Clinical benefits of dexmedetomidine versus propofol in adult intensive care unit patients: a meta-analysis of randomized clinical trials

Comparing different postoperative sedation strategies for patients in the intensive care unit after cardiac surgery: A systematic review of randomized controlled trials and network meta-analysis

BACKGROUND

Various postoperative sedation protocols with different anaesthetics lead to profound effects on the outcomes for post-cardiac surgery patients. However, a comprehensive analysis of optimal postoperative sedation strategies for patients in the intensive care unit (ICU) after cardiac surgery is lacking.

METHODS

We systematically searched for randomized controlled trials (RCTs) in databases including PubMed and Embase. The primary outcome measured the duration of mechanical ventilation (MV) in the ICU, and the secondary outcome encompassed the length of stay (LOS) in the ICU and hospital and the monitoring adverse events.

RESULTS

The literature included 18 RCTs (1652 patients) with 13 sedation regimens. Dexmedetomidine plus ketamine and sevoflurane were associated with a significantly reduced duration of MV when compared with propofol. Our results also suggested that dexmedetomidine plus ketamine may associated with a shorter LOS in ICU, and sevoflurane associated with a shorter LOS in the hospital, respectively.

CONCLUSIONS

The combination of dexmedetomidine and ketamine seems to be a better option for adult patients needing sedation after cardiac surgery, and the incidence of side effects is lower with dexmedetomidine. These findings have potential implications for medication management in the perioperative pharmacotherapy of cardiac surgery patients.

A comparation of dexmedetomidine and midazolam for sedation in patients with mechanical ventilation in ICU: A systematic review and meta-analysis

BACKGROUND

The use of dexmedetomidine rather than midazolam may improve ICU outcomes. We summarized the available recent evidence to further verify this conclusion.

METHODS

An electronic search of PubMed, Medline, Embase, Cochrane Library, and Web of Science was conducted. Risk ratios (RR) were used for binary categorical variables, and for continuous variables, weighted mean differences (WMD) were calculated, the effect sizes are expressed as 95% confidence intervals (CI), and trial sequential analysis was performed.

RESULTS

16 randomized controlled trials were enrolled 2035 patients in the study. Dexmedetomidine as opposed to midazolam achieved a shorter length of stay in ICU (MD = -2.25, 95%CI = -2.94, -1.57, p<0.0001), lower risk of delirium (RR = 0.63, 95%CI = 0.50, 0.81, p = 0.0002), and shorter duration of mechanical ventilation (MD = -0.83, 95%CI = -1.24, -0.43, p<0.0001). The association between dexmedetomidine and bradycardia was also found to be significant (RR 2.21, 95%CI 1.31, 3.73, p = 0.003). We found no difference in hypotension (RR = 1.44, 95%CI = 0.87, 2.38, P = 0.16), mortality (RR = 1.02, 95%CI = 0.83, 1.25, P = 0.87), neither in terms of adverse effects requiring intervention, hospital length of stay, or sedation effects.

CONCLUSIONS

Combined with recent evidence, compared with midazolam, dexmedetomidine decreased the risk of delirium, mechanical ventilation, length of stay in the ICU, as well as reduced patient costs. But dexmedetomidine could not reduce mortality and increased the risk of bradycardia.

Palliative Sedation Therapy Practice Comparison - A Survey of Pediatric Palliative Care and Pain Management Specialists

Context: Palliative sedation therapy (PST) can relieve suffering at end-of-life (EOL) in children with intolerable and refractory symptoms. However, updated and consistent guidance on PST practices are imperative. Objectives: We investigate current variations in clinical practice and PST implementation among pediatric palliative care (PPC) and pain management (PM) specialists. Methods: We distributed an IRB-exempt electronic anonymous survey via email through the Society of Pediatric Pain Medicine, and the American Academy of Hospice and Palliative Medicine. Survey responses were collated and descriptively reported. Results: Of 83 survey responses, the majority (75%) represented large academic children's hospitals. The distribution between PPC and pediatric pain management specialists' responses was 60% and 40%, respectively. Most respondents reported having designated pain management and/or palliative care teams (70% and 90%, respectively). Approximately half (48%) reported following an institutional PST protocol, most not requiring formal ethics consult (69%). Only 54% of respondents noted that the Do Not Resuscitate (DNR) order was required prior to PST initiation. PST was primarily utilized for children with oncologic diagnoses (76%). The primary and secondary medications of choice for PST implementation were reported to be opioids (39%) and benzodiazepines (36%) by pain management specialists, and benzodiazepines (52%) and barbiturates (28%) by palliative care specialists. Conclusions: Our study highlights the variability in the practice and implementation of PST. Further educational efforts are key for establishing PST practices and efficient protocol development.

