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Effect of Dexmedetomidine on Cardiac Surgery Patients. J Cardiovasc Pharmacol 2023; 81:104-113. [PMID: 36607614 DOI: 10.1097/fjc.0000000000001384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 10/10/2022] [Indexed: 01/07/2023]
Abstract
ABSTRACT Dexmedetomidine, an alpha-2 adrenoreceptor agonist that is widely used as a sedative medication, is becoming more and more attractive in clinical application on cardiac surgery patients. In this review, we aim to summarize and discuss both retrospective studies and clinical trials regarding the effect of dexmedetomidine on patients who underwent cardiac surgery (including coronary artery bypass grafting, valve surgery, aortic surgery, percutaneous coronary intervention, and so on), which illustrates that the clinical effects of dexmedetomidine could effectively reduce mortality, major complications, and the intensive care unit and hospital length of stay without comprising safety. In addition, inconsistent results from both retrospective studies and clinical trials have also been demonstrated. Although the effectiveness and safety of dexmedetomidine on cardiac surgery patients is suggested, high-quality clinical trials are needed for further verification.
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Romano S, Guerreiro JP, Teixeira Rodrigues A. Drug shortages in community pharmacies: Impact on patients and on the health system. J Am Pharm Assoc (2003) 2021; 62:791-799.e2. [DOI: 10.1016/j.japh.2021.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 12/29/2021] [Accepted: 12/29/2021] [Indexed: 11/15/2022]
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Shukar S, Zahoor F, Hayat K, Saeed A, Gillani AH, Omer S, Hu S, Babar ZUD, Fang Y, Yang C. Drug Shortage: Causes, Impact, and Mitigation Strategies. Front Pharmacol 2021; 12:693426. [PMID: 34305603 PMCID: PMC8299364 DOI: 10.3389/fphar.2021.693426] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 06/29/2021] [Indexed: 11/13/2022] Open
Abstract
Drug shortage is a global issue affecting low, middle, and high-income countries. Many countries have developed various strategies to overcome the problem, while the problem is accelerating, affecting the whole world. All types of drugs, such as essential life-saving drugs, oncology medicines, antimicrobial drugs, analgesics, opioids, cardiovascular drugs, radiopharmaceutical, and parenteral products, are liable to the shortage. Among all pharmaceutical dosage forms, sterile injectable products have a higher risk of shortage than other forms. The causes of shortage are multifactorial, including supply issues, demand issues, and regulatory issues. Supply issues consist of manufacturing problems, unavailability of raw materials, logistic problems, and business problems. In contrast, demand issues include just-in-time inventory, higher demand for a product, seasonal demand, and unpredictable demand. For regulatory issues, one important factor is the lack of a unified definition of drug shortage. Drug shortage affects all stakeholders from economic, clinical, and humanistic aspects. WHO established global mitigation strategies from four levels to overcome drug shortages globally. It includes a workaround to tackle the current shortage, operational improvements to reduce the shortage risk and achieve early warning, changes in governmental policies, and education and training of all health professionals about managing shortages.
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Affiliation(s)
- Sundus Shukar
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong University, Xi’an, China
- Center for Drug Safety and Policy Research, Xian Jiaotong University, Xi’an, China
- Shaanxi Centre for Health Reform and Development Research, Xi’an, China
- Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, China’s Western Technological Innovation Harbor, Xi’an, China
| | - Fatima Zahoor
- Department of Pharmacy, Quaid-i-Azam University, Islamabad, Pakistan
- Yusra Institute of Pharmaceutical Sciences, Islamabad, Pakistan
| | - Khezar Hayat
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong University, Xi’an, China
- Center for Drug Safety and Policy Research, Xian Jiaotong University, Xi’an, China
- Shaanxi Centre for Health Reform and Development Research, Xi’an, China
- Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, China’s Western Technological Innovation Harbor, Xi’an, China
- Institute of Pharmaceutical Sciences, University of Veterinary and Animal Sciences, Lahore, Pakistan
| | - Amna Saeed
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong University, Xi’an, China
- Center for Drug Safety and Policy Research, Xian Jiaotong University, Xi’an, China
- Shaanxi Centre for Health Reform and Development Research, Xi’an, China
- Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, China’s Western Technological Innovation Harbor, Xi’an, China
| | - Ali Hassan Gillani
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong University, Xi’an, China
- Center for Drug Safety and Policy Research, Xian Jiaotong University, Xi’an, China
- Shaanxi Centre for Health Reform and Development Research, Xi’an, China
- Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, China’s Western Technological Innovation Harbor, Xi’an, China
| | - Sumaira Omer
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong University, Xi’an, China
