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Bermúdez-Barrezueta L, Mayordomo-Colunga J, Miñambres-Rodríguez M, Reyes S, Valencia-Ramos J, Lopez-Fernandez YM, Mendizábal-Diez M, Vivanco-Allende A, Palacios-Cuesta A, Oviedo-Melgares L, Unzueta-Roch JL, López-González J, Jiménez-Villalta MT, Cuervas-Mons Tejedor M, Artacho González L, Jiménez Olmos A, Pons-Òdena M. Implications of sedation during the use of noninvasive ventilation in children with acute respiratory failure (SEDANIV Study). Crit Care 2024; 28:235. [PMID: 38992698 PMCID: PMC11241858 DOI: 10.1186/s13054-024-04976-2] [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] [Received: 03/24/2024] [Accepted: 05/29/2024] [Indexed: 07/13/2024] Open
Abstract
BACKGROUND The objective of this study was to analyze the effects of sedation administration on clinical parameters, comfort status, intubation requirements, and the pediatric intensive care unit (PICU) length of stay (LOS) in children with acute respiratory failure (ARF) receiving noninvasive ventilation (NIV). METHODS Thirteen PICUs in Spain participated in a prospective, multicenter, observational trial from January to December 2021. Children with ARF under the age of five who were receiving NIV were included. Clinical information and comfort levels were documented at the time of NIV initiation, as well as at 3, 6, 12, 24, and 48 h. The COMFORT-behavior (COMFORT-B) scale was used to assess the patients' level of comfort. NIV failure was considered to be a requirement for endotracheal intubation. RESULTS A total of 457 patients were included, with a median age of 3.3 months (IQR 1.3-16.1). Two hundred and thirteen children (46.6%) received sedation (sedation group); these patients had a higher heart rate, higher COMFORT-B score, and lower SpO2/FiO2 ratio than did those who did not receive sedation (non-sedation group). A significantly greater improvement in the COMFORT-B score at 3, 6, 12, and 24 h, heart rate at 6 and 12 h, and SpO2/FiO2 ratio at 6 h was observed in the sedation group. Overall, the NIV success rate was 95.6%-intubation was required in 6.1% of the sedation group and in 2.9% of the other group (p = 0.092). Multivariate analysis revealed that the PRISM III score at NIV initiation (OR 1.408; 95% CI 1.230-1.611) and respiratory rate at 3 h (OR 1.043; 95% CI 1.009-1.079) were found to be independent predictors of NIV failure. The PICU LOS was correlated with weight, PRISM III score, respiratory rate at 12 h, SpO2 at 3 h, FiO2 at 12 h, NIV failure and NIV duration. Sedation use was not found to be independently related to NIV failure or to the PICU LOS. CONCLUSIONS Sedation use may be useful in children with ARF treated with NIV, as it seems to improve clinical parameters and comfort status but may not increase the NIV failure rate or PICU LOS, even though sedated children were more severe at technique initiation in the present sample.
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Affiliation(s)
- Lorena Bermúdez-Barrezueta
- Pediatric and Neonatal Intensive Care, Department of Pediatrics, Hospital Clínico Universitario de Valladolid, Av. Ramón y Cajal, 3, 47003, Valladolid, Spain.
- Department of Pediatrics, Faculty of Medicine, Valladolid University, Valladolid, Spain.
| | - Juan Mayordomo-Colunga
- Pediatric Intensive Care Unit, Hospital Universitario Central de Asturias, Oviedo, Spain
- Department of Pediatrics, University of Oviedo, Oviedo, Spain
- Centro de Investigación Biomédica en Red Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin (RICORS), Instituto de Salud Carlos III, RD21/0012/0020, Madrid, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
| | - María Miñambres-Rodríguez
- Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Susana Reyes
- Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Juan Valencia-Ramos
- Pediatric Intensive Care Unit, Department of Pediatrics, Complejo Asistencial Universitario de Burgos, Burgos, Spain
- Ciencias de la Salud, University of Burgos, Burgos, Spain
| | - Yolanda Margarita Lopez-Fernandez
- Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Universitario de Cruces, BioBizkaia-Bizkaia Health Research Institute, Bizkaia, Spain
| | - Mikel Mendizábal-Diez
- Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Universitario de Navarra, Pamplona, Spain
| | - Ana Vivanco-Allende
- Pediatric Intensive Care Unit, Hospital Universitario Central de Asturias, Oviedo, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
| | - Alba Palacios-Cuesta
- Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Universitario, 12 de Octubre, Madrid, Spain
| | - Lidia Oviedo-Melgares
- Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Universitario, 12 de Octubre, Madrid, Spain
| | - José Luis Unzueta-Roch
- Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Jorge López-González
- Pediatric Intensive Care Unit Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Maite Cuervas-Mons Tejedor
- Pediatric Intensive Care Unit, Department of Pediatrics, Complejo Asistencial Universitario de Burgos, Burgos, Spain
| | - Lourdes Artacho González
- Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Ainhoa Jiménez Olmos
- Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Martí Pons-Òdena
- Inmune and Respiratory Dysfunction Research Group, Institut de Recerca Sant Joan de Déu, Santa Rosa 39-57, 08950, Esplugues de Llobregat, Spain
- Pediatric Intensive Care and Intermediate Care Department, Hospital Universitario Sant Joan de Déu, Universitat de Barcelona, Esplugues de Llobregat, Spain
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Dunbar PJ, Peterson R, McGrath M, Pomponio R, Kiser TH, Ho PM, Vandivier RW, Burnham EL, Moss M, Sottile PD. Analgesia and Sedation Use During Noninvasive Ventilation for Acute Respiratory Failure. Crit Care Med 2024; 52:1043-1053. [PMID: 38506571 DOI: 10.1097/ccm.0000000000006253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
OBJECTIVES To describe U.S. practice regarding administration of sedation and analgesia to patients on noninvasive ventilation (NIV) for acute respiratory failure (ARF) and to determine the association of this practice with odds of intubation or death. DESIGN A retrospective multicenter cohort study. SETTING A total of 1017 hospitals contributed data between January 2010 and September 2020 to the Premier Healthcare Database, a nationally representative healthcare database in the United States. PATIENTS Adult (≥ 18 yr) patients admitted to U.S. hospitals requiring NIV for ARF. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We identified 433,357 patients on NIV of whom (26.7% [95% CI] 26.3%-27.0%) received sedation or analgesia. A total of 50,589 patients (11.7%) received opioids only, 40,646 (9.4%) received benzodiazepines only, 20,146 (4.6%) received opioids and benzodiazepines, 1.573 (0.4%) received dexmedetomidine only, and 2,639 (0.6%) received dexmedetomidine in addition to opioid and/or benzodiazepine. Of 433,357 patients receiving NIV, 50,413 (11.6%; 95% CI, 11.5-11.7%) patients underwent invasive mechanical ventilation on hospital days 2-5 or died on hospital days 2-30. Intubation was used in 32,301 patients (7.4%; 95% CI, 7.3-7.6%). Further, death occurred in 24,140 (5.6%; 95% CI, 5.5-5.7%). In multivariable analysis adjusting for relevant covariates, receipt of any medication studied was associated with increased odds of intubation or death. In inverse probability weighting, receipt of any study medication was also associated with increased odds of intubation or death (average treatment effect odds ratio 1.38; 95% CI, 1.35-1.40). CONCLUSIONS The use of sedation and analgesia during NIV is common. Medication exposure was associated with increased odds of intubation or death. Further investigation is needed to confirm this finding and determine whether any subpopulations are especially harmed by this practice.
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Affiliation(s)
- Peter J Dunbar
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado, School of Medicine, Aurora, CO
| | - Ryan Peterson
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, CO
| | - Max McGrath
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, CO
| | - Raymond Pomponio
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, CO
| | - Tyree H Kiser
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO
| | - P Michael Ho
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - R William Vandivier
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado, School of Medicine, Aurora, CO
| | - Ellen L Burnham
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado, School of Medicine, Aurora, CO
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado, School of Medicine, Aurora, CO
| | - Peter D Sottile
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado, School of Medicine, Aurora, CO
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Yildirim F, Karaman I, Yıldırım M, Karabacak H. Benefits of dexmedetomidine during noninvasive mechanical ventilation in major abdominal surgery patients with postoperative respiratory failure. Front Surg 2024; 11:1357492. [PMID: 38800629 PMCID: PMC11120960 DOI: 10.3389/fsurg.2024.1357492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 04/15/2024] [Indexed: 05/29/2024] Open
Abstract
Objective The efficacy of non-invasive mechanical ventilation (NIMV) on the postoperative ARF is conflicting and the failure rate of NIMV in this patient population is high. In our study, we hypothesized that the use of dexmedetomidine during NIMV in major abdominal surgical patients can reduce NIMV failure without significant side affect. Methods Medical records of patients who underwent major abdominal surgery, admitted to our general surgery intensive care unit (ICU), developed postoperative ARF, received NIMV (with oro-nasal mask) and dexmedetomidine infusion were enrolled in this study. The infusion rate was adjusted to maintain a target sedation level of a Richmond Agitation-Sedation Scale (RASS) (-2)-(-3). The sedation was stopped when NIMV was discontinued. Results A total of 60 patients, 42 (70.0%) male, and 18 (30.0%) female, with a mean age of 68 ± 11 years were included in the study. The mean APACHE II score was 20 ± 6. Dexmedetomidine was infused for a median of 25 h (loading dose of 0.2 mcg/kg for 10 min, maintained at 0.2-0.7 mcg/kg/h, titrated every 30 min). RASS score of all study group significantly improved at the 2 h of dexmedetomidine initiation (+3 vs. -2, p = 0.01). A targeted sedation level was achieved in 92.5% of patients. Six (10.0%) patients developed bradycardia and 5 (8.3%) patients had hypotension. The mean NIMV application time was 23.4 ± 6.1 h. Seven (11.6%) patients experienced NIMV failure, all due to worsening pulmonary conditions, and required intubation and invasive ventilation. Fifty-three (88.3%) patients were successfully weaned from NIMV with dexmedetomidine sedation and discharged from ICU. The duration of NIMV application and ICU stay was shorter in NIMV succeded group (21.4 ± 3.2 vs. 29.9 ± 6.4; p = 0.012). Conclusion Our study suggests that dexmedetomidine demonstrates effective sedation in patients with postoperative ARF during NIMV application after abdominal surgery. Dexmedetomidine can be considered safe and capable of improving NIMV success.