Dexmedetomidine: A Sedation Alternative in the Intensive Care Setting

In the last 20 years, the occurrences of drug shortages have increased in frequency as well as duration before returning to the mainstream market. This has prompted intensive care unit nurses and medical staff to seek alternate medication infusion options that provide safe yet effective sedation for patients admitted to intensive care units across the country. Dexmedetomidine (PRECEDEX) emerged in 1999 after the Federal Drug Administration approved it for intensive care use but was quickly embraced by anesthesia providers as it rendered patients undergoing procedures or surgery with adequate analgesia and sedation. Dexmedetomidine (PRECEDEX) continued to maintain patients who required short-term intubation and mechanical ventilation with adequate sedation throughout the entire perioperative period. With patients remaining hemodynamically stable in the initial postoperative period, critical care nurses embraced the use of dexmedetomidine (PRECEDEX) in the intensive care unit setting. As dexmedetomidine (PRECEDEX) gained popularity, it has been used to help manage multiple disease processes such as delirium, agitation, alcoholic withdrawal, and anxiety. Dexmedetomidine (PRECEDEX) has been indicated to be a safer alternative to benzodiazepines, narcotics, or propofol (Diprivan), while providing adequate sedation and allowing patients to maintain hemodynamic stability.

Comparison Between Dexmedetomidine and Propofol for Sedation on Outcomes After Cardiac Surgery in Patients Requiring Mechanical Ventilation: A Meta-Analysis of Randomized-Control Trials

The aim of this study was to compare outcomes between dexmedetomidine and propofol for sedation after cardiac surgery in patients requiring mechanical ventilation. This meta-analysis was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Online databases, including EMBASE, PubMed, and the Cochrane Library, were comprehensively searched to identify relevant randomized controlled trials (RCTs) comparing the safety and efficacy of dexmedetomidine and propofol in patients undergoing cardiac surgery and requiring mechanical ventilation. The examined outcomes included the mean length of intensive care unit (ICU) stay in hours, duration of mechanical ventilation in hours, length of hospital stay in days, and number of patients diagnosed with delirium. A total of 14 studies were included in the present meta-analysis while 1360 patients undergoing cardiac surgery were involved in these studies. Pooled results showed that the duration of mechanical ventilation was lower in the dexmedetomidine group compared to the propofol group (mean difference (MD): 0.75, 95% confidence interval (CI): 0.06-1.44, p-value: 0.03). We also found a significantly low length of stay in ICU in the dexmedetomidine group compared to the propofol (MD: 0.89, 95% CI: 0.04-1.74, p-value: 0.04). The length of hospital stay was also significantly lower in patients receiving dexmedetomidine as compared to the propofol group (MD: 0.51, 95% CI: 0.32-0.70, p-value<0.001). Risk of delirium was significantly higher in patients receiving propofol compared to patients receiving dexmedetomidine (RR: 2.02, 95% CI: 1.48-2.74, p-value<0.001). In conclusion, our meta-analysis provides evidence of the beneficial impacts of dexmedetomidine on clinical outcomes in patients undergoing cardiac surgery. Dexmedetomidine was associated with a significant reduction in the duration of mechanical ventilation, length of stay in the intensive care unit (ICU) and hospital, and the risk of delirium.

Dexmedetomidine and Propofol at End of Life in Pediatric Oncology: Trends in Palliative Sedation Therapy