- Center for Drug Safety and Policy Research, Xian Jiaotong University, Xi’an, China
- Shaanxi Centre for Health Reform and Development Research, Xi’an, China
- Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, China’s Western Technological Innovation Harbor, Xi’an, China
| | - Shuchen Hu
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong University, Xi’an, China
- Center for Drug Safety and Policy Research, Xian Jiaotong University, Xi’an, China
- Shaanxi Centre for Health Reform and Development Research, Xi’an, China
- Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, China’s Western Technological Innovation Harbor, Xi’an, China
| | - Zaheer-Ud-Din Babar
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield, United Kingdom
| | - Yu Fang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong University, Xi’an, China
- Center for Drug Safety and Policy Research, Xian Jiaotong University, Xi’an, China
- Shaanxi Centre for Health Reform and Development Research, Xi’an, China
- Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, China’s Western Technological Innovation Harbor, Xi’an, China
| | - Caijun Yang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong University, Xi’an, China
- Center for Drug Safety and Policy Research, Xian Jiaotong University, Xi’an, China
- Shaanxi Centre for Health Reform and Development Research, Xi’an, China
- Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, China’s Western Technological Innovation Harbor, Xi’an, China
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Clinical and economic impact of the use of dexmedetomidine for sedation in the intensive care unit compared to propofol. Int J Clin Pharm 2020; 42:1419-1424. [PMID: 32860596 DOI: 10.1007/s11096-020-01103-3] [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: 04/04/2020] [Accepted: 07/08/2020] [Indexed: 10/23/2022]
Abstract
Background Despite the advantages of dexmedetomidine (DEX) over propofol (PRO) including minimal respiratory depression and the potential for preventing and/or treating intensive care unit (ICU) delirium, PRO has been the preferred agent due to its lower cost. However, the acquisition cost of DEX has considerably decreased as a generic version of DEX has recently become available. Objective To evaluate clinical and economic outcomes of DEX-based sedation compared to PRO in the ICU. Setting A retrospective cohort study of 86 ICU patients who received either DEX or PRO for a period ≥ 12 h. Method Patients were matched by age, sex, and Sequential Organ Failure Assessment scores in a 1:1 ratio. Main outcome measure Clinical outcomes included the duration of mechanical ventilation (MV), ICU and hospital length of stay (LOS), and requirements of concomitant sedatives and opioids. Economic outcomes included the ICU and hospital costs as well as the cost of sedatives or combined sedatives and opioids per patient. Results There were no significant differences in ICU and hospital LOS and time on MV in both groups (median ICU LOS 7 [DEX] vs. 9 [PRO] days, p = 0.07; median hospital LOS 12 [DEX] vs. 14 [PRO] days, p = 0.261; median time of MV 144 [DEX] vs. 158 [PRO] hours, p = 0.176). DEX-based sedation compared to PRO was associated with similar ICU and hospital costs (US$ 67,561 vs. 78,429, p = 0.39; US$ 71,923 vs. 71,084, p = 0.1). Conclusion The clinical outcomes and economic impact associated with DEX- and PRO-based sedation were similar.
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Aggarwal J, Lustrino J, Stephens J, Morgenstern D, Tang WY. <p>Cost-Minimization Analysis of Dexmedetomidine Compared to Other Sedatives for Short-Term Sedation During Mechanical Ventilation in the United States</p>. CLINICOECONOMICS AND OUTCOMES RESEARCH 2020; 12:389-397. [PMID: 32801809 PMCID: PMC7395701 DOI: 10.2147/ceor.s242994] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 07/02/2020] [Indexed: 12/04/2022] Open
Abstract
Purpose Mechanical ventilation (MV) remains a substantial cost driver in intensive care units (ICU) in the United States (US). Evaluations of standard sedation treatments used to relieve pain and discomfort in this setting have found varying impacts on ICU length of stay. This cost analysis examines both length-of=stay costs and the total cost implications among MV patients receiving common sedative treatments (dexmedetomidine, propofol, or midazolam) in short-term sedation settings (<24 hours). Methods A cost-minimization model was conducted from the hospital provider perspective. Clinical outcomes were obtained from published literature and included ICU length of stay, MV duration, prescription of sedatives and pain medication, and the occurrence of adverse events. Outcomes costs were obtained from previously conducted ICU cost studies and Medicare payment fee schedules. All costs were estimated in 2018 US Dollars. Results The per patient costs associated with dexmedetomidine, propofol, and midazolam were estimated to be $21,115, $27,073, and $27,603, respectively. Dexmedetomidine was associated with a savings of $5958 per patient compared to propofol and a saving of $6487 compared to midazolam. These savings were primarily driven by a reduction in ICU length of stay and the degree of monitoring and management. Conclusion Dexmedetomidine was associated with reduced costs when compared to propofol or midazolam used for short-term sedation during MV in the ICU, suggesting sedative choice can have a potential impact on overall cost per episode.