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Affiliation(s)
- Fatma Yildirim
- General Surgery Intensive Care Unit, Department of Pulmonary and Critical Care Medicine, Dışkapı Yıldırım Beyazıt Research and Education Hospital, University of Health Sciences, Ankara, Türkiye
| | - Irem Karaman
- School of Medicine, Bahçeşehir University, Istanbul, Türkiye
| | - Mehmet Yıldırım
- Department of Internal Medicine - Internal Medicine Intensive Care Unit, Dışkapı Yıldırım Beyazıt Research and Education Hospital, University of Health Sciences, Ankara, Türkiye
| | - Harun Karabacak
- Department of General Surgery, Dışkapı Yıldırım Beyazıt Research and Education Hospital, University of Health Sciences, Ankara, Türkiye
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Quickfall D, Sklar MC, Tomlinson G, Orchanian-Cheff A, Goligher EC. The influence of drugs used for sedation during mechanical ventilation on respiratory pattern during unassisted breathing and assisted mechanical ventilation: a physiological systematic review and meta-analysis. EClinicalMedicine 2024; 68:102417. [PMID: 38235422 PMCID: PMC10789641 DOI: 10.1016/j.eclinm.2023.102417] [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: 09/12/2023] [Revised: 12/20/2023] [Accepted: 12/20/2023] [Indexed: 01/19/2024] Open
Abstract
Background Sedation management has a major impact on outcomes in mechanically ventilated patients, but sedation strategies do not generally consider the differential effects of different sedatives on respiration and respiratory pattern. A systematic review was undertaken to quantitatively summarize the known effects of different classes of drugs used for sedation on respiratory pattern during both spontaneous breathing and assisted mechanical ventilation. Methods This was a systematic review and meta-analysis conducted using Ovid MEDLINE, Embase, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials up to June 2020 to retrieve studies that measured respiratory parameters before and after the administration of opioids, benzodiazepines, intravenous and inhaled anaesthetic agents, and other hypnotic agents (PROSPERO #CRD42020190017). A random-effects meta-analytic model was employed to estimate the mean percentage change in each of the respiratory indices according to medication exposure with and without mechanical ventilation. Risk of bias was assessed using the Cochrane risk of bias assessment tools. Findings Fifty-one studies were included in the analysis. Risk of bias was generally deemed to be low for most studies. Respiratory rate decreased with the administration of opioids in both non-ventilated patients (18% decrease, 95% CI 12-24%) and ventilated patients (26% decrease, 95% CI 15-37%) and increased with inhaled anaesthetics in non-ventilated patients (83% increase, 95% CI 49-118%) and ventilated patients (50% increase, 28-72%). In non-ventilated patients, tidal volume decreased following administration of inhaled aesthetics (55% decrease, 95% CI 25-86%), propofol (36% decrease, 95% CI 20-52%), and benzodiazepines (28% decrease, 95% CI 17-40%); in patients receiving assisted mechanical ventilation, tidal volume was not significantly affected by sedation. Administration of other hypnotic agents was not associated with changes in respiratory rate or tidal volume. Interpretation Different classes of drugs used for sedation exert differential effects on respiratory pattern, and this may influence weaning and outcomes in mechanically ventilated patients. Funding This study did not receive any funding support.
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Affiliation(s)
- Danica Quickfall
- Department of Critical Care Medicine, University of Calgary, Calgary, Canada
| | - Michael C. Sklar
- Unity Health, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - George Tomlinson
- Department of Medicine, University Health Network, Toronto, Canada
| | - Ani Orchanian-Cheff
- Library and Information Services, University Health Network, Toronto, Canada
| | - Ewan C. Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Department of Medicine, University Health Network, Toronto, Canada
- Toronto General Hospital Research Institute, Toronto, Canada
- Department of Physiology, University of Toronto, Toronto, Canada
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Yang B, Gao L, Tong Z. Sedation and analgesia strategies for non-invasive mechanical ventilation: A systematic review and meta-analysis. Heart Lung 2024; 63:42-50. [PMID: 37769542 DOI: 10.1016/j.hrtlng.2023.09.005] [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] [Received: 06/11/2023] [Revised: 09/08/2023] [Accepted: 09/08/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND The use of sedative and analgesic drugs during non-invasive ventilation (NIV) in patients with acute respiratory failure (ARF) is controversial. OBJECTIVES To assess the clinical effectiveness of sedative and analgesic medications used during NIV for patients with ARF to no sedation or analgesia. In addition, to investigate the characteristics of dexmedetomidine in comparison to other medications. METHODS PubMed, Embase, Web of Science, Cochrane Library and China National Knowledge Infrastructure (CNKI) were searched. Mean differences (MDs) or pooled risk ratios (RRs) were computed using random-effects models. We applied the Cochrane risk-of-bias assessment tool 2.0 to assess the methodological quality of eligible studies and the GRADE approach to evaluate the evidence certainty. RESULTS Twenty-one studies were selected. Whether in Group A (using sedative and analgesic drugs vs. nonuse) or Group B (using dexmedetomidine vs. other drugs), the rates of tracheal intubation and delirium, the length of NIV, and the length of stay in the intensive care unit (ICU LOS) all decreased in both experimental groups (P < 0.05). And there were no significant differences in all-cause mortality and the incidence of hypotension between the two groups (P > 0.05), while both Group A and Group B's experimental groups had greater incidences of bradycardia. CONCLUSIONS Administering sedative and analgesic medications during NIV can reduce the risk of tracheal intubation and delirium. Additionally, dexmedetomidine outperformed other sedative medications in terms of these clinical outcomes, making it the better option when closely monitoring patients' vital signs.
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Affiliation(s)
- Baolu Yang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongti South Road, Chaoyang District, Beijing 100020, China
| | - Leyi Gao
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongti South Road, Chaoyang District, Beijing 100020, China
| | - Zhaohui Tong
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongti South Road, Chaoyang District, Beijing 100020, China.
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Hendrikse C, Ngah V, Kallon II, Thom G, Leong TD, Cohen K, McCaul M. Signal of harm in morphine use in adults with acute pulmonary oedema: A rapid systematic review. S Afr Med J 2023; 113:39-43. [PMID: 37882120 DOI: 10.7196/samj.2023.v113i8.348] [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: 10/26/2022] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND Heart failure affects nearly 65 million people globally, resulting in recurrent hospital admissions and substantial healthcare expenditure. The use of morphine in the management of acute pulmonary oedema remains controversial, with conflicting guidance and significant variation in practice. Synthesised evidence is needed to inform standard treatment guidelines and clinical practice. OBJECTIVE To determine whether morphine should be used in the treatment of acute pulmonary oedema (APE) in adults. METHODS A rapid review of systematic reviews of randomised controlled trials or observational studies, and then randomised controlled trials, was conducted searching three electronic databases (PubMed, Embase, Cochrane Library) and one clinical trial registry on 12 February 2022. We used a prespecified protocol following Cochrane rapid review methods and aligned to the National Standard Treatment Guidelines and Essential Medicines List methodology. We first considered relevant high-quality systematic reviews of randomised controlled trials or observational studies, then (if required) randomised controlled trials to inform time-sensitive or urgent evidence requests, clinical practice, policy, or standard treatment guidelines. RESULTS We identified four systematic reviews of observational studies. The two most relevant, up-to-date, and highest-quality reviews were used to inform evidence for critical outcomes. Morphine may increase in-hospital mortality (odds ratio (OR) 1.78; 95% confidence interval (CI) 1.01 - 3.13; low certainty of evidence; six observational studies, n=151 735 participants), resulting in 15 more per 1 000 hospital deaths, ranging from 0 to 40 more hospital deaths. Morphine may result in a large increase in invasive mechanical ventilation (OR 2.72; 95% CI 1.09 - 6.80; low certainty of evidence; four observational studies, n=167 847 participants), resulting in 45 more per 1 000 ventilations, ranging from 2 more to 136 more. Adverse events and hospital length of stay were not measured across reviews or trials. CONCLUSION Based on the most recent, relevant and best-available quality evidence, morphine use in adults with APE may increase in-hospital and all-cause mortality and may result in a large increase in the need for invasive mechanical ventilation compared to not using morphine. Recommending against the use of morphine in pulmonary oedema may improve patient outcomes. Disinvesting in morphine for this indication may result in cost savings, noting the possible accrued benefits of fewer patients requiring invasive ventilation and management of morphine-related side-effects.