Context: Palliative sedation therapy (PST) can address suffering at the end of life (EOL) in children with cancer; yet, little is known about PST in this population. Objectives: We sought to describe the characteristics of pediatric oncology patients requiring PST at the EOL. Methods: A retrospective review was completed for pediatric oncology patients who required PST at a United States academic institution over 10 years, including demographics, disease characteristics, EOL characteristics, and medications for PST and symptom management. Results: PST was utilized in 3% of patients at the EOL. Of 24 study participants receiving PST, 83% (n = 20), 12.5% (n = 3), and 4.2% (n = 1) received dexmedetomidine, propofol, or both, respectively. The most frequent diagnosis for patients receiving PST was acute myelogenous leukemia (20.8%, n = 5). All patients were followed up by the palliative care team, and two-thirds (66.6%, n = 16) were also followed up by the pain management service; 79% (n = 19) were enrolled in hospice, and 98.5% (n = 23) had a Physician Orders for Scope of Treatment in place. Pain was the most common refractory symptom leading to PST initiation (33.3%, n = 8), followed by neuroagitation and dyspnea. PST was initiated a median of 2.5 days before death. A third of deaths occurred in the intensive care unit (33.3%, n = 8). Conclusions: PST was rare in this study; dexmedetomidine was used as first-line treatment for PST in patients at the EOL with refractory symptoms. Its place in PST protocols in pediatric oncology should be validated with prospective studies. Our study suggests the potential value of collaboration between palliative care and pain specialists in the context of PST.

Palliative Sedation Therapy in Pediatrics: An Algorithm and Clinical Practice Update

Palliative sedation therapy (PST) is an important clinical intervention for pediatric patients with refractory symptoms and suffering during the end-of-life (EOL) period. Variations in PST implementation including medication selection, limited literature regarding feasibility in various clinical settings, particularly non-intensive care units, and lack of education on evolving definitions and ideal practices may all contribute to the current underutilization of this valuable resource. We therefore offer a clinical algorithm for identifying appropriate patients for PST, ensuring all other modalities for symptom management have been considered and/or optimized, and present a guideline for PST implementation that can be adapted and individualized based on institutional experience and resource availability. Furthermore, through case-based clinical scenarios, we demonstrate how to incorporate this algorithm into EOL practice.

Effect of low-dose dexmedetomidine on sleep quality in postoperative patients with mechanical ventilation in the intensive care unit: A pilot randomized trial

Background

Sleep disturbances are prevalent in patients requiring invasive mechanical ventilation in the intensive care unit (ICU) and are associated with worse outcomes. Sedative-dose dexmedetomidine may improve sleep quality in this patient population but is associated with adverse events. Herein, we tested the effect of low-dose dexmedetomidine infusion on nighttime sleep quality in postoperative ICU patients with invasive ventilation.

Methods

In this pilot randomized trial, 80 adult patients who were admitted to the ICU after non-cardiac surgery and required invasive mechanical ventilation were randomized to receive either low-dose dexmedetomidine (0.1 to 0.2 μg/kg/h, n = 40) or placebo (n = 40) for up to 72 h. The primary endpoint was overall subjective sleep quality measured using the Richards–Campbell Sleep Questionnaire (score ranges from 0 to 100, with a higher score indicating better quality) in the night of surgery. Secondary outcomes included sleep structure parameters monitored with polysomnography from 9:00 PM on the day of surgery to the next 6:00 AM.

Results

All 80 patients were included in the intention-to-treat analysis. The overall subjective sleep quality was median 52 (interquartile 20, 66) with placebo vs. 61 (27, 79) with dexmedetomidine, and the difference was not statistically significant (median difference 8; 95% CI: −2, 22; P = 0.120). Among 68 patients included in sleep structure analysis, those in the dexmedetomidine group tended to have longer total sleep time [median difference 54 min (95% CI: −4, 120); P = 0.061], higher sleep efficiency [median difference 10.0% (95% CI: −0.8%, 22.3%); P = 0.060], lower percentage of stage N1 sleep [median difference −3.9% (95% CI: −11.8%, 0.5%); P = 0.090], higher percentage of stage N3 sleep [median difference 0.0% (95% CI: 0.0%, 0.4%); P = 0.057], and lower arousal index [median difference −0.9 (95% CI −2.2, 0.1); P = 0.091] but not statistically significant. There were no differences between the two groups regarding the incidence of adverse events.

Conclusion

Among patients admitted to the ICU after surgery with intubation and mechanical ventilation, low-dose dexmedetomidine infusion did not significantly improve the sleep quality pattern, although there were trends of improvement. Our findings support the conduct of a large randomized trial to investigate the effect of low-dose dexmedetomidine in this patient population.

Clinical trial registration

ClinicalTrial.gov, identifier: NCT03335527.

Outcomes of dexmedetomidine versus propofol sedation in critically ill adults requiring mechanical ventilation: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Guidelines have recommended the use of dexmedetomidine or propofol for sedation after cardiac surgery, and propofol monotherapy for other patients. Further outcome data are required for these drugs.