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Affiliation(s)
| | | | | | | | - Wing Yu Tang
- Pfizer, New York, NY, USA
- Correspondence: Wing Yu Tang Pfizer, 235 E. 42nd St, New York, NY10017, USA Email
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Cardiovascular Safety of Clonidine and Dexmedetomidine in Critically Ill Patients after Cardiac Surgery. Crit Care Res Pract 2020; 2020:4750615. [PMID: 32455009 PMCID: PMC7229561 DOI: 10.1155/2020/4750615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 02/26/2020] [Indexed: 12/17/2022] Open
Abstract
Purpose The aim of this retrospective study was to assess the haemodynamic adverse effects of clonidine and dexmedetomidine in critically ill patients after cardiac surgery. Methods 2769 patients were screened during the 30-month study period. Heart rate (HR), mean arterial pressure (MAP), and norepinephrine requirements were assessed 3-hourly during the first 12 hours of the continuous drug infusion. Results are given as median (interquartile range) or numbers (percentages). Results Patients receiving clonidine (n = 193) were younger (66 (57-73) vs 70 (63-77) years, p=0.003) and had a lower SAPS II (35 (27-48) vs 41 (31-54), p=0.008) compared with patients receiving dexmedetomidine (n = 141). At the start of the drug infusion, HR (90 (75-100) vs 90 (80-105) bpm, p=0.028), MAP (70 (65-80) vs 70 (65-75) mmHg, p=0.093), and norepinephrine (0.05 (0.00-0.11) vs 0.12 (0.03-0.19) mcg/kg/min, p < 0.001) were recorded in patients with clonidine and dexmedetomidine. Bradycardia (HR < 60 bpm) developed in 7.8% with clonidine and 5.7% with dexmedetomidine (p=0.51). Between baseline and 12 hours, norepinephrine remained stable in the clonidine group (0.00 (-0.04-0.02) mcg/kg/min) and decreased in the dexmedetomidine group (-0.03 (-0.10-0.02) mcg/kg/min, p=0.007). Conclusions Dexmedetomidine and the low-cost drug clonidine can both be used safely in selected patients after cardiac surgery.
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Brock L. Dexmedetomidine in Adult Patients in Cardiac Surgery Critical Care: An Evidence-Based Review. AACN Adv Crit Care 2020; 30:259-268. [PMID: 31462522 DOI: 10.4037/aacnacc2019888] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Although several options are available for postoperative sedation in the intensive care unit, the selective α2-adrenoceptor agonist dexmedetomidine may offer advantages for patients after cardiac surgery. The author conducted a review of the literature on the use of dexmedetomidine in the cardiac surgery population to determine possible advantages and disadvantages in this patient population. Although the use of dexmedetomidine has not been conclusively shown to change overall morbidity and mortality and may be associated with higher drug cost, its other demonstrated effects offer advantages for postoperative cardiac surgery patients that other forms of sedation cannot match.
