blind, noninferiority trial included patients with American Society of Anesthesiologists (ASA) physical status I to II who had been scheduled for ERCP. All patients received .05 mg/kg midazolam intravenously as pretreatment before receiving etomidate or propofol. Either etomidate or propofol was then administered according to group allocation. The primary endpoint was an overall respiratory event. A noninferiority margin of 10% was assumed. RESULTS Sixty-three and 64 patients were enrolled in the etomidate and propofol groups, respectively. Respiratory events were identified in 10 patients (15.6%) in the etomidate group and 16 patients (25.4%) on the propofol group, with a rate difference of -9.8% (1-sided 97.5% confidence interval, -∞ to 4.2%). The overall incidence of cardiovascular events tended to be higher in the etomidate group (67.2% vs 50.8%, P = .060). In particular, tachycardia (heart rate > 100 beats/min) was more common in the etomidate group than in the propofol group (64.1% vs 34.9%, P = .001). Transient hypotension tended to be less common in the etomidate group (6.3 vs 15.9%, P = .084). CONCLUSIONS Etomidate-based sedation during ERCP was noninferior to propofol-based sedation in terms of the overall incidence of respiratory events in patients with ASA physical status I to II. (International Clinical Trials Registry Platform number: KCT0001926.).
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Jerath A, Parotto M, Wasowicz M, Ferguson ND. Opportunity Knocks? The Expansion of Volatile Agent Use in New Clinical Settings. J Cardiothorac Vasc Anesth 2017; 32:1946-1954. [PMID: 29449155 DOI: 10.1053/j.jvca.2017.12.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Indexed: 12/27/2022]
Affiliation(s)
- Angela Jerath
- Department of Anesthesia and Pain Medicine, Toronto General Hospital, Toronto, Ontario, Canada.
| | - Matteo Parotto
- Department of Anesthesia and Pain Medicine, Toronto General Hospital, Toronto, Ontario, Canada
| | - Marcin Wasowicz
- Department of Anesthesia and Pain Medicine, Toronto General Hospital, Toronto, Ontario, Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, University Health Network, Toronto, Ontario, Canada
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Cividjian A, Petitjeans F, Liu N, Ghignone M, de Kock M, Quintin L. Do we feel pain during anesthesia? A critical review on surgery-evoked circulatory changes and pain perception. Best Pract Res Clin Anaesthesiol 2017; 31:445-467. [DOI: 10.1016/j.bpa.2017.05.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 05/10/2017] [Indexed: 02/08/2023]
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Pradelli L, Povero M, Bürkle H, Kampmeier TG, Della-Rocca G, Feuersenger A, Baron JF, Westphal M. Propofol or benzodiazepines for short- and long-term sedation in intensive care units? An economic evaluation based on meta-analytic results. CLINICOECONOMICS AND OUTCOMES RESEARCH 2017; 9:685-698. [PMID: 29184423 PMCID: PMC5687490 DOI: 10.2147/ceor.s136720] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose This evaluation compares propofol and benzodiazepine sedation for mechanically ventilated patients in intensive care units (ICUs) in order to identify the potential economic benefits from different payers' perspectives. Methods The patient-level simulation model incorporated efficacy estimates from a structured meta-analysis and ICU-related costs from Italy, Germany, France, UK, and the USA. Efficacy outcomes were ICU length of stay (LOS), mechanical ventilation duration, and weaning time. We calculated ICU costs from mechanical ventilation duration and ICU LOS based on national average ICU costs with and without mechanical ventilation. Three scenarios were investigated: 1) long-term sedation >24 hours based on results from randomized controlled trials (RCTs); 2) long-term sedation based on RCT plus non-RCT results; and 3) short-term sedation <24 hours based on RCT results. We tested the model's robustness for input uncertainties by deterministic (DSA) and probabilistic sensitivity analyses (PSA). Results In the base case, mean savings with propofol versus benzodiazepines in long-term sedation ranged from €406 (95% confidence interval [CI]: 646 to 164) in Italy to 1,632 € (95% CI: 2,362 to 880) in the USA. Inclusion of non-RCT data corroborated these results. Savings in short-term sedation ranged from €148 (95% CI: 291 to 2) in Italy to €502 (95% CI: 936 to 57) in the USA. Parameters related to ICU and mechanical ventilation had a stronger influence in the DSA than drug-related parameters. In PSA, propofol reduced costs and ICU LOS compared to benzodiazepines in 94%-100% of simulations. The largest savings may be possible in the UK and the USA due to higher ICU costs. Conclusion Current ICU sedation guidelines recommend propofol rather than midazolam for mechanically ventilated patients. This evaluation endorses the recommendation as it may lead to better outcomes and savings for health care systems, especially in countries with higher ICU-related costs.