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Affiliation(s)
- C Hendrikse
- Division of Emergency Medicine, Department of Family, Community and Emergency Care, Faculty of Health Sciences, University of Cape Town, South Africa; Ministerially appointed PHC/Adult Hospital Level Expert Review Committee of the National Essential Medicines List Committee, National Department of Health (2019 - 2023), Pretoria, South Africa.
| | - V Ngah
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - I I Kallon
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - G Thom
- Ministerially appointed PHC/Adult Hospital Level Expert Review Committee of the National Essential Medicines List Committee, National Department of Health (2019 - 2023), Pretoria, South Africa; Amajuba District Clinical Specialist Team, KwaZulu-Natal Department of Health, Pretoria, South Africa.
| | - T D Leong
- Secretariat to the PHC/Adult Hospital Level Expert Review Committee (2020 - 2023); Secretariat to the National Essential Medicines List Committee, National Department of Health (2021 - 2022), Durban, South Africa; Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa.
| | - K Cohen
- Ministerially appointed PHC/Adult Hospital Level Expert Review Committee of the National Essential Medicines List Committee, National Department of Health (2019 - 2023), Pretoria, South Africa; Division of Clinical Pharmacology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa.
| | - M McCaul
- Ministerially appointed PHC/Adult Hospital Level Expert Review Committee of the National Essential Medicines List Committee, National Department of Health (2019 - 2023), Pretoria, South Africa; Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; South African GRADE Network, Centre for Evidence-based Health Care, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
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Altınkaya Çavuş M, Gökbulut Bektaş S, Turan S. Comparison of clinical safety and efficacy of dexmedetomidine, remifentanil, and propofol in patients who cannot tolerate non-invasive mechanical ventilation: A prospective, randomized, cohort study. Front Med (Lausanne) 2022; 9:995799. [PMID: 36111123 PMCID: PMC9468549 DOI: 10.3389/fmed.2022.995799] [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: 07/16/2022] [Accepted: 08/04/2022] [Indexed: 11/13/2022] Open
Abstract
Background and objectivesNon-invasive ventilation (NIV) is used in intensive care units (ICUs) to treat of respiratory failure. Sedation and analgesia are effective and safe for improving compliance in patients intolerant to NIV. Our study aimed to evaluate the effects of dexmedetomidine, remifentanil, and propofol on the clinical outcomes in NIV intolerant patients.MethodsThis prospective randomized cohort study was conducted in a tertiary ICU, between December 2018 and December 2019. We divided a total of 120 patients into five groups (DEXL, DEXH, REML, REMH, PRO). IBM SPSS Statistics 20 (IBM Corporation, Armonk, New York, USA) was used to conduct the statistical analyses.ResultsThe DEXL, DEXH, REML, and REMH groups consisted of 23 patients each while the PRO group consisted of 28 patients. Seventy-five patients (62.5%) became tolerant of NIV after starting the drugs. The NIV time, IMV time, ICU LOS, hospital LOS, intubation rate, side effects, and mortality were significantly different among the five groups (P = 0.05). In the groups that were given dexmedetomidine (DEXL, and DEXH), NIV failure, mortality, ICU LOS, and hospital LOS were lower than in the other groups.ConclusionIn this prospective study, we compared the results of three drugs (propofol, dexmedetomidine, and remifentanil) in patients with NIV intolerance. The use of sedation increased NIV success in patients with NIV intolerance. NIV failure, mortality, ICU LOS, IMV time, and hospital LOS were found to be lower with dexmedetomidine.
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Affiliation(s)
- Mine Altınkaya Çavuş
- Kayseri City Hospital, Republic of Turkey Ministry of Health Sciences, Kayseri, Turkey
- *Correspondence: Mine Altınkaya Çavuş
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Karim HMR, Šarc I, Calandra C, Spadaro S, Mina B, Ciobanu LD, Gonçalves G, Caldeira V, Cabrita B, Perren A, Fiorentino G, Utku T, Piervincenzi E, El-Khatib M, Alpay N, Ferrari R, Abdelrahim MEA, Saeed H, Madney YM, Harb HS, Vargas N, Demirkiran H, Bhakta P, Papadakos P, Gómez-Ríos MÁ, Abad A, Alqahtani JS, Hadda V, Singha SK, Esquinas AM. Role of Sedation and Analgesia during Noninvasive Ventilation: Systematic Review of Recent Evidence and Recommendations. Indian J Crit Care Med 2022; 26:938-948. [PMID: 36042773 PMCID: PMC9363803 DOI: 10.5005/jp-journals-10071-23950] [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] [Indexed: 11/28/2022] Open
Abstract
Aim This systematic review aimed to investigate the drugs used and their potential effect on noninvasive ventilation (NIV). Background NIV is used increasingly in acute respiratory failure (ARF). Sedation and analgesia are potentially beneficial in NIV, but they can have a deleterious impact. Proper guidelines to specifically address this issue and the recommendations for or against it are scarce in the literature. In the most recent guidelines published in 2017 by the European Respiratory Society/American Thoracic Society (ERS/ATS) relating to NIV use in patients having ARF, the well-defined recommendation on the selective use of sedation and analgesia is missing. Nevertheless, some national guidelines suggested using sedation for agitation. Methods Electronic databases (PubMed/Medline, Google Scholar, and Cochrane library) from January 1999 to December 2019 were searched systematically for research articles related to sedation and analgosedation in NIV. A brief review of the existing literature related to sedation and analgesia was also done. Review results Sixteen articles (five randomized trials) were analyzed. Other trials, guidelines, and reviews published over the last two decades were also discussed. The present review analysis suggests dexmedetomidine as the emerging sedative agent of choice based on the most recent trials because of better efficacy with an improved and predictable cardiorespiratory profile. Conclusion Current evidence suggests that sedation has a potentially beneficial role in patients at risk of NIV failure due to interface intolerance, anxiety, and pain. However, more randomized controlled trials are needed to comment on this issue and formulate strong evidence-based recommendations. How to cite this article Karim HMR, Šarc I, Calandra C, Spadaro S, Mina B, Ciobanu LD, et al. Role of Sedation and Analgesia during Noninvasive Ventilation: Systematic Review of Recent Evidence and Recommendations. Indian J Crit Care Med 2022;26(8):938–948.
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Affiliation(s)
- Habib MR Karim
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
- Habib MR Karim, Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India, Phone: +91 9612372585, e-mail:
| | - Irena Šarc
- Department of Morphology, Surgery and Experimental Medicine, Section of Anesthesiology and Intensive Care, University of Ferrara, Ferrara, Italy
| | - Camilla Calandra
- Department of Morphology, Surgery and Experimental Medicine, Section of Anesthesiology and Intensive Care, University of Ferrara, Ferrara, Italy
| | - Savino Spadaro
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Northwell Health, Lenox Hill Hospital, New York, New York, United States
| | - Bushra Mina
- Department of Internal Medicine, University of Medicine and Pharmacy “Grigore T Popa”, Iasi, Romania; Consultant in Internal Medicine and Pulmonology, Clinical Hospital of Rehabilitation, Iasi, Romania
| | - Laura D Ciobanu
- Pulmonology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Gil Gonçalves
- Pulmonology Department, Santa Marta Hospital, Lisbon, Portugal
| | - Vania Caldeira
- Pulmonology Department, Hospital Pedro Hispano, Matosinhos, Portugal
| | - Bruno Cabrita
- Department of Intensive Care Medicine EOC, Ospedale Regionale Bellinzona e Valli, Bellinzona, Switzerland
| | - Andreas Perren
- Respiratory Unit, AO dei Colli Monaldi Hospital, Naples, Italy
| | - Giuseppe Fiorentino
- Department of Anaesthesiology and Reanimation, General Intensive Care, Yeditepe University Medical Faculty, Istanbul, Turkey
| | - Tughan Utku
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Italy; Anesthesia, Emergency and Intensive Care Medicine, Agostino Gemelli University Policlinic, IRCCS, Italy
| | - Edoardo Piervincenzi
- Department of Anesthesiology, American University of Beirut-Medical Center, Beirut, Lebanon
| | - Mohamad El-Khatib
- Department of Anesthesiology and Reanimation, Cukurova University Faculty of Dentistry, Adana, Turkey
| | - Nilgün Alpay
- Emergency Department, Santa Maria della Scaletta Hospital, AUSL Imola, Imola, Italy
| | - Rodolfo Ferrari
- Noninvasive Ventilation Department, University Clinic for Pulmonary and Allergic Diseases, Golnik, Slovenia
| | - Mohamed EA Abdelrahim
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Haitham Saeed
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Yasmin M Madney
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Hadeer S Harb
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Nicola Vargas
- Geriatric and Intensive Geriatric Cares Unit, Medicine Department, “San Giuseppe Moscati” Hospital, Avellino, Italy
| | - Hilmi Demirkiran
- Department of Anaesthesiology and Reanimation, Faculty of Medicine, Van Yuzuncu Yil University, Van, Turkey
| | - Pradipta Bhakta
- Department of Anaesthesia and Intensive Care, Cork University Hospital, Cork, Ireland
| | - Peter Papadakos
- Department of Anesthesiology, University of Rochester, Rochester, New York, United States
| | - Manuel Á Gómez-Ríos
- Department of Anesthesia and Perioperative Medicine, Complejo Hospitalario Universitario de A Coruña, Galicia, Spain
| | - Alfredo Abad
- Anestesia y Reanimación, Hospital Universitario La Paz, Madrid, Spain
| | - Jaber S Alqahtani
- Department of Respiratory Care, Prince Sultan Military College of Health Sciences, Dammam, Saudi Arabia
| | - Vijay Hadda
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Subrata K Singha
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
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9
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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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Hussain Khan Z, Maki Aldulaimi A, Varpaei HA, Mohammadi M. Various Aspects of Non-Invasive Ventilation in COVID-19 Patients: A Narrative Review. IRANIAN JOURNAL OF MEDICAL SCIENCES 2022; 47:194-209. [PMID: 35634520 PMCID: PMC9126903 DOI: 10.30476/ijms.2021.91753.2291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 09/21/2021] [Accepted: 10/01/2021] [Indexed: 01/08/2023]
Abstract
Non-invasive ventilation (NIV) is primarily used to treat acute respiratory failure. However, it has broad applications to manage a range of other diseases successfully.
The main advantage of NIV lies in its capability to provide the same physiological effects as invasive ventilation while avoiding the placement of an
artificial airway and its associated life-threatening complications. The war on the COVID-19 pandemic is far from over. The present narrative review aimed at identifying various aspects of NIV usage, in COVID-19 and other patients,
such as the onset time, mode, setting, positioning, sedation, and types of interface. A search for articles published from May 2020 to April 2021 was conducted using MEDLINE,
PMC central, Scopus, Web of Science, Cochrane Library, and Embase databases. Of the initially identified 5,450 articles, 73 studies and 24 guidelines on the use of NIV were included.
The search was limited to studies involving human cases and English language articles. Despite several reported benefits of NIV, the evidence on the use of NIV in
COVID-19 patients does not yet fully support its routine use.