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Affiliation(s)
- Lyndsay Brock
- Lyndsay Brock is Acute Care Nurse Practitioner, Surgical Intensive Care Unit, University Hospitals of Cleveland Ahuja Medical Center, 3999 Richmond Rd, Beachwood, OH 44122
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The impacts of medication shortages on patient outcomes: A scoping review. PLoS One 2019; 14:e0215837. [PMID: 31050671 PMCID: PMC6499468 DOI: 10.1371/journal.pone.0215837] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 04/09/2019] [Indexed: 12/29/2022] Open
Abstract
Background In recent years, medication shortages have become a growing worldwide issue. This scoping review aimed to systematically synthesise the literature to report on the economic, clinical, and humanistic impacts of medication shortages on patient outcomes. Methods Medline, Embase, Global Health, PsycINFO and International Pharmaceutical Abstracts were searched using the two key concepts of medicine shortage and patient outcomes. Articles were limited to the English language, human studies and there were no limits to the year of publication. Manuscripts included contained information regarding the shortage of a scheduled medication and had gathered data regarding the economic, clinical, and/or humanistic outcomes of drug shortages on human patients. Findings We found that drug shortages were predominantly reported to have adverse economic, clinical and humanistic outcomes to patients. Patients were more commonly reported to have increased out of pocket costs, rates of drug errors, adverse events, mortality, and complaints during times of shortage. There were also reports of equivalent and improved patient outcomes in some cases. Conclusions The results of this review provide valuable insights into the impact drug shortages have on patient outcomes. The majority of studies reported medication shortages resulted in negative patient clinical, economic and humanistic outcomes.
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Klaus DA, de Bettignies AM, Seemann R, Krenn CG, Roth GA. Impact of a remifentanil supply shortage on mechanical ventilation in a tertiary care hospital: a retrospective comparison. Crit Care 2018; 22:267. [PMID: 30367645 PMCID: PMC6204001 DOI: 10.1186/s13054-018-2198-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 09/24/2018] [Indexed: 11/17/2022] Open
Abstract
Background The continuous administration of opioids in critical care patients is a common therapy for the tolerance of mechanical ventilation. Opioid choice has a crucial impact on the length of mechanical ventilation. Owing to its very short context-sensitive half-life, remifentanil widens the available options for sedoanalgetic strategies. Supply disruption of such established intensive care medication has been reported to worsen clinical outcomes. Methods This retrospective study investigated the influence of a nationwide supply shortage of remifentanil on mechanical ventilation and ventilation-associated outcomes at three perioperative intensive care units (ICUs) in a tertiary care hospital in Vienna. Two groups were followed: patients admitted to the ICU during the remifentanil shortage (July 1, 2016 to September 30, 2016) and a control group one year after the remifentanil shortage (July 1, 2017 to September 30, 2017). Included patients were adults, received mechanical ventilation for at least 6 h, were admitted less than 90 days in the respective ICU, and survived their admission. Results For comparison, Poisson count regression models and logistic regression models were computed. To compensate for multiple testing, the significance level was split (0.02 for the primary and 0.006 for secondary outcome parameters). Patients in the remifentanil shortage group received significantly longer mechanical ventilation (risk ratio 2.19, 95% confidence interval 2.14–2.24, P <0.001) with significantly prolonged ICU stay (P <0.001), days with non-invasive ventilation (P <0.001), and length of hospital stay (P <0.001). No significant difference was found in the occurrence of pneumonia (P = 0.040) and sepsis (P = 0.061). A greater proportion of patients in the shortage group underwent secondary tracheostomy (P <0.001). Conclusions The remifentanil shortage caused a significant impairment of essential outcome parameters in the ICU. Electronic supplementary material The online version of this article (10.1186/s13054-018-2198-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Daniel A Klaus
- Department of Anaesthesiology, General Intensive Care and Pain Medicine, Medical University of Vienna, Waehringer Gürtel 18-20, A-1090, Vienna, Austria. .,RAIC Laboratory 13C1, Medical University of Vienna, Waehringer Gürtel 18-20, A-1090, Vienna, Austria.