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Affiliation(s)
| | | | - Hartmut Bürkle
- Department of Anaesthesiology and Critical Care Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg
| | - Tim-Gerald Kampmeier
- Clinic for Anesthesiology and Surgical Intensive Care Medicine, University Hospital Münster, Münster, Germany
| | - Giorgio Della-Rocca
- Department of Anaesthesia and Intensive Care Medicine, Medical School of the University of Udine, Udine, Italy
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Liu H, Ji F, Peng K, Applegate RL, Fleming N. Sedation After Cardiac Surgery: Is One Drug Better Than Another? Anesth Analg 2017; 124:1061-1070. [PMID: 27984229 DOI: 10.1213/ane.0000000000001588] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The classic high-dose narcotic-based cardiac anesthetic has been modified to facilitate a fast-track, rapid recovery in the intensive care unit (ICU). Postoperative sedation is consequently now an essential component in recovery of the patient undergoing cardiac surgery. It must facilitate the patient's unawareness of the environment as well as reduce the discomfort and anxiety caused by surgery, intubation, mechanical ventilation, suction, and physiotherapy. Benzodiazepines seem well suited for this role, but propofol, opioids, and dexmedetomidine are among other agents commonly used for sedation in the ICU. However, what is an ideal sedative for this application? When compared with benzodiazepine-based sedation regimens, nonbenzodiazepines have been associated with shorter duration of mechanical ventilation and ICU length of stay. Current sedation guidelines recommend avoiding benzodiazepine use in the ICU. However, there are no recommendations on which alternatives should be used. In postcardiac surgery patients, inotropes and vasoactive medications are often required because of the poor cardiac function. This makes sedation after cardiac surgery unique in comparison with the requirements for most other ICU patient populations. We reviewed the current literature to try to determine if 1 sedative regimen might be better than others; in particular, we compare outcomes of propofol and dexmedetomidine in postoperative sedation in the cardiac surgical ICU.
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Affiliation(s)
- Hong Liu
- From the *Department of Anesthesiology and Pain Medicine, University of California Davis Health System, Sacramento, California; and †Department of Anesthesiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu/China
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Pasero D, Sangalli F, Baiocchi M, Blangetti I, Cattaneo S, Paternoster G, Moltrasio M, Auci E, Murrino P, Forfori F, Forastiere E, De Cristofaro MG, Deste G, Feltracco P, Petrini F, Tritapepe L, Girardis M. Experienced Use of Dexmedetomidine in the Intensive Care Unit: A Report of a Structured Consensus. Turk J Anaesthesiol Reanim 2017; 46:176-183. [PMID: 30140512 DOI: 10.5152/tjar.2018.08058] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 05/28/2018] [Indexed: 11/22/2022] Open
Abstract
Objective Management of pain, agitation and delirium (PAD) remains to be a true challenge in critically ill patients. The pharmacological proprieties of dexmedetomidine (DEX) make it an ideal candidate drug for light and cooperative sedation, but many practical questions remain unanswered. This structured consensus from 17 intensivists well experienced on PAD management and DEX use provides indications for the appropriate use of DEX in clinical practice. Methods A modified RAND/UCLA appropriateness method was used. In four predefined patient populations, the clinical scenarios do not properly cope by the current recommended pharmacological strategies (except DEX), and the possible advantages of DEX use were identified and voted for agreement, after reviewing literature data. Results Three scenarios in medical patients, five scenarios in patients with acute respiratory failure undergoing non-invasive ventilation, three scenarios in patients with cardiac surgery in the early postoperative period and three scenarios in patients with overt delirium were identified as challenging with the current PAD strategies. In these scenarios, the use of DEX was voted as potentially useful by most of the panellists owing to its specific pharmacological characteristics, such as conservation of cognitive function, lack of effects on the respiratory drive, low induction of delirium and analgesia effects. Conclusion DEX might be considered as a first-line sedative in different scenarios even though conclusive data on its benefits are still lacking.