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Affiliation(s)
- Zahid Hussain Khan
- Department of Anesthesiology and Critical Care, Imam Khomeini Medical Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Ahmed Maki Aldulaimi
- Al-furat Al-awsat Hospital, Al-furat Al-awsat Technical University, Health and Medical Technical College, Department of Anesthesia and Critical Care, Kufa, Iraq
| | - Hesam Aldin Varpaei
- Department of Nursing and Midwifery, School of Nursing, Islamic Azad University Tehran Medical Sciences, Tehran, Iran
| | - Mostafa Mohammadi
- Department of Anesthesiology and Critical Care, Tehran University of Medical Sciences, Tehran. Iran
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Cammarota G, Simonte R, De Robertis E. Comfort During Non-invasive Ventilation. Front Med (Lausanne) 2022; 9:874250. [PMID: 35402465 PMCID: PMC8988041 DOI: 10.3389/fmed.2022.874250] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 02/28/2022] [Indexed: 01/03/2023] Open
Abstract
Non-invasive ventilation (NIV) has been shown to be effective in avoiding intubation and improving survival in patients with acute hypoxemic respiratory failure (ARF) when compared to conventional oxygen therapy. However, NIV is associated with high failure rates due, in most cases, to patient discomfort. Therefore, increasing attention has been paid to all those interventions aimed at enhancing patient's tolerance to NIV. Several practical aspects have been considered to improve patient adaptation. In particular, the choice of the interface and the ventilatory setting adopted for NIV play a key role in the success of respiratory assistance. Among the different NIV interfaces, tolerance is poorest for the nasal and oronasal masks, while helmet appears to be better tolerated, resulting in longer use and lower NIV failure rates. The choice of fixing system also significantly affects patient comfort due to pain and possible pressure ulcers related to the device. The ventilatory setting adopted for NIV is associated with varying degrees of patient comfort: patients are more comfortable with pressure-support ventilation (PSV) than controlled ventilation. Furthermore, the use of electrical activity of the diaphragm (EADi)-driven ventilation has been demonstrated to improve patient comfort when compared to PSV, while reducing neural drive and effort. If non-pharmacological remedies fail, sedation can be employed to improve patient's tolerance to NIV. Sedation facilitates ventilation, reduces anxiety, promotes sleep, and modulates physiological responses to stress. Judicious use of sedation may be an option to increase the chances of success in some patients at risk for intubation because of NIV intolerance consequent to pain, discomfort, claustrophobia, or agitation. During the Coronavirus Disease-19 (COVID-19) pandemic, NIV has been extensively employed to face off the massive request for ventilatory assistance. Prone positioning in non-intubated awake COVID-19 patients may improve oxygenation, reduce work of breathing, and, possibly, prevent intubation. Despite these advantages, maintaining prone position can be particularly challenging because poor comfort has been described as the main cause of prone position discontinuation. In conclusion, comfort is one of the major determinants of NIV success. All the strategies aimed to increase comfort during NIV should be pursued.
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Sinnott J, Holthaus CV, Ablordeppey E, Wessman BT, Roberts BW, Fuller BM. The Use of Dexmedetomidine in the Emergency Department: A Cohort Study. West J Emerg Med 2021; 22:1202-1209. [PMID: 34546899 PMCID: PMC8463063 DOI: 10.5811/westjem.2021.4.50917] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 04/08/2021] [Indexed: 11/14/2022] Open
Abstract
Introduction Management of sedation, analgesia, and anxiolysis are cornerstone therapies in the emergency department (ED). Dexmedetomidine (DEX), a central alpha-2 agonist, is increasingly being used, and intensive care unit (ICU) data demonstrate improved outcomes in patients with respiratory failure. However, there is a lack of ED-based data. We therefore sought to: 1) characterize ED DEX use; 2) describe the incidence of adverse events; and 3) explore factors associated with adverse events among patients receiving DEX in the ED. Methods This was a single-center, retrospective, cohort study of consecutive ED patients administered DEX (January 1, 2017–July 1, 2019) at an academic, tertiary care ED with an annual census of ~90,000 patient visits. All included patients (n= 103) were analyzed for characterization of DEX use in the ED. The primary outcome was a composite of adverse events, bradycardia and hypotension. Secondary clinical outcomes included ventilator-, ICU-, and hospital-free days, and hospital mortality. To examine for variables associated with adverse events, we used a multivariable logistic regression model. Results We report on 103 patients. Dexmedetomidine was most commonly given for acute respiratory failure, including sedation for mechanical ventilation (28.9%) and facilitation of non-invasive ventilation (17.4%). Fifty-four (52.4%) patients experienced the composite adverse event, with hypotension occurring in 41 patients (39.8%) and bradycardia occurring in 18 patients (17.5%). Dexmedetomidine was stopped secondary to an adverse event in eight patients (7.8%). Duration of DEX use in the ED was associated with an increase adverse event risk (adjusted odds ratio, 1.004; 95% confidence interval, 1.001, 1.008). Conclusion Dexmedetomidine is most commonly administered in the ED for patients with acute respiratory failure. Adverse events are relatively common, yet DEX is discontinued comparatively infrequently due to adverse events. Our results suggest that DEX could be a viable option for analgesia, anxiolysis, and sedation in ED patients.
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Affiliation(s)
- Joseph Sinnott
- Washington University School of Medicine in St. Louis, Department of Emergency Medicine, St. Louis, Missouri
| | - Christopher V Holthaus
- Washington University School of Medicine in St. Louis, Department of Emergency Medicine, St. Louis, Missouri
| | - Enyo Ablordeppey
- Washington University School of Medicine in St. Louis, Department of Emergency Medicine, St. Louis, Missouri.,Washington University School of Medicine in St. Louis, Department of Anesthesiology, St. Louis, Missouri
| | - Brian T Wessman
- Washington University School of Medicine in St. Louis, Department of Emergency Medicine, St. Louis, Missouri.,Washington University School of Medicine in St. Louis, Department of Anesthesiology, St. Louis, Missouri
| | - Brian W Roberts
- Cooper University Hospital, Department of Emergency Medicine, Camden, New Jersey
| | - Brian M Fuller
- Washington University School of Medicine in St. Louis, Department of Emergency Medicine, St. Louis, Missouri.,Washington University School of Medicine in St. Louis, Department of Anesthesiology, St. Louis, Missouri
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13
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Lewis K, Piticaru J, Chaudhuri D, Basmaji J, Fan E, Møller MH, Devlin JW, Alhazzani W. Safety and Efficacy of Dexmedetomidine in Acutely Ill Adults Requiring Noninvasive Ventilation: A Systematic Review and Meta-analysis of Randomized Trials. Chest 2021; 159:2274-2288. [PMID: 33434496 DOI: 10.1016/j.chest.2020.12.052] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 11/24/2020] [Accepted: 12/26/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Although clinical studies have evaluated dexmedetomidine as a strategy to improve noninvasive ventilation (NIV) comfort and tolerance in patients with acute respiratory failure (ARF), their results have not been summarized. RESEARCH QUESTION Does dexmedetomidine, when compared with another sedative or placebo, reduce the risk of delirium, mortality, need for intubation and mechanical ventilation, or ICU length of stay (LOS) in adults with ARF initiated on NIV in the ICU? STUDY DESIGN AND METHODS We electronically searched MEDLINE, EMBASE, and the Cochrane Library from inception through July 31, 2020, for randomized clinical trials (RCTs). We calculated pooled relative risks (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes with the corresponding 95% CIs using a random-effect model. RESULTS Twelve RCTs were included in our final analysis (n = 738 patients). The use of dexmedetomidine, compared with other sedation strategies or placebo, reduced the risk of intubation (RR, 0.54; 95% CI, 0.41-0.71; moderate certainty), delirium (RR, 0.34; 95% CI, 0.22-0.54; moderate certainty), and ICU LOS (MD, -2.40 days; 95% CI, -3.51 to -1.29 days; low certainty). Use of dexmedetomidine was associated with an increased risk of bradycardia (RR, 2.80; 95% CI, 1.92-4.07; moderate certainty) and hypotension (RR, 1.98; 95% CI, 1.32-2.98; moderate certainty). INTERPRETATION Compared with any sedation strategy or placebo, dexmedetomidine reduced the risk of delirium and the need for mechanical ventilation while increasing the risk of bradycardia and hypotension. The results are limited by imprecision, and further large RCTs are needed. TRIAL REGISTRY PROSPERO; No.: 175086; URL: www.crd.york.ac.uk/prospero/.
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Affiliation(s)
- Kimberley Lewis
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Joshua Piticaru
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - John Basmaji
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Morten Hylander Møller
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - John W Devlin
- School of Pharmacy, Northeastern University, Boston, MA; Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA
| | - Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
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15
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Sivasubramani S, Pandyan DA, Ravindran C. Comparision of Vital Surgical Parameters, after Administration of Midazolam and Dexmedetomidine for Conscious Sedation in Minor Oral Surgery. Ann Maxillofac Surg 2020; 9:283-288. [PMID: 31909006 PMCID: PMC6933995 DOI: 10.4103/ams.ams_17_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Aim: The aim of this study is to compare the efficacy between midazolam and dexmedetomidine in relation to vital parameters, sedation score, pain score, cognitive judgment, and postoperative amnesia to the event in conscious sedation for minor oral surgical procedure. Materials and Methods: A sample size of 30 patients were selected in each group: Group M (midazolam) and Group D (dexmedetomidine). Results: The mean heart rate (HR) and systolic and diastolic blood pressure measurements were significantly higher in Group M after the 20th min when compared to Group D. The visual analog scale (VAS) scores of pain were not statistically significant between the two groups during the procedure, but at the time of discharge, statistically significant VAS scores were found between the two groups. Nine (30%) patients in Group D and 21 (70%) patients in Group M showed cognitive judgment impairment with the Stroop Color and Word Test at the 30th min. Conclusion: The dexmedetomidine group of patients had reduced blood pressure and HR. No significant differences were noted in oxygen saturation or in respiratory rate between the two drugs. Patients had better sedation, analgesia, lesser cognitive impairment, and amnesia in the dexmedetomidine group.