| | - Albert M de Bettignies
- Department of Anaesthesiology, General Intensive Care and Pain Medicine, Medical University of Vienna, Waehringer Gürtel 18-20, A-1090, Vienna, Austria.,RAIC Laboratory 13C1, Medical University of Vienna, Waehringer Gürtel 18-20, A-1090, Vienna, Austria
| | - Rudolf Seemann
- Department of Craniomaxillofacial and Oral Surgery, Medical University of Vienna, Waehringer Gürtel 18-20, A-1090, Vienna, Austria
| | - Claus G Krenn
- Department of Anaesthesiology, General Intensive Care and Pain Medicine, Medical University of Vienna, Waehringer Gürtel 18-20, A-1090, Vienna, Austria.,RAIC Laboratory 13C1, Medical University of Vienna, Waehringer Gürtel 18-20, A-1090, Vienna, Austria
| | - Georg A Roth
- Department of Anaesthesiology, General Intensive Care and Pain Medicine, Medical University of Vienna, Waehringer Gürtel 18-20, A-1090, Vienna, Austria.,RAIC Laboratory 13C1, Medical University of Vienna, Waehringer Gürtel 18-20, A-1090, Vienna, Austria.,Department of Anaesthesia and Intensive Care Medicine, Franziskus Hospital, Nikolsdorfergasse 32, A-1050, Vienna, Austria
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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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Nguyen J, Nacpil N. Effectiveness of dexmedetomidine versus propofol on extubation times, length of stay and mortality rates in adult cardiac surgery patients. ACTA ACUST UNITED AC 2018; 16:1220-1239. [DOI: 10.11124/jbisrir-2017-003488] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Evaluation of Practice Changes in the Care of Patients with Septic Shock during the U.S. Norepinephrine Shortage. Ann Am Thorac Soc 2018. [PMID: 29537858 DOI: 10.1513/annalsats.201712-926rl] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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Nguyen J, Nacpil N. A comparison between dexmedetomidine and propofol on extubation times in postoperative adult cardiac surgery patients: a systematic review protocol. ACTA ACUST UNITED AC 2018; 14:63-71. [PMID: 27941511 DOI: 10.11124/jbisrir-2016-003195] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
REVIEW QUESTION/OBJECTIVE The objective of this systematic review is to synthesize the best available evidence regarding the effects of dexmedetomidine compared to propofol on time to extubation, intensive care unit (ICU) length of stay (LOS), hospital LOS and mortality in postoperative adult cardiac surgery patients.The specific review question is as follows:What is the effectiveness of dexmedetomidine compared to propofol on times to extubation, ICU LOS, hospital LOS and mortality in postoperative adults undergoing cardiac surgery?
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Affiliation(s)
- John Nguyen
- The Center for Translational Research: a Joanna Briggs Institute Center of Excellence, Forth Worth, USA
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De Weerdt E, Simoens S, Casteels M, Huys I. Clinical, Economic and Policy Implications of Drug Shortages in the European Union. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2017; 15:441-445. [PMID: 27480539 DOI: 10.1007/s40258-016-0264-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Drug shortages are an international problem, which seems to worsen. In this paper, the clinical, economic and policy implications of drug shortages are discussed, based on data available for the EU. Research on the clinical impact is scarce. Most data describe that patients will experience more side effects or need to postpone their treatment. However, more detailed research such as case studies and the number of patients affected are lacking. Information on the economic impact is described as an estimation of the time spent by hospital pharmacies. Other stakeholders are also burdened: manufacturers loose part of their profit, patients may pay more for the alternative treatment and society pays for additional health-care costs. However, no data are available. Again more detailed and objective research is necessary to know where the problem is situated and how solutions can be proposed. Policy implications are also rather scarce. However, once more detailed and objective research has been conducted, policy changes will follow. All stakeholders should be involved in the discussions, prior to the implementation of policy measures.
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Affiliation(s)
- Elfi De Weerdt
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Herestraat 49 Box 521, 3000, Louvain, Belgium.
| | - Steven Simoens
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Herestraat 49 Box 521, 3000, Louvain, Belgium
| | - Minne Casteels
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Herestraat 49 Box 521, 3000, Louvain, Belgium
| | - Isabelle Huys
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Herestraat 49 Box 521, 3000, Louvain, Belgium
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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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Blaine KP, Press C, Lau K, Sliwa J, Rao VK, Hill C. Comparative effectiveness of epsilon-aminocaproic acid and tranexamic acid on postoperative bleeding following cardiac surgery during a national medication shortage. J Clin Anesth 2016; 35:516-523. [PMID: 27871586 DOI: 10.1016/j.jclinane.2016.08.037] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 08/14/2016] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVE The aim of this study was to compare the effectiveness of epsilon-aminocaproic acid (εACA) and tranexamic acid (TXA) in contemporary clinical practice during a national medication shortage. DESIGN A retrospective cohort study. SETTING The study was performed in all consecutive cardiac surgery patients (n=128) admitted to the cardiac-surgical intensive care unit after surgery at a single academic center immediately before and during a national medication shortage. MEASUREMENTS Demographic, clinical, and outcomes data were compared by descriptive statistics using χ2 and t test. Surgical drainage and transfusions were compared by multivariate linear regression for patients receiving εACA before the shortage and TXA during the shortage. MAIN RESULTS In multivariate analysis, no statistical difference was found for surgical drain output (OR 1.10, CI 0.97-1.26, P=.460) or red blood cell transfusion requirement (OR 1.79, CI 0.79-2.73, P=.176). Patients receiving εACA were more likely to receive rescue hemostatic medications (OR 1.62, CI 1.02-2.55, P=.041). CONCLUSIONS Substitution of εACA with TXA during a national medication shortage produced equivalent postoperative bleeding and red cell transfusions, although patients receiving εACA were more likely to require supplemental hemostatic agents.