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Affiliation(s)
- Daniela Pasero
- Department of Anaesthesia and Intensive Care, AOU Città della Salute e della Scienza, Turin, Italy
| | - Fabio Sangalli
- Department of Perioperative Medicine and Intensive Care, Cardiothoracic And Vascular Anaesthesia and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - Massimo Baiocchi
- Department of Cardiovascular and Thoracic Surgery, University Hospital of Bologna "s. Orsola-malpighi", Bologna, Italy
| | - Ilaria Blangetti
- Department of Cardiovascular and Thoracic Surgery, Azienda Ospedaliera Santa Croce E Carle, Cuneo, Italy
| | - Sergio Cattaneo
- Department of Anaesthesia and Intensive Care Medicine, Aziende Socio Sanitarie Territoriali Papa Giovanni Xxiii, Bergamo, Italy
| | - Gianluca Paternoster
- Department of Anaesthesia and Intensive Care, Azienda Ospedaliera Regionale San Carlo, Potenza, Italy
| | - Marco Moltrasio
- Cardiac Intensive Care Unit, Centro Cardiologico Monzino, Milan, Italy
| | - Elisabetta Auci
- Department of Anesthesiology and Intensive Care, S. Maria Della Misericordia Hospital, Udine, Italy
| | - Patrizia Murrino
- Department of Anaesthesia and Critical Care Medicine, Aorn Ospedali Dei Colli, Naples, Italy
| | - Francesco Forfori
- Department of Anaesthesia and Critical Care Medicine, Azienda Ospedaliera Pisana, Pisa, Italy
| | - Ester Forastiere
- Department of Anaesthesiology, Regina Elena National Cancer Institute, Rome, Italy
| | | | - Giorgio Deste
- Uoc Anestesia E Rianimazione, Policlinico Casilino, Roma
| | - Paolo Feltracco
- Department of Medicine, Anaesthesia and Intensive Care, University Hospital of Padova, Italy
| | - Flavia Petrini
- Department of Anaesthesia and Intensive Care, University Hospital of Chieti, Chieti, Italy
| | - Luigi Tritapepe
- Department of Anaesthesiology and Intensive Care Medicine, Umberto I Hospital, "sapienza" University, Rome, Italy
| | - Massimo Girardis
- Department of Anaesthesia and Intensive Care, University Hospital of Modena, Modena, Italy
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Romantsik O, Calevo MG, Norman E, Bruschettini M. Clonidine for sedation and analgesia for neonates receiving mechanical ventilation. Cochrane Database Syst Rev 2017; 5:CD012468. [PMID: 28488361 PMCID: PMC6481534 DOI: 10.1002/14651858.cd012468.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although routine administration of pharmacologic sedation or analgesia during mechanical ventilation in preterm neonates is not recommended, its use in clinical practice remains common. Alpha-2 agonists, mainly clonidine and dexmedetomidine, are used as adjunctive (or alternative) sedative agents alongside opioids and benzodiazepines. Clonidine has not been systematically assessed for use in neonatal sedation during ventilation. OBJECTIVES To assess whether clonidine administered to term and preterm newborn infants receiving mechanical ventilation reduces morbidity and mortality rates. To compare the intervention versus placebo, no treatment, and dexmedetomidine; and to assess the safety of clonidine infusion for potential harms.To perform subgroup analyses according to gestational age; birth weight; administration method (infusion or bolus therapy); dose, duration, and route of clonidine administration; and pharmacologic sedation as a co-intervention. SEARCH METHODS We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 12) in the Cochrane Library, MEDLINE via PubMed (1966 to January 10, 2017), Embase (1980 to January 10, 2017), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to January 10, 2017). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomized controlled trials and quasi-randomized trials. SELECTION CRITERIA We searched for randomized controlled trials, quasi-randomized controlled trials, and cluster trials comparing clonidine versus placebo, no treatment, or dexmedetomidine administered to term and preterm newborns receiving mechanical ventilation via an endotracheal tube. DATA COLLECTION AND ANALYSIS For the included trial, two review authors independently extracted data (e.g. number of participants, birth weight, gestational age, all-cause death during initial hospitalization, duration of respiratory support, sedation scale, duration of hospital stay) and assessed risk of bias (e.g. adequacy of randomization, blinding, completeness of follow-up). This review considered primary outcomes of all-cause neonatal death, all-cause death during initial hospitalization, and duration of mechanical ventilation in