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Affiliation(s)
- Suryahanthmihiran Sivasubramani
- Department of Oral and Maxillofacial Surgery, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Deepak Abraham Pandyan
- Department of Oral and Maxillofacial Surgery, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - C Ravindran
- Department of Oral and Maxillofacial Surgery, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
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Kink E, Erler L, Fritz W, Funk GC, Gäbler M, Krenn F, Kühteubl G, Schindler O, Wanke T. Beatmung bei COPD: von der Präklinik bis zur außerklinischen Beatmung. Eine Übersicht des Arbeitskreises für Beatmung und Intensivmedizin der österreichischen Gesellschaft für Pneumologie. Wien Klin Wochenschr 2019; 131:417-427. [PMID: 31111203 DOI: 10.1007/s00508-019-1515-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
This paper was created by the Austrian Society of Pneumology (Working group Ventilation and Intensive Care) to summarize the specific characteristics of mechanical ventilation in patients presenting with chronic obstructive pulmonary disease (COPD). The main differences in pathophysiology and mechanical ventilation are shown, including acute respiratory failure and out-of-hospital mechanical ventilation.
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Affiliation(s)
- Eveline Kink
- Abteilung für Innere Medizin und Pneumologie, LKH Graz II, Standort Enzenbach, Hörgas 30, 8112, Gratwein-Straßengel, Österreich
| | - Lorenz Erler
- Abteilung für Lungenkrankheiten, Leoben, Österreich
| | - Wilfried Fritz
- Klinische Abteilung für Lungenkrankheiten, Universitätsklinikum für Innere Medizin, LKH.-Univ. Klinikum Graz, Graz, Österreich
| | | | - Martin Gäbler
- Institut für Präventiv- und Angewandte Sportmedizin, Universitätsklinikum Krems, Karl Landsteiner Privatuniversität für Gesundheitswissenschaften, Mitterweg 10, 3500, Krems an der Donau, Österreich
| | | | | | - Otmar Schindler
- Abteilung für Innere Medizin und Pneumologie, LKH Graz II, Standort Enzenbach, Hörgas 30, 8112, Gratwein-Straßengel, Österreich
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Dexmedetomidine to facilitate non-invasive ventilation after blunt chest trauma: A randomised, double-blind, crossover, placebo-controlled pilot study. Anaesth Crit Care Pain Med 2019; 38:477-483. [PMID: 31319192 DOI: 10.1016/j.accpm.2019.06.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 06/26/2019] [Accepted: 06/26/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Although non-invasive ventilation (NIV) is recommended in patients with chest trauma, this procedure may expose to discomfort and even failure due to agitation or excessive pain. We tested the impact of dexmedetomidine on the duration of the first session of NIV. METHODS This randomised, crossover study enrolled 19 patients with blunt chest trauma who needed NIV. During one cycle comprising two NIV sessions, patients received in a random order an intravenous infusion of dexmedetomidine (0.7mcg/kg/h) and placebo (saline solution) that was initiated 60min prior to NIV. Dexmedetomidine (or placebo) was titrated to maintain a Richmond Agitation Sedation Scale (RASS) score between 0 and -3. A 6-h washout period was observed between NIV sessions. The reproducibility of the drug-related effects was tested during a second cycle of two NIV sessions. RESULTS During the first cycle, dexmedetomidine prolonged the duration of NIV compared to placebo: 280min (118-450) (median, 25-75th quartiles) versus 120min (68-287) respectively, corresponding to a median increased duration of 96min (12-180) (P=0.03). Dexmedetomidine was associated with a lower score for RASS: -0.8 (-1.0;0.0) versus 0.0 (-0.5;0.0) (P<0.01), and reduced respiratory discomfort according to the 10cm visual similar scale: 0.6cm (0.0-3.0) versus 2.2cm (0.0-5.3) (P=0.05). Pain scores, morphine consumption, and blood gas measurements were comparable between groups. No difference in the duration of non-invasive ventilation was found during the second cycle. CONCLUSIONS In this pilot trial, dexmedetomidine could facilitate the acceptance of the first session of non-invasive ventilation for patients with chest trauma.
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Abdelgalel EF. Dexmedetomidine versus haloperidol for prevention of delirium during non-invasive mechanical ventilation. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2016.05.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Essam F. Abdelgalel
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Zagazig University, Zagazig, Egypt
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Chalela R, Gallart L, Pascual-Guardia S, Sancho-Muñoz A, Gea J, Orozco-Levi M. Bispectral index in hypercapnic encephalopathy associated with COPD exacerbation: a pilot study. Int J Chron Obstruct Pulmon Dis 2019; 13:2961. [PMID: 30310272 PMCID: PMC6167126 DOI: 10.2147/copd.s167020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Hypercapnic encephalopathy is relatively frequent in severe exacerbations of COPD (ECOPDs), with its intensity usually being evaluated through clinical scales. Bispectral index (BIS) is a relatively new technique, based on the analysis of the electroencephalographic signal, which provides a good approximation to the level of consciousness, having already been validated in anesthesia. OBJECTIVE The objective of the study was to evaluate the utility of BIS in the assessment of the intensity of hypercapnic encephalopathy in ECOPD patients. PATIENTS AND METHODS A total of ten ECOPD patients were included, and the level of brain activity was assessed using BIS and different scales: Glasgow Coma Scale, Ramsay Sedation Scale (RSS), and Richmond Agitation-Sedation Scale. The evaluation was performed both in the acute phase and 3 months after discharge. RESULTS BIS was recorded for a total of about 600 minutes. During ECOPD, BIS values ranged from 58.8 (95% CI: 48.6-69) for RSS score of 4 to 92.2 (95% CI: 90.1-94.3) for RSS score of 2. A significant correlation was observed between values obtained with BIS and those from the three scales, although the best fit was for RSS, followed by Glasgow and Richmond (r=-0.757, r=0.701, and r=0.615, respectively; P<0.001 for all). In the stable phase after discharge, BIS showed values considered as normal for a wake state (94.6; 95% CI: 91.7-97.9). CONCLUSION BIS may be useful for the objective early detection and automatic monitoring of the intensity of hypercapnic encephalopathy in ECOPD, facilitating the early detection and follow-up of this condition, which may avoid management problems in these patients.
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Affiliation(s)
- Roberto Chalela
- Respiratory Medicine Department, Hospital del Mar-IMIM, Barcelona, Spain, .,Department CEXS, Universitat Pompeu Fabra, Barcelona, Spain, .,CIBERES, ISCIII, Barcelona, Spain,
| | - Lluis Gallart
- Department of Anesthesia, Hospital del Mar-IMIM, Barcelona, Spain.,Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Sergi Pascual-Guardia
- Respiratory Medicine Department, Hospital del Mar-IMIM, Barcelona, Spain, .,Department CEXS, Universitat Pompeu Fabra, Barcelona, Spain, .,CIBERES, ISCIII, Barcelona, Spain,
| | - Antonio Sancho-Muñoz
- Respiratory Medicine Department, Hospital del Mar-IMIM, Barcelona, Spain, .,Department CEXS, Universitat Pompeu Fabra, Barcelona, Spain,
| | - Joaquim Gea
- Respiratory Medicine Department, Hospital del Mar-IMIM, Barcelona, Spain, .,Department CEXS, Universitat Pompeu Fabra, Barcelona, Spain, .,CIBERES, ISCIII, Barcelona, Spain,
| | - Mauricio Orozco-Levi
- Respiratory Medicine Department, Hospital del Mar-IMIM, Barcelona, Spain, .,Department CEXS, Universitat Pompeu Fabra, Barcelona, Spain, .,CIBERES, ISCIII, Barcelona, Spain,
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Comellini V, Pacilli AMG, Nava S. Benefits of non-invasive ventilation in acute hypercapnic respiratory failure. Respirology 2019; 24:308-317. [PMID: 30636373 DOI: 10.1111/resp.13469] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 11/18/2018] [Accepted: 12/09/2018] [Indexed: 02/02/2023]
Abstract
Non-invasive ventilation (NIV) with bilevel positive airway pressure is a non-invasive technique, which refers to the provision of ventilatory support through the patient's upper airway using a mask or similar device. This technique is successful in correcting hypoventilation. It has become widely accepted as the standard treatment for patients with hypercapnic respiratory failure (HRF). Since the 1980s, NIV has been used in intensive care units and, after initial anecdotal reports and larger series, a number of randomized trials have been conducted. Data from these trials have shown that NIV is a valuable treatment for HRF. This review aims to explore the principal areas in which NIV can be useful, focusing particularly on patients with acute HRF (AHRF). We will update the evidence base with the goal of supporting clinical practice. We provide a practical description of the main indications for NIV in AHRF and identify the group of patients with hypercapnic failure who will benefit most from the application of NIV.
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Affiliation(s)
- Vittoria Comellini
- Respiratory and Critical Care Unit, University Hospital St Orsola-Malpighi, Bologna, Italy
| | - Angela Maria Grazia Pacilli
- Department of Specialistic, Diagnostic and Experimental Medicine (DIMES), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Stefano Nava
- Respiratory and Critical Care Unit, University Hospital St Orsola-Malpighi, Bologna, Italy.,Department of Specialistic, Diagnostic and Experimental Medicine (DIMES), Alma Mater Studiorum University of Bologna, Bologna, Italy
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21
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Bourke SC, Piraino T, Pisani L, Brochard L, Elliott MW. Beyond the guidelines for non-invasive ventilation in acute respiratory failure: implications for practice. THE LANCET RESPIRATORY MEDICINE 2018; 6:935-947. [DOI: 10.1016/s2213-2600(18)30388-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 09/13/2018] [Accepted: 09/13/2018] [Indexed: 12/31/2022]
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Park SW, Choi JH, Kim HT, Cho YH. Replacement of dexmedetomidine loading with midazolam for sedation in elderly patients with spinal anesthesia. Medicine (Baltimore) 2018; 97:e12565. [PMID: 30278560 PMCID: PMC6181574 DOI: 10.1097/md.0000000000012565] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Dexmedetomidine is an effective sedative during spinal anesthesia. However, it requires a loading dose, which can result in transient hypertension, hypotension, bradycardia, and/or sinus arrest. In addition, the time required to reach an appropriate depth of sedation may cause anxiety to the patients. Therefore, we examined whether an intravenous bolus of midazolam could replace the loading dose of dexmedetomidine for sedation during surgery in elderly patients who received spinal anesthesia. METHODS Patients aged over 60 years who scheduled to undergo total knee arthroplasty under spinal anesthesia were enrolled in this study. The patients were randomized into 2 groups. Patients in dexmedetomidine group (group D) (n = 20) were administered a loading dose of dexmedetomidine (1.0 μg/kg over 10 min) intravenously followed by dexmedetomidine maintenance (0.5 μg/kg/h). Patients in group MD (n = 20) were administered an intravenous midazolam (0.05 mg/kg) followed by dexmedetomidine maintenance (0.5 μg/kg/h) intravenously. Heart rate (HR), mean arterial blood pressure (MBP), peripheral oxygen saturation (SpO2), and patient state index (PSI) were recorded. Ramsay sedation scale (RSS) scores were evaluated at 10 minutes after drug administration and the end of surgery. RESULTS A total of 40 subjects were enrolled in the present study. At baseline, there was no between-group difference in HR. Ten minutes after drug administration, group D had lower HR than group MD (62.1 ± 9.4 versus 69.6 ± 13.4, P = .047). PSI was significantly lower in group MD at 10 minutes after drug administration (82.8 ± 13.0 versus 72.0 ± 16.0, P = .024); there was no between-group difference at 30 and 60 minutes, and lower values in group D at the end of surgery (70.2 ± 22.6 versus 79.7 ± 10.9, P = .011). The RSS score showed statistically significantly deeper sedation in group MD 10 minutes after drug administration, but no difference at the end of surgery. CONCLUSIONS An intravenous bolus of midazolam is a viable alternative to dexmedetomidine loading for sedation during surgery in elderly patients who received spinal anesthesia. This is especially effective for patients who are at high risk for bradycardia or who want a faster sedation.