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Affiliation(s)
- Kevin P Blaine
- Department of Anesthesia, Pain, and Perioperative Medicine, Stanford University Medical Center, 300 Pasteur Dr, H3580, Stanford, CA 97305.
| | - Christopher Press
- Department of Anesthesia, Pain, and Perioperative Medicine, Stanford University Medical Center, 300 Pasteur Dr, H3580, Stanford, CA 97305
| | - Ken Lau
- Department of Anesthesia, Pain, and Perioperative Medicine, Stanford University Medical Center, 300 Pasteur Dr, H3580, Stanford, CA 97305
| | - Jan Sliwa
- Department of Anesthesia, Pain, and Perioperative Medicine, Stanford University Medical Center, 300 Pasteur Dr, H3580, Stanford, CA 97305
| | - Vidya K Rao
- Department of Anesthesia, Pain, and Perioperative Medicine, Stanford University Medical Center, 300 Pasteur Dr, H3580, Stanford, CA 97305
| | - Charles Hill
- Department of Anesthesia, Pain, and Perioperative Medicine, Stanford University Medical Center, 300 Pasteur Dr, H3580, Stanford, CA 97305
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Dexmedetomidine versus Propofol Sedation Reduces Delirium after Cardiac Surgery: A Randomized Controlled Trial. Anesthesiology 2016; 124:362-8. [PMID: 26575144 DOI: 10.1097/aln.0000000000000951] [Citation(s) in RCA: 221] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Postoperative delirium (POD) is a serious complication after cardiac surgery. Use of dexmedetomidine to prevent delirium is controversial. The authors hypothesized that dexmedetomidine sedation after cardiac surgery would reduce the incidence of POD. METHODS After institutional ethics review board approval, and informed consent, a single-blinded, prospective, randomized controlled trial was conducted in patients 60 yr or older undergoing cardiac surgery. Patients with a history of serious mental illness, delirium, and severe dementia were excluded. Upon admission to intensive care unit (ICU), patients received either dexmedetomidine (0.4 μg/kg bolus followed by 0.2 to 0.7 μg kg h infusion) or propofol (25 to 50 μg kg min infusion) according to a computer-generated randomization code in blocks of four. Assessment of delirium was performed with confusion assessment method for ICU or confusion assessment method after discharge from ICU at 12-h intervals during the 5 postoperative days. Primary outcome was the incidence of POD. RESULTS POD was present in 16 of 91 (17.5%) and 29 of 92 (31.5%) patients in dexmedetomidine and propofol groups, respectively (odds ratio, 0.46; 95% CI, 0.23 to 0.92; P = 0.028). Median onset of POD was on postoperative day 2 (1 to 4 days) versus 1 (1 to 4 days), P = 0.027, and duration of POD 2 days (1 to 4 days) versus 3 days (1 to 5 days), P = 0.04, in dexmedetomidine and propofol groups, respectively. CONCLUSIONS When compared with propofol, dexmedetomidine sedation reduced incidence, delayed onset, and shortened duration of POD in elderly patients after cardiac surgery. The absolute risk reduction for POD was 14%, with a number needed to treat of 7.1.