METHODS

This systematic review and meta-analysis was prospectively registered on PROSPERO. The primary outcome was ICU length of stay. Secondary outcomes included duration of mechanical ventilation, ICU delirium, all-cause mortality, and haemodynamic effects. Intensive care patients were analysed separately as cardiac surgical, medical/noncardiac surgical, those with sepsis, and patients in neurocritical care. Subgroup analyses based on age and dosage were conducted.

RESULTS

Forty-one trials (N=3948) were included. Dexmedetomidine did not significantly affect ICU length of stay across any ICU patient subtype when compared with propofol, but it reduced the duration of mechanical ventilation (mean difference -0.67 h; 95% confidence interval: -1.31 to -0.03 h; P=0.041; low certainty) and the risk of ICU delirium (risk ratio 0.49; 95% confidence interval: 0.29-0.87; P=0.019; high certainty) across cardiac surgical patients. Dexmedetomidine was also associated with a greater risk of bradycardia across a variety of ICU patients. Subgroup analyses revealed that age might affect the incidence of haemodynamic side-effects and mortality among cardiac surgical and medical/other surgical patients.

CONCLUSION

Dexmedetomidine did not significantly impact ICU length of stay compared with propofol, but it significantly reduced the duration of mechanical ventilation and the risk of delirium in cardiac surgical patients. It also significantly increased the risk of bradycardia across ICU patient subsets.

Effects of general anesthesia on behavioral circadian rhythms and clock-gene expression in the suprachiasmatic nucleus in rats

The suprachiasmatic nucleus (SCN) of the hypothalamus is a nucleus that regulates circadian rhythms through the cyclic expression of clock genes. It has been suggested that circadian-rhythm-related, adverse postoperative events, including sleep disturbances and delirium, are partly caused by anesthesia-induced disruption of clock-gene expression. We examined the effects of multiple general anesthetics on the expression cycle of Period2 (Per2), one of the clock genes that regulate circadian rhythms in the SCN, and on the behavioral rhythms of animals. Rats were treated with sevoflurane, propofol, and dexmedetomidine for 4 h. The expression of Per2 in SCN was analyzed using in situ hybridization, and the behavioral rhythm before and after anesthesia was analyzed. Per2 expression in the SCN decreased significantly immediately after anesthesia in all groups compared with corresponding control groups. However, Per2 returned to normal levels within 24 h, and there was no phase change in the gene expression cycle or behavioral rhythm. This study suggests that acute suppression of Per2 expression may be a general phenomenon induced by general anesthesia, but that the molecular mechanism of the body clock is resilient to disturbances to some extent.

Recent Advances in the Clinical Value and Potential of Dexmedetomidine

Dexmedetomidine, a highly selective α2-adrenoceptor agonist, has sedative, anxiolytic, analgesic, sympatholytic, and opioid-sparing properties and induces a unique sedative response which shows an easy transition from sleep to wakefulness, thus allowing a patient to be cooperative and communicative when stimulated. Recent studies indicate several emerging clinical applications via different routes. We review recent data on dexmedetomidine studies, particularly exploring the varying routes of administration, experimental implications, clinical effects, and comparative advantages over other drugs. A search was conducted on the PubMed and Web of Science libraries for recent studies using different combinations of the words “dexmedetomidine”, “route of administration”, and pharmacological effect. The current routes, pharmacological effects, and application categories of dexmedetomidine are presented. It functions by stimulating pre- and post-synaptic α2-adrenoreceptors within the central nervous system, leading to hyperpolarization of noradrenergic neurons, induction of an inhibitory feedback loop, and reduction of norepinephrine secretion, causing a sympatholytic effect, in addition to its anti-inflammation, sleep induction, bowel recovery, and sore throat reduction effects. Compared with similar α2-adrenoceptor agonists, dexmedetomidine has both pharmacodynamics advantage of a significantly greater α2:α1-adrenoceptor affinity ratio and a pharmacokinetic advantage of having a significantly shorter elimination half-life. In its clinical application, dexmedetomidine has been reported to present a significant number of benefits including safe sedation for various surgical interventions, improvement of intraoperative and postoperative analgesia, sedation for compromised airways without respiratory depression, nephroprotection and stability of hypotensive hemodynamics, reduction of postoperative nausea and vomiting and postoperative shivering incidence, and decrease of intraoperative blood loss. Although the clinical application of dexmedetomidine is promising, it is still limited and further research is required to enhance understanding of its pharmacological properties, patient selection, dosage, and adverse effects.