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Affiliation(s)
- Sung Wook Park
- Department of Anesthesiology and Pain Medicine, College of Medicine, Kyung Hee University
| | - Jeong-Hyun Choi
- Department of Anesthesiology and Pain Medicine, College of Medicine, Kyung Hee University
| | - Hyung-Tak Kim
- Department of Anesthesiology and Pain Medicine, Seoul Sungsim General Hospital, Seoul, Korea
| | - Yong Hyun Cho
- Department of Anesthesiology and Pain Medicine, Seoul Sungsim General Hospital, Seoul, Korea
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23
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Piastra M, Pizza A, Gaddi S, Luca E, Genovese O, Picconi E, De Luca D, Conti G. Dexmedetomidine is effective and safe during NIV in infants and young children with acute respiratory failure. BMC Pediatr 2018; 18:282. [PMID: 30144795 PMCID: PMC6109351 DOI: 10.1186/s12887-018-1256-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 08/16/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Noninvasive ventilation (NIV) is increasingly utilized in infants and young children, though associated with high failure rates due to agitation and poor compliance, mostly if patient-ventilator synchronization is required. METHODS A retrospective cohort study was carried out in an academic pediatric intensive care unit (PICU). Dexmedetomidine (DEX) was infused as unique sedative in 40 consecutive pediatric patients (median age 16 months) previously showing intolerance and agitation during NIV application. RESULTS During NIV clinical application both COMFORT-B Score and Richmond Agitation-Sedation Scale (RASS) were serially evaluated. Four patients experiencing NIV failure, all due to pulmonary condition worsening, required intubation and invasive ventilation. 36 patients were successfully weaned from NIV under DEX sedation and discharged from PICU. All patients survived until home discharge. CONCLUSION Our data suggest that DEX may represent an effective sedative agent in infants and children showing agitation during NIV. Early use of DEX in infants/children receiving NIV for acute respiratory failure (ARF) should be considered safe and capable of improving NIV, thus permitting both lung recruitment and patient-ventilator synchronization.
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Affiliation(s)
- M Piastra
- Pediatric Intensive Care Unit, Fondazione Policlinico A. Gemelli IRCCS and Catholic University of Rome, L.go A.Gemelli, 8, Rome, Italy
| | - A Pizza
- Pediatric Intensive Care Unit, Fondazione Policlinico A. Gemelli IRCCS and Catholic University of Rome, L.go A.Gemelli, 8, Rome, Italy.
| | - S Gaddi
- Pediatric Intensive Care Unit, Fondazione Policlinico A. Gemelli IRCCS and Catholic University of Rome, L.go A.Gemelli, 8, Rome, Italy
| | - E Luca
- Pediatric Intensive Care Unit, Fondazione Policlinico A. Gemelli IRCCS and Catholic University of Rome, L.go A.Gemelli, 8, Rome, Italy
| | - O Genovese
- Pediatric Intensive Care Unit, Fondazione Policlinico A. Gemelli IRCCS and Catholic University of Rome, L.go A.Gemelli, 8, Rome, Italy
| | - E Picconi
- Pediatric Intensive Care Unit, Fondazione Policlinico A. Gemelli IRCCS and Catholic University of Rome, L.go A.Gemelli, 8, Rome, Italy
| | - D De Luca
- Division of Pediatrics and Neonatal Critical Care, Medical Center "A.Béclère", South Paris University Hospitals, Paris, France
| | - G Conti
- Pediatric Intensive Care Unit, Fondazione Policlinico A. Gemelli IRCCS and Catholic University of Rome, L.go A.Gemelli, 8, Rome, Italy
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24
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Arhami Dolatabadi A, Memary E, Shojaee M, Kamalifard H. Dexmedetomidine-Fentanyl versus Midazolam-Fentanyl in Pain Management of Distal Radius Fractures Reduction; a Randomized Clinical Trial. EMERGENCY (TEHRAN, IRAN) 2018; 6:e10. [PMID: 29503835 PMCID: PMC5827042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Affiliation(s)
- Ali Arhami Dolatabadi
- Emergency Department, Imam Hossein Hospital, Shahid Beheshti University Of Medical Sciences, Tehran, Iran
| | - Elham Memary
- Anesthesiology Department, Imam Hossein Hospital, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Majid Shojaee
- Emergency Department, Imam Hossein Hospital, Shahid Beheshti University Of Medical Sciences, Tehran, Iran
| | - Hossein Kamalifard
- Emergency Department, Imam Hossein Hospital, Shahid Beheshti University Of Medical Sciences, Tehran, Iran
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Kurhekar P, Vinod K, Rajarathinam B, Dhiviya Krishna JS, Raghuraman MS. Randomized comparison between dexmedetomidine and midazolam for prevention of emergence agitation after nasal surgeries. Saudi J Anaesth 2018; 12:61-66. [PMID: 29416458 PMCID: PMC5789508 DOI: 10.4103/sja.sja_419_17] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Background Emergence agitation (EA) in nasal surgeries is seen in around 22% of patients, which can go to dangerous levels. Dexmedetomidine is effective in prevention of EA in such patients. Midazolam given as premedication fails to prevent EA due to its short half-life. In this study, we compared efficacy of dexmedetomidine and midazolam by intravenous infusion for prevention of EA in adult nasal surgeries. Materials and Methods Seventy patients belonging to American society of anesthesiologist Status I and II, between 18 and 60 years of age posted for elective nasal surgeries were randomly divided into two groups. Group D received intravenous dexmedetomidine 0.5 mcg/kg over 15 min followed by 0.1 mcg/kg/h. Group M received intravenous midazolam 0.02 mg/kg over 15 min followed by 0.02 mg/kg/h. EA scores, emergence times, and hemodynamic parameters were monitored and compared between the groups. Statistical analysis was done by independent t-test, Mann-Whitney U-test, and Chi-square test as applicable. Results Incidence of EA was comparable between the groups (P = 0.23). Two patients in midazolam group developed dangerous agitation while none in dexmedetomidine group. Patients in midazolam group (12.4%) were agitated even in postoperative period, which was not seen with dexmedetomidine group. Hypotension and bradycardia were seen more in dexmedetomidine group. Conclusion Efficacy of midazolam when given as an intravenous infusion is comparable to dexmedetomidine in prevention of EA in nasal surgeries.
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Affiliation(s)
- Pranjali Kurhekar
- Department of Anesthesiology, Shri Sathya Sai Medical College and Research Institute, Kancheepuram, India
| | - Krishnagopal Vinod
- Department of Pain Medicine, Shri Sathya Sai Medical College and Research Institute, Kancheepuram, India
| | | | - J Shesha Dhiviya Krishna
- Department of Anesthesiology, Shri Sathya Sai Medical College and Research Institute, Kancheepuram, India
| | - M S Raghuraman
- Department of Anesthesiology, Shri Sathya Sai Medical College and Research Institute, Kancheepuram, India
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26
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Ni YN, Wang T, Yu H, Liang BM, Liang ZA. The effect of sedation and/or analgesia as rescue treatment during noninvasive positive pressure ventilation in the patients with Interface intolerance after Extubation. BMC Pulm Med 2017; 17:125. [PMID: 28915879 PMCID: PMC5602861 DOI: 10.1186/s12890-017-0469-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 09/06/2017] [Indexed: 02/05/2023] Open
Abstract
Background Sedation and/or analgesia can relieve the patient-ventilator asynchrony. However, whether sedation and/or analgesia can benefit the clinical outcome of the patients with interface intolerance is still unclear. Methods A retrospective study was performed on patients with interface intolerance who received noninvasive positive pressure ventilation (NIPPV) after extubation in seven intensive care units (ICU) of West China Hospital, Sichuan University. The primary outcome was rate of NIPPV failure (defined as need for reintubation and mechanical ventilation); Secondary outcomes were hospital mortality rate and length of ICU stay after extubation. Results A total of 80 patients with oral-nasal mask (90%) and facial mask (10%) were included in the analysis. 41 out of 80 patients received sedation and/or analgesia treatment (17 used analgesia, 11 used sedation and 13 used both) at some time during NIPPV. They showed a decrease of NIPPV failure rate, (15% vs. 38%, P = 0.015; adjusted odd ratio [OR] 0.29, 95% confidence interval [CI] 0.10–0.86, P = 0.025), mortality rate (7% vs. 33%, P = 0.004; adjusted OR 0.14, 95% CI 0.03–0.60, P = 0.008), and the length of ICU stay after extubation. Conclusion This clinical study suggests that sedation and/or analgesia treatment can decrease the rate of NIPPV failure, hospital mortality rate and ICU LOS in patients with interface intolerance after extubution during NIPPV. Electronic supplementary material The online version of this article (10.1186/s12890-017-0469-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yue-Nan Ni
- Department of Respiratory and Critical Care, No.37 Guoxue Alley, Chengdu, 610041, China
| | - Ting Wang
- Department of Respiratory and Critical Care, No.37 Guoxue Alley, Chengdu, 610041, China
| | - He Yu
- Department of Critical Care Medicine, West China School of Medicine and West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Bin-Miao Liang
- Department of Respiratory and Critical Care, No.37 Guoxue Alley, Chengdu, 610041, China.
| | - Zong-An Liang
- Department of Respiratory and Critical Care, No.37 Guoxue Alley, Chengdu, 610041, China.