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Sheu R, Cormican D, McConnell M. Con: Dexmedetomidine Sedation Should Not Be Used Routinely for All Post-cardiac Surgical Patients in the Intensive Care Unit. J Cardiothorac Vasc Anesth 2016; 30:1422-4. [PMID: 27640896 DOI: 10.1053/j.jvca.2016.05.043] [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: 05/18/2016] [Indexed: 01/22/2023]
Affiliation(s)
- Richard Sheu
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA.
| | - Daniel Cormican
- Department of Anesthesiology, Allegheny Health Network, Pittsburgh, PA
| | - Matthew McConnell
- Department of Anesthesiology, Allegheny Health Network, Pittsburgh, PA
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Weatherspoon D, Sullivan D, Weatherspoon CA. Obstructive Sleep Apnea and Modifications in Sedation: An Update. Crit Care Nurs Clin North Am 2016; 28:217-26. [PMID: 27215359 DOI: 10.1016/j.cnc.2016.02.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
One factor that may contribute to an increased risk for airway compromise is obstructive sleep apnea (OSA). Sedation in this population carries an increased risk for hypopnea. Critical care nurses must decide on the amount and type of sedation to administer at the point of care. It is important for them to understand OSA and the routinely prescribed sedatives that may affect this disorder. This article discusses the pathophysiology of OSA and traits that may help identify patients with undiagnosed OSA. The most commonly prescribed sedative pharmacologic agents and adjunctive airway support mechanisms are reviewed for use in this population.
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Affiliation(s)
- Deborah Weatherspoon
- School of Nursing Graduate Program, College of Health Sciences, Walden University, Washington Avenue South, Suite 900, Minneapolis, MN 55401, USA.
| | - Debra Sullivan
- School of Nursing MSN Program, School of Nursing Graduate Program, College of Health Sciences, Walden University, Washington Avenue South, Suite 900, Minneapolis, MN 55401, USA
| | - Christopher A Weatherspoon
- School of Nursing Graduate Program, College of Health Sciences, Walden University, Washington Avenue South, Suite 900, Minneapolis, MN 55401, USA; Veteran Affairs, Tennessee Valley Health System, Fort Campbell, KY, USA
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Abstract
PURPOSE OF REVIEW There is recognition that the use of sedative drugs in critically ill patients is potentially harmful, particularly in relation to ICU delirium and clinical outcomes. In that context, there is an increasing interest in maintaining light sedation, the use of non-gamma-aminobutyric acid agonist agents and antipsychotics. RECENT FINDINGS The sedative drugs currently available have limitations relating to duration of action, cost or variability in response. Recent reviews and meta-analyses comparing sedatives in ICU patients differ in their findings depending on whether trials in elective cardiac surgical patients are included. Dexmedetomidine does appear to reduce the number of ventilator days in the less sick critically ill patient. There is currently no evidence to support the routine use of antipsychotics in ICU patients to prevent or treat delirium, although they will reduce agitation and they appear to be well tolerated when used in the critically ill patient. Sedation protocols and early mobilization reduce the use of sedative drugs and improve some outcomes but are challenging to implement in practice. SUMMARY The bedside clinician needs to balance the need to sedate the patient and maintain life-saving support, while keeping their patient responsive, cooperative and pain free.
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Turunen H, Jakob SM, Ruokonen E, Kaukonen KM, Sarapohja T, Apajasalo M, Takala J. Dexmedetomidine versus standard care sedation with propofol or midazolam in intensive care: an economic evaluation. Crit Care 2015; 19:67. [PMID: 25887576 PMCID: PMC4391080 DOI: 10.1186/s13054-015-0787-y] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 02/04/2015] [Indexed: 11/14/2022] Open
Abstract
Introduction Dexmedetomidine was shown in two European randomized double-blind double-dummy trials (PRODEX and MIDEX) to be non-inferior to propofol and midazolam in maintaining target sedation levels in mechanically ventilated intensive care unit (ICU) patients. Additionally, dexmedetomidine shortened the time to extubation versus both standard sedatives, suggesting that it may reduce ICU resource needs and thus lower ICU costs. Considering resource utilization data from these two trials, we performed a secondary, cost-minimization analysis assessing the economics of dexmedetomidine versus standard care sedation. Methods The total ICU costs associated with each study sedative were calculated on the basis of total study sedative consumption and the number of days patients remained intubated, required non-invasive ventilation, or required ICU care without mechanical ventilation. The daily unit costs for these three consecutive ICU periods were set to decline toward discharge, reflecting the observed reduction in mean daily Therapeutic Intervention Scoring System (TISS) points between the periods. A number of additional sensitivity analyses were performed, including one in which the total ICU costs were based on the cumulative sum of daily TISS points over the ICU period, and two further scenarios, with declining direct variable daily costs only. Results Based on pooled data from both trials, sedation with dexmedetomidine resulted in lower total ICU costs than using the standard sedatives, with a difference of €2,656 in the median (interquartile range) total ICU costs—€11,864 (€7,070 to €23,457) versus €14,520 (€7,871 to €26,254)—and €1,649 in the mean total ICU costs. The median (mean) total ICU costs with dexmedetomidine compared with those of propofol or midazolam were €1,292 (€747) and €3,573 (€2,536) lower, respectively. The result was robust, indicating lower costs with dexmedetomidine in all sensitivity analyses, including those in which only direct variable ICU costs were considered. The likelihood of dexmedetomidine resulting in lower total ICU costs compared with pooled standard care was 91.0% (72.4% versus propofol and 98.0% versus midazolam). Conclusions From an economic point of view, dexmedetomidine appears to be a preferable option compared with standard sedatives for providing light to moderate ICU sedation exceeding 24 hours. The savings potential results primarily from shorter time to extubation. Trial registration ClinicalTrials.gov NCT00479661 (PRODEX), NCT00481312 (MIDEX). Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-0787-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Heidi Turunen
- Orion Corporation Orion Pharma, Orionintie 1, FI-02100, Espoo, Finland.