The Effect of Dexmedetomidine as a Sedative Agent for Mechanically Ventilated Patients With Sepsis: A Systematic Review and Meta-Analysis

Purpose: Dexmedetomidine has been shown to improve clinical outcomes in critically ill patients. However, its effect on septic patients remains controversial. Therefore, the purpose of this meta-analysis was to assess the effect of dexmedetomidine as a sedative agent for mechanically ventilated patients with sepsis. Methods: We searched PubMed, Embase, Scopus, and Cochrane Library from inception through May 2021 for randomized controlled trials that enrolled mechanically ventilated, adult septic patients comparing dexmedetomidine with other sedatives or placebo. Results: A total of nine studies involving 1,134 patients were included in our meta-analysis. The overall mortality (RR 0.97, 95%CI 0.82 to 1.13, P = 0.67, I² = 25%), length of intensive care unit stay (MD -1.12, 95%CI -2.89 to 0.64, P = 0.21, I² = 71%), incidence of delirium (RR 0.95, 95%CI 0.72 to 1.25, P = 0.70, I² = 0%), and delirium free days (MD 1.76, 95%CI -0.94 to 4.47, P = 0.20, I² = 80%) were not significantly different between dexmedetomidine and other sedative agents. Alternatively, the use of dexmedetomidine was associated with a significant reduction in the duration of mechanical ventilation (MD -0.53, 95%CI -0.85 to -0.21, P = 0.001, I² = 0%) and inflammatory response (TNF-α: MD -5.27, 95%CI -7.99 to -2.54, P<0.001, I² = 0%; IL-1β: MD -1.25, 95%CI -1.91 to -0.59, P<0.001, I² = 0%). Conclusions: For patients with sepsis, the use of dexmedetomidine as compared with other sedative agents does not affect all-cause mortality, length of intensive care unit stay, the incidence of delirium, and delirium-free days. But the dexmedetomidine was associated with the reduced duration of mechanical ventilation and inflammatory response.

Effect of enterally administered sleep-promoting medication on the intravenous sedative dose and its safety and cost profile in mechanically ventilated patients: A retrospective cohort study

BACKGROUND

The clinical effect of enteral administration of sleep-promoting medication (SPM) in mechanically ventilated patients remains unclear. This study aimed to investigate the relationship between enteral SPM administration and the intravenous sedative dose and examine the safety and cost of enteral SPM administration.

METHODS

This single-center retrospective cohort study was conducted in a Japanese tertiary hospital intensive care unit (ICU). The exposure was enteral SPM administration during mechanical ventilation. The outcome was the average daily propofol dose per body weight administered as a continuous sedative during mechanical ventilation. Patients were divided into three groups based on the timing of SPM administration at ICU admission: "administration within 48 hours (early administration [EA])," "administration after 48 hours (late administration [LA])," and "no administration (NA)." We used multiple linear regression models.

RESULTS

Of 123 included patients, 37, 50, and 36 patients were assigned to the EA, LA, and NA groups, respectively. The average daily propofol dose per body weight was significantly lower in the EA group than in the LA and NA groups (β -5.13 [95% confidence interval (CI) -8.93 to -1.33] and β -4.51 [95% CI -8.59 to -0.43], respectively). Regarding safety, enteral SPM administration did not increase adverse events, including self-extubation. The total cost of neuroactive drugs tended to be lower in the EA group than in the LA and NA groups.

CONCLUSIONS

Early enteral SPM administration reduced the average daily propofol dose per body weight without increasing adverse events.

Dexmedetomidine and paralytic exposure after damage control laparotomy: risk factors for delirium? Results from the EAST SLEEP-TIME multicenter trial

PURPOSE

To evaluate factors associated with ICU delirium in patients who underwent damage control laparotomy (DCL), with the hypothesis that benzodiazepines and paralytic infusions would be associated with increased delirium risk. We also sought to evaluate the differences in sedation practices between trauma (T) and non-trauma (NT) patients.

METHODS

We reviewed retrospective data from 15 centers in the EAST SLEEP-TIME registry admitted from January 1, 2017 to December 31, 2018. We included all adults undergoing DCL, regardless of diagnosis, who had completed daily Richmond Agitation Sedation Score (RASS) and Confusion Assessment Method-ICU (CAM-ICU). We excluded patients younger than 18 years, pregnant women, prisoners and patients who died before the first re-laparotomy. Data collected included age, number of re-laparotomies after DCL, duration of paralytic infusion, duration and type of sedative and opioid infusions as well as daily CAM-ICU and RASS scores to analyze risk factors associated with the proportion of delirium-free/coma-free ICU days during the first 30 days (DF/CF-ICU-30) using multivariate linear regression.