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Abstract
OBJECTIVES To describe the use of dexmedetomidine for sedation in a large cohort of nonintubated children with acute respiratory insufficiency receiving noninvasive ventilatory support. DESIGN Single-center, retrospective, observational cohort study. SETTING A large quaternary-care PICU. PATIENTS The study cohort included 202 children receiving noninvasive ventilatory and a dexmedetomidine infusion within 48 hours of PICU admission over a 6-month period. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary respiratory diagnoses in the cohort (median age, 2 yr) included status asthmaticus (60%) and bronchiolitis (29%). Dexmedetomidine was infused for a median of 35 hours with a median hourly dose across the patient cohort of 0.61 μg/kg/hr (range, 0.4-0.8 μg/kg/hr). The target sedation level was achieved in 168 patients (83%) in the cohort for greater than or equal to 80% of the recorded values over the entire noninvasive ventilatory course, with dexmedetomidine as the only continuously administered sedative agent. While vital signs were frequently abnormal relative to age-based norms, clinical interventions were needed rarely to treat bradycardia (13%), hypotension (20%), and hypopnea (5%). The most frequently used of these interventions was a dexmedetomidine dose reduction, fluid bolus, and titration of noninvasive ventilatory support. Five patients (2.5%) required endotracheal intubation: three due to progression of their respiratory illness, one with septic shock, and one with apnea requiring resuscitation. In 194 of 202 patients (96%), the outcome of the noninvasive ventilatory course was successful with the patient being weaned from noninvasive respiratory support to nasal cannula or room air. CONCLUSIONS Dexmedetomidine was often effective as a single continuous sedative infusion during pediatric noninvasive ventilatory. Cardiorespiratory events associated with its use were typically mild and/or reversible with dose reduction, fluid administration, and/or noninvasive ventilatory titration. Prospective studies comparing dexmedetomidine with other agents in this setting are warranted.
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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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Davidson AC, Banham S, Elliott M, Kennedy D, Gelder C, Glossop A, Church AC, Creagh-Brown B, Dodd JW, Felton T, Foëx B, Mansfield L, McDonnell L, Parker R, Patterson CM, Sovani M, Thomas L. BTS/ICS guideline for the ventilatory management of acute hypercapnic respiratory failure in adults. Thorax 2016; 71 Suppl 2:ii1-35. [DOI: 10.1136/thoraxjnl-2015-208209] [Citation(s) in RCA: 195] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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30
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Funk GC. [Pain, agitation and delirium in acute respiratory failure]. Med Klin Intensivmed Notfmed 2016; 111:29-36. [PMID: 26817653 DOI: 10.1007/s00063-015-0136-6] [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: 10/12/2015] [Revised: 11/21/2015] [Accepted: 12/08/2015] [Indexed: 10/22/2022]
Abstract
Avoiding pain, agitation and delirium as well as avoiding unnecessary deep sedation is a powerful yet challenging strategy in critical care medicine. A number of interactions between cerebral function and respiratory function should be regarded in patients with respiratory failure and mechanical ventilation. A cooperative sedation strategy (i.e. patient is awake and free of pain and delirium) is feasible in many patients requiring invasive mechanical ventilation. Especially patients with mild acute respiratory distress syndrome (ARDS) seem to benefit from preserved spontaneous breathing. While completely disabling spontaneous ventilation with or without neuromuscular blockade is not a standard strategy in ARDS, it might be temporarily required in patients with severe ARDS, who have substantial dyssynchrony or persistent hypoxaemia. Since pain, agitation and delirium compromise respiratory function they should also be regarded during noninvasive ventilation and during ventilator weaning. Pharmacological sedation can have favourable effects in these situations, but should not be given routinely or uncritically.
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Affiliation(s)
- G-C Funk
- I. Interne Lungenabteilung mit Intensivstation, Otto Wagner Spital, Sanatoriumstrasse 2, 1140, Wien, Österreich.
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31
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Conti G, Hill NS, Nava S. Is sedation safe and beneficial in patients receiving NIV? No. Intensive Care Med 2015; 41:1692-5. [PMID: 26149298 DOI: 10.1007/s00134-015-3915-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 06/08/2015] [Indexed: 12/20/2022]
Affiliation(s)
- Giorgio Conti
- Department of Intensive Care and Anesthesia, Catholic University of Rome, Largo A Gemelli 1, 00168, Rome, Italy
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32
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Hilbert G, Navalesi P, Girault C. Is sedation safe and beneficial in patients receiving NIV? Yes. Intensive Care Med 2015; 41:1688-91. [DOI: 10.1007/s00134-015-3935-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 06/17/2015] [Indexed: 01/27/2023]
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Muriel A, Peñuelas O, Frutos-Vivar F, Arroliga AC, Abraira V, Thille AW, Brochard L, Nin N, Davies AR, Amin P, Du B, Raymondos K, Rios F, Violi DA, Maggiore SM, Soares MA, González M, Abroug F, Bülow HH, Hurtado J, Kuiper MA, Moreno RP, Zeggwagh AA, Villagómez AJ, Jibaja M, Soto L, D’Empaire G, Matamis D, Koh Y, Anzueto A, Ferguson ND, Esteban A. Impact of sedation and analgesia during noninvasive positive pressure ventilation on outcome: a marginal structural model causal analysis. Intensive Care Med 2015; 41:1586-600. [DOI: 10.1007/s00134-015-3854-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 04/28/2015] [Indexed: 10/23/2022]
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Delayed Sequence Intubation: A Prospective Observational Study. Ann Emerg Med 2015; 65:349-55. [DOI: 10.1016/j.annemergmed.2014.09.025] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 09/16/2014] [Accepted: 09/26/2014] [Indexed: 02/03/2023]
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Sedation in non-invasive ventilation: do we know what to do (and why)? Multidiscip Respir Med 2014; 9:56. [PMID: 25699177 PMCID: PMC4333891 DOI: 10.1186/2049-6958-9-56] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 10/06/2014] [Indexed: 01/01/2023] Open
Abstract
This review examines some of the issues encountered in the use of sedation in patients receiving respiratory support from non-invasive ventilation (NIV). This is an area of critical and intensive care medicine where there are limited (if any) robust data to guide the development of best practice and where local custom appears to exert a strong influence on patterns of care. We examine aspects of sedation for NIV where the current lack of structure may be contributing to missed opportunities to improve standards of care and examine the existing sedative armamentarium. No single sedative agent is currently available that fulfils the criteria for an ideal agent but we offer some observations on the relative merits of different agents as they relate to considerations such as effects on respiratory drive and timing, and airways patency. The significance of agitation and delirium and the affective aspect(s) of dyspnoea are also considered. We outline an agenda for placing the use of sedation in NIV on a more systematic footing, including clearly expressed criteria and conditions for terminating NIV and structural and organizational conditions for prospective multicentre trials.
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Devlin JW, Al-Qadheeb NS, Chi A, Roberts RJ, Qawi I, Garpestad E, Hill NS. Efficacy and safety of early dexmedetomidine during noninvasive ventilation for patients with acute respiratory failure: a randomized, double-blind, placebo-controlled pilot study. Chest 2014; 145:1204-1212. [PMID: 24577019 DOI: 10.1378/chest.13-1448] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Successful application of noninvasive ventilation (NIV) for acute respiratory failure (ARF) requires patient cooperation and comfort. The efficacy and safety of early IV dexmedetomidine when added to protocolized, as-needed IV midazolam and fentanyl remain unclear. METHODS Adults with ARF and within 8 h of starting NIV were randomized to receive IV dexmedetomidine (0.2 μg/kg/h titrated every 30 min to 0.7 μg/kg/h to maintain a Sedation-Agitation Scale [SAS] score of 3 to 4) or placebo in a double-blind fashion up to 72 h, until NIV was stopped for ≥ 2 h, or until intubation. Patients with agitation (SAS ≥ 5) or pain (visual analog scale ≥ 5 of 10 cm) 15 min after each dexmedetomidine and placebo increase could receive IV midazolam 0.5 to 1.0 mg or IV fentanyl 25 to 50 μg, respectively, at a minimum interval of every 3 h. RESULTS The dexmedetomidine (n = 16) and placebo (n = 17) groups were similar at baseline. Use of early dexmedetomidine did not improve NIV tolerance (score, 1 of 4; OR, 1.44; 95% CI, 0.44-4.70; P = .54) nor, vs. placebo, led to a greater median (interquartile range) percent time either tolerating NIV (99% [61%-100%] vs. 67% [40%-100%], P = .56) or remaining at the desired sedation level (SAS score = 3 or 4, 100% [86%-100%] vs. 100% [100%-100%], P = .28], or fewer intubations (P = .79). Although use of dexmedetomidine was associated with a greater duration of NIV vs placebo (37 [16-72] vs. 12 [4-22] h, P = .03), the total ventilation duration (NIV + invasive) was similar (3.3 [2-4] days vs. 3.8 [2-5] days, P = .52). More patients receiving dexmedetomidine had one or more episodes of deep sedation vs placebo (SAS ≤ 2, 25% vs. 0%, P = .04). Use of midazolam (P = .40) and episodes of either severe bradycardia (heart rate ≤ 50 beats/min, P = .18) or hypotension (systolic BP ≤ 90 mm Hg, P = .64) were similar. CONCLUSIONS Initiating dexmedetomidine soon after NIV initiation in patients with ARF neither improves NIV tolerance nor helps to maintain sedation at a desired goal. Randomized, multicenter trials targeting patients with initial intolerance are needed to further elucidate the role for dexmedetomidine in this population.