| | - Stephan M Jakob
- Department of Intensive Care Medicine, Bern University Hospital and University of Bern, Freiburgstrasse, CH-3010, Bern, Switzerland.
| | - Esko Ruokonen
- Department of Intensive Care Medicine, Kuopio University Hospital, Puijonlaaksontie 2, FI-70210, Kuopio, Finland.
| | - Kirsi-Maija Kaukonen
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, 99 Commercial Road, 3004, Melbourne, Victoria, Australia. .,Intensive Care Units, Helsinki University Central Hospital, Haartmaninkatu 2, 00029 HUS, Helsinki, Finland.
| | - Toni Sarapohja
- Orion Corporation Orion Pharma, Orionintie 1, FI-02100, Espoo, Finland.
| | - Marjo Apajasalo
- Orion Corporation Orion Pharma, Orionintie 1, FI-02100, Espoo, Finland.
| | - Jukka Takala
- Department of Intensive Care Medicine, Bern University Hospital and University of Bern, Freiburgstrasse, CH-3010, Bern, Switzerland.
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Patanwala AE, Erstad BL. Comparison of Dexmedetomidine Versus Propofol on Hospital Costs and Length of Stay. J Intensive Care Med 2014; 31:466-70. [PMID: 25061063 DOI: 10.1177/0885066614544452] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 05/21/2014] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The objective of this evaluation was to compare total hospital costs and length of stay of critically ill patients who received dexmedetomidine versus propofol for sedation in the intensive care unit (ICU). METHODS This was a retrospective quality improvement evaluation at a tertiary care, academic medical center in the United States. Data were retrieved for patients discharged between April 2012 and June 2013. Patients were included if they were admitted to the ICU, were 18 years of age or older, and received dexmedetomidine or propofol for sedation. Multivariate regression models were developed to determine the association between sedative type and hospital costs, ICU length of stay, and hospital length of stay. RESULTS The final cohort included 3294 patients. Of these, 2685 received propofol and 609 received dexmedetomidine. The median hospital cost was US$31 041 (interquartile range [IQR] US$17 963-US$57 826) in the propofol group and US$46 716 (IQR US$31 247 to US$85 490) in the dexmedetomidine group (P < .001). The median ICU length of stay was 2 days (IQR 1-6 days) and 4 days (IQR 2-9 days) in the propofol and dexmedetomidine groups, respectively (P < .001). Overall, hospital length of stay was 8 days (IQR 4-15 days) and 9 days (IQR 5-18 days) in the 2 groups, respectively (P < .001). In the multivariate analyses, dexmedetomidine use was associated with increased costs, ICU length of stay, and hospital length of stay (P < .001 for each outcome). CONCLUSIONS In this academic medical center, dexmedetomidine use was associated with higher costs when compared to propofol for sedation in the ICU. Also, use of dexmedetomidine was associated with increased lengths of ICU and hospital stay. Future prospective trials are needed to confirm these findings.
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Affiliation(s)
- Asad E Patanwala
- Department of Pharmacy Practice and Science, College of Pharmacy, The University of Arizona, Tucson, AZ, USA
| | - Brian L Erstad
- Department of Pharmacy Practice and Science, College of Pharmacy, The University of Arizona, Tucson, AZ, USA
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