RESULTS

A 353 patient subset (73.2% trauma) from the overall 567-patient cohort had complete daily RASS and CAM-ICU data. NT patients were older (58.9 ± 16.0 years vs 40.5 ± 17.0 years [p < 0.001]). Mean DF/CF-ICU-30 days was 73.7 ± 96.4% for the NT and 51.3 ± 38.7% in the T patients (p = 0.030). More T patients were exposed to Midazolam, 41.3% vs 20.3% (p = 0.002). More T patients were exposed to Propofol, 91.0% vs 71.9% (p < 0.001) with longer infusion times in T compared to NT (71.2 ± 85.9 vs 48.9 ± 69.8 h [p = 0.017]). Paralytic infusions were also used more in T compared to NT, 34.8% vs 18.2% (p < 0.001). Using linear regression, dexmedetomidine infusion and paralytic infusions were associated with decreases in DF/CF-ICU-30, (- 2.78 (95%CI [- 5.54, - 0.024], p = 0.040) and (- 7.08 ([- 13.0, - 1.10], p = 0.020) respectively.

CONCLUSIONS

Although the relationship between paralytic use and delirium is well-established, the observation that dexmedetomidine exposure is independently associated with increased delirium and coma is novel and bears further study.

Effects of Intraoperative Dexmedetomidine Infusion on Postoperative Delirium in Elderly Patients Undergoing Total Hip Arthroplasty

Objective

To investigate the effects of dexmedetomidine on postoperative delirium in elderly patients undergoing total hip arthroplasty.

Methods

A total of 100 patients, 42 male and 58 female, ages 60 to 85 years, American Society of Anesthesiologists grade I or II, who were undergoing total hip arthroplasty were randomly divided into 2 groups: a dexmedetomidine group (group D; n = 50) and a control group (group C; n = 50). Group D patients were infused with 0.3 μg · kg−1 · h−1 of dexmedetomidine from 5 minutes prior to anesthesia induction until the end of surgery. Group C patients received an equal volume of saline. Heart rate and mean arterial pressure (MAP) were recorded before anesthesia induction (T0), 1 minute before extubation (T1), and 30 minutes after extubation (T2). The Visual Analog Score (VAS) at 1, 2, and 3 days after surgery, the incidence and duration of postoperative delirium, and the length of hospital stay were recorded. Adverse reactions, such as nausea, vomiting, and lethargy, were also recorded.

Results

The Visual Analog Scores in the 2 groups were similar. In group D, there was no significant difference in heart rate (P = 0.232) and MAP (P = 0.056) between T0 and T1. However, in group C, heart rate significantly increased by 15.3 bpm (P = 0.000) and MAP significantly increased by 10.7 mmHg (P = 0.001) at T1 compared with those at T0. The incidence of postoperative delirium in group D (10%) was significantly lower than that in group C (26%; P = 0.037). The duration of delirium in group D (1.3 ± 0.6 days) was shorter than that in group C (3.0 ± 0.5 days; P = 0.000). The length of hospital stay in group D (13.2 ± 0.9 days) was shorter than that in group C (16.1 ± 0.7 days; P = 0.000). No significant differences were observed in adverse effects between the 2 groups.

Conclusion

Intravenous infusion of dexmedetomidine can not only reduce the incidence and duration of postoperative delirium, but also shorten the length of hospital stay in elderly patients undergoing total hip arthroplasty.

How We Prevent and Treat Delirium in the ICU

Delirium is a serious and complex problem facing critically ill patients, their families, and the health care system. When delirium develops, it is associated with prolonged hospital stays, increased costs, and long-term cognitive impairment in many patients. This article uses a clinical case to discuss our approach to delirium prevention and treatment in the ICU. We believe that an effective strategy to combat delirium requires implementation and adherence to a pain and sedation protocol as part of bundled care, use of a validated tool to detect delirium when present, and a focus on nonpharmacologic care strategies, including reorientation, early mobility, and incorporating family into care when possible. At present, the evidence does not support the routine administration of medications to prevent or treat delirium. A pharmacologic approach may be needed for agitated delirium, and we discuss our evaluation of the evidence for and against particular medications. Although delirium can be a distressing problem, there is evidence that it can be addressed through careful attention to prevention, detection, and minimizing the long-term impact on patients and their families.