days. MAIN RESULTS One trial, which included 112 infants, met the inclusion criteria for this review. Term newborn infants on mechanical ventilation with the need for continuous analgesia and sedation with fentanyl and midazolam were eligible for enrollment during the first 96 hours of ventilation. Study authors administered clonidine 1 μg/kg/h or placebo on day 4 after intubation.We found no differences between the two groups in all-cause death during hospitalization (risk ratio [RR] 0.69, 95% confidence interval [CI] 0.12 to 3.98). The quality of the evidence supporting these findings is low owing to imprecision of the estimates (one study; few events). The median (interquartile range) duration of mechanical ventilation was 7.1 days (5.7 to 9.1 days) in the clonidine group and 5.8 days (4.9 to 7.9 days) in the placebo group, respectively (P = 0.070). Among secondary outcomes, we found no differences in terms of duration of stay in the intensive care unit. Sedation scale values (COMFORT) and analgesia scores (Hartwig) during the first 72 hours of infusion of study medication were lower in the clonidine group than in the placebo group. AUTHORS' CONCLUSIONS At present, evidence is insufficient to show the efficacy and safety of clonidine for sedation and analgesia in term and preterm newborn infants receiving mechanical ventilation.
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Affiliation(s)
- Olga Romantsik
- Lund University, Skåne University HospitalDepartment of PaediatricsLundSweden
| | - Maria Grazia Calevo
- Istituto Giannina GasliniEpidemiology, Biostatistics and Committees UnitGenoaItaly16147
| | - Elisabeth Norman
- Lund University, Skane University HospitalDepartment of PaediatricsLundSweden
| | - Matteo Bruschettini
- Lund University, Skåne University HospitalDepartment of PaediatricsLundSweden
- Skåne University HospitalResearch & Development, Section for HTA AnalysisLasarettsgatan 40LundSweden
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Shiotsuka J, Steel A, Downar J. The Sedative Effect of Propranolol on Critically Ill Patients: A Case Series. Front Med (Lausanne) 2017; 4:44. [PMID: 28523268 PMCID: PMC5415564 DOI: 10.3389/fmed.2017.00044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 04/05/2017] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Recent studies have examined the effectiveness of alpha-2 adrenergic agonists for controlling delirium and agitation. Propranolol, a non-selective beta-adrenergic antagonist with good penetration of the blood-brain barrier, has not been investigated for this purpose. MATERIALS AND METHODS We retrospectively reviewed the medical records of all patients who were prescribed propranolol in our Medical Surgical ICU from January 1, 2010, to December 31, 2013. We recorded the sedation level and daily dose of sedatives, analgesics, and antipsychotics administered each day for 6 days after starting propranolol, and compared them to the day before starting propranolol. RESULTS Sixty-four patients met inclusion criteria. Thirty-eight episodes met exclusion criteria, leaving 27 patients (31 episodes). The administration of propranolol was associated with significant reductions in fentanyl equivalents (65%, p = 0.009), midazolam equivalents (57%, p = 0.048), propofol (16%, p = 0.009), and haloperidol (44%, p = 0.024) on day 2 after starting propranolol compared with baseline. A stratified analysis showed that these decreases were seen regardless of clinical improvement or deterioration. CONCLUSION The use of propranolol was associated with a significant reduction in doses of sedatives and analgesia. Further studies are needed to determine whether propranolol may be a useful adjuvant for managing delirium and agitation in the ICU.
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Affiliation(s)
- Junji Shiotsuka
- Division of Critical Care, University Health Network, Toronto, ON, Canada
| | - Andrew Steel
- Division of Critical Care, University Health Network, Toronto, ON, Canada.,Department of Anaesthesiology, University Health Network, Toronto, ON, Canada
| | - James Downar
- Division of Critical Care, University Health Network, Toronto, ON, Canada
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Stollings JL, Bloom SL, Huggins EL, Grayson SL, Jackson JC, Sevin CM. Medication Management to Ameliorate Post-Intensive Care Syndrome. AACN Adv Crit Care 2017; 27:133-40. [PMID: 27153300 DOI: 10.4037/aacnacc2016931] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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