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Affiliation(s)
- John W Devlin
- School of Pharmacy, Northeastern University; Division of Pulmonary, Critical Care and Sleep Medicine.
| | | | - Amy Chi
- Division of Pulmonary, Critical Care and Sleep Medicine
| | | | - Imrana Qawi
- Division of Pulmonary, Critical Care and Sleep Medicine
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Abstract
After the institution of positive-pressure ventilation, the use of noninvasive ventilation (NIV) through an interface substantially increased. The first technique was continuous positive airway pressure; but, after the introduction of pressure support ventilation at the end of the 20th century, this became the main modality. Both techniques, and some others that have been recently introduced and which integrate some technological innovations, have extensively demonstrated a faster improvement of acute respiratory failure in different patient populations, avoiding endotracheal intubation and facilitating the release of conventional invasive mechanical ventilation. In acute settings, NIV is currently the first-line treatment for moderate-to-severe chronic obstructive pulmonary disease exacerbation as well as for acute cardiogenic pulmonary edema and should be considered in immunocompromised patients with acute respiratory insufficiency, in difficult weaning, and in the prevention of postextubation failure. Alternatively, it can also be used in the postoperative period and in cases of pneumonia and asthma or as a palliative treatment. NIV is currently used in a wide range of acute settings, such as critical care and emergency departments, hospital wards, palliative or pediatric units, and in pre-hospital care. It is also used as a home care therapy in patients with chronic pulmonary or sleep disorders. The appropriate selection of patients and the adaptation to the technique are the keys to success. This review essentially analyzes the evidence of benefits of NIV in different populations with acute respiratory failure and describes the main modalities, new devices, and some practical aspects of the use of this technique.
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Affiliation(s)
- Arantxa Mas
- Critical Care Department, Consorci Sanitari Integral (CSI), Hospital Sant Joan Despí Moisès Broggi and Hospital General de l’Hospitalet, University of Barcelona, Barcelona, Spain
| | - Josep Masip
- Critical Care Department, Consorci Sanitari Integral (CSI), Hospital Sant Joan Despí Moisès Broggi and Hospital General de l’Hospitalet, University of Barcelona, Barcelona, Spain
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Pasin L, Landoni G, Nardelli P, Belletti A, Di Prima AL, Taddeo D, Isella F, Zangrillo A. Dexmedetomidine reduces the risk of delirium, agitation and confusion in critically Ill patients: a meta-analysis of randomized controlled trials. J Cardiothorac Vasc Anesth 2014; 28:1459-66. [PMID: 25034724 DOI: 10.1053/j.jvca.2014.03.010] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Delirium frequently is observed in critically ill patients in the intensive care unit (ICU) and is associated strongly with a poor outcome. Dexmedetomidine seems to reduce time to extubation and ICU stay without detrimental effects on mortality. The objective of the authors' study was to evaluate the effect of this drug on delirium, agitation, and confusion in the ICU setting. DESIGN Meta-analysis of all the randomized clinical trials ever performed on dexmedetomidine versus any comparator in the ICU setting. SETTING Intensive care units. PARTICIPANTS Critically ill patients. INTERVENTIONS None MEASUREMENTS AND MAIN RESULTS Pertinent studies were independently searched in BioMedCentral, PubMed, Embase, and the Cochrane Central Register of clinical trials. Primary endpoint was the rate of delirium, including the adverse events, agitation and confusion. The 13 included manuscripts (14 trials) randomized 3,029 patients. Overall analysis showed that the use of dexmedetomidine was associated with significant reductions in the incidence of delirium, agitation and confusion (298/1,565 [19%] in the dexmedetomidine group v 337/1,464 [23%] in the control group, RR = 0.68 [0.49 to 0.96], p = 0.03). Results were confirmed in subanalyses performed on patients undergoing noninvasive ventilation (1/53 [2%] in the dexmedetomidine group v 7/49 [14%] in the control group, RR=0.18 [0.03 to 1.01], p = 0.05), receiving midazolam as a comparator (268/1,164 [23%] in the dexmedetomidine group v 277/1,025 [27%] in the control group, RR = 0.68 [0.47 to 1.00], p = 0.05) and in general ICU setting patients (204/688 [30%] in the dexmedetomidine group v 204/560 [36%] in the control group, RR = 0.68 [0.45 to 0.81], p < 0.01). CONCLUSIONS This meta-analysis of randomized controlled studies suggests that dexmedetomidine could help to reduce delirium in critically ill patients.
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Affiliation(s)
- Laura Pasin
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Pasquale Nardelli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Ambra Licia Di Prima
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Daiana Taddeo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesca Isella
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Jakob S, Ruokonen E, Takala J. Efficacy of dexmedetomidine compared with midazolam for sedation in adult intensive care patients. Br J Anaesth 2014; 112:581-2. [DOI: 10.1093/bja/aeu032] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Clinical practice guidelines for evidence-based management of sedoanalgesia in critically ill adult patients. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.medine.2013.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Celis-Rodríguez E, Birchenall C, de la Cal M, Castorena Arellano G, Hernández A, Ceraso D, Díaz Cortés J, Dueñas Castell C, Jimenez E, Meza J, Muñoz Martínez T, Sosa García J, Pacheco Tovar C, Pálizas F, Pardo Oviedo J, Pinilla DI, Raffán-Sanabria F, Raimondi N, Righy Shinotsuka C, Suárez M, Ugarte S, Rubiano S. Guía de práctica clínica basada en la evidencia para el manejo de la sedoanalgesia en el paciente adulto críticamente enfermo. Med Intensiva 2013; 37:519-74. [DOI: 10.1016/j.medin.2013.04.001] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 04/16/2013] [Indexed: 01/18/2023]
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Adams R, Brown GT, Davidson M, Fisher E, Mathisen J, Thomson G, Webster NR. Efficacy of dexmedetomidine compared with midazolam for sedation in adult intensive care patients: a systematic review. Br J Anaesth 2013; 111:703-10. [PMID: 23748199 DOI: 10.1093/bja/aet194] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Patients in Intensive Care Unit (ICU) often require sedatives which commonly include midazolam and the more recently developed α2-receptor agonist, dexmedetomidine. It was our aim to compare the sedative and clinical effectiveness of dexmedetomidine vs midazolam in adults admitted to ICU, using an objective appraisal of randomized control trials. Medline, Embase, SCOPUS, Web of Knowledge, Cinhal, the United States National Library of Medicine, and the Cochrane Database of Systematic Reviews were searched using keywords: 'dexmedetomidine', 'midazolam', and 'intensive care'. These were limited to human studies and adults (>18 yr old). Six randomized controlled trials were found and were critically appraised using a standardized appraisal method. Two papers described the time spent by each intervention group within a specified target sedation range and both found no statistically significant difference between midazolam and dexmedetomidine (P=0.18 and P=0.15). A third paper found no statistically significant difference in the length of time that patients were sedated within a target zone (P=0.445). Two additional pilot studies did not report P values as they were insufficiently statistically powered. A final paper found that, of the eight occasions measured, patients on dexmedetomidine were more often within the target sedation range than patients on midazolam. The sedative benefits of dexmedetomidine vs midazolam remain inconclusive. While some secondary outcomes showed clinical effectiveness of dexmedetomidine, more research is needed to validate the findings of these studies.
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Affiliation(s)
- R Adams
- University of Aberdeen, Foresterhill, Aberdeen AB25 2ZD, UK
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Romera Ortega MA, Chamorro Jambrina C, Lipperheide Vallhonrat I, Fernández Simón I. [Indications of dexmedetomidine in the current sedoanalgesia tendencies in critical patients]. Med Intensiva 2013; 38:41-8. [PMID: 23683866 DOI: 10.1016/j.medin.2013.03.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Revised: 03/08/2013] [Accepted: 03/12/2013] [Indexed: 11/20/2022]
Abstract
Recently, dexmedetomidine has been marketed in Spain and other European countries. The published experience regarding its use has placed dexmedetomidine on current trends in sedo-analgesic strategies in the adult critically ill patient. Dexmedetomidine has sedative and analgesic properties, without respiratory depressant effects, inducing a degree of depth of sedation in which the patient can open its eyes to verbal stimulation, obey simple commands and cooperate in nursing care. It is therefore a very useful drug in patients who can be maintained on mechanical ventilation with these levels of sedation avoiding the deleterious effects of over or infrasedation. Because of its effects on α2-receptors, it's very useful for the control and prevention of tolerance and withdrawal to other sedatives and psychotropic drugs. The use of dexmedetomidine has been associated with lower incidence of delirium when compared with other sedatives. Moreover, it's a potentially useful drug for sedation of patients in non-invasive ventilation.
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Affiliation(s)
- M A Romera Ortega
- Servicio de Medicina Intensiva, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España
| | - C Chamorro Jambrina
- Servicio de Medicina Intensiva, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España.
| | - I Lipperheide Vallhonrat
- Servicio de Medicina Intensiva, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España
| | - I Fernández Simón
- Servicio de Medicina Intensiva, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España
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[Non-invasive mechanical ventilation in COPD]. Med Klin Intensivmed Notfmed 2012; 107:185-91. [PMID: 22415450 DOI: 10.1007/s00063-011-0067-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Accepted: 02/06/2012] [Indexed: 01/09/2023]
Abstract
Non-invasive mechanical ventilation is the preferred method for the treatment of acute respiratory failure in patients with chronic obstructive pulmonary disease (COPD). Primary contraindications and stopping criteria must be regarded to avoid delaying endotracheal intubation. The primary interface is usually a nasal-oral mask. Cautious sedation can facilitate non-invasive ventilation in some patients. Under certain circumstances non-invasive ventilation may enable successful extubation in COPD patients with prolonged weaning. COPD patients can also benefit from preventive non-invasive ventilation in order to avoid re-intubation after a planned extubation. Domiciliary nocturnal non-invasive ventilation is an option for some patients with COPD in chronic hypercapnic respiratory failure. This treatment should be established in a specialised unit.
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