Dexmedetomidine with sufentanil in intravenous patient-controlled analgesia for relief from postoperative pain, inflammation and delirium after esophageal cancer surgery

BACKGROUND AND AIMS

Postoperative pain can cause serious adverse reactions that severely affect postoperative outcome. The present study evaluated the effect of dexmedetomidine (DEX) added to sufentanil in intravenous patient-controlled analgesia (PCA) on the relief of pain and inflammatory responses during postoperative recovery of patients undergoing a combined thoracoscopic-laparoscopic esophagectomy (TLE).

METHODS

Sixty patients undergoing TLE were randomly allocated to receive 1 μg/ml of sufentanil alone (Group S) or 1 μg/ml of sufentanil plus 2.5 μg/ml of DEX (Group D) for postoperative intravenous (IV) PCA. Postoperative pain relief, cumulative PCA requirements, inflammatory marker levels, delirium and recovery were assessed.

RESULTS

A joint DEX and sufentanil regimen significantly reduced the area under the curve of numerical rating scores for pain at rest (NRSR) and coughing (NRSC) at 1-48 h postoperatively (P = 0.000) that were associated with lower PCA-delivered cumulative sufentanil consumption and less PCA frequency until 48 h postoperatively (P < 0.05 and P < 0.0001, respectively). The simultaneous administration of DEX and sufentanil significantly reduced plasma IL-6 and TNF-α concentrations and increased IL-10 level (P < 0.0001, P = 0.0003 and P = 0.0345, respectively), accompanied by better postoperative delirium categories and health statuses of patients (P = 0.024 and P < 0.05, respectively). There was no hypotension, bradycardia, respiratory depression or oversedation in Group D.

CONCLUSION

Patients receiving DEX in addition to IV PCA sufentanil for TLE exhibited better postoperative analgesia, fewer inflammatory responses and lower postoperative delirium categories and better health statuses.

Consensus for the management of analgesia, sedation and delirium in adults with COVID-19-associated acute respiratory distress syndrome

OBJECTIVE

To propose agile strategies for a comprehensive approach to analgesia, sedation, delirium, early mobility and family engagement for patients with COVID-19-associated acute respiratory distress syndrome, considering the high risk of infection among health workers, the humanitarian treatment that we must provide to patients and the inclusion of patients' families, in a context lacking specific therapeutic strategies against the virus globally available to date and a potential lack of health resources.

METHODS

A nonsystematic review of the scientific evidence in the main bibliographic databases was carried out, together with national and international clinical experience and judgment. Finally, a consensus of recommendations was made among the members of the Committee for Analgesia, Sedation and Delirium of the Sociedad Argentina de Terapia Intensiva.

RESULTS

Recommendations were agreed upon, and tools were developed to ensure a comprehensive approach to analgesia, sedation, delirium, early mobility and family engagement for adult patients with acute respiratory distress syndrome due to COVID-19.

DISCUSSION

Given the new order generated in intensive therapies due to the advancing COVID-19 pandemic, we propose to not leave aside the usual good practices but to adapt them to the particular context generated. Our consensus is supported by scientific evidence and national and international experience and will be an attractive consultation tool in intensive therapies.

The Protective Effects of Dexmedetomidine Preconditioning on Hepatic Ischemia/Reperfusion Injury in Rats

BACKGROUND

Ischemia/reperfusion (IR) injury is 1 of the major problems in liver surgery. This study aims to evaluate the histologic and biochemical effects of dexmedetomidine on ischemia/reperfusion injury in the liver of rats.

METHODS

Twenty-two Sprague-Dawley male rats were separated into 3 groups: group sham, IR (IR injury), and IR-D (IR with dexmedetomidine). Ischemia was induced for 45 minutes with portal clampage and the reperfusion period was 120 minutes. Group IR-D received 3 μg/kg of dexmedetomidine with loading for 10 minutes and then 3 μg/kg/h of dexmedetomidine was continuously injected intravenously 30 minutes before portal clampage. Biochemical factors (alanine aminotransferase and aspartate aminotransferase), variable cytokines (B cell lymphoma-2 (Bcl-2), Bax, caspase 3, caspase 8, nuclear factor-kappa B, interleukin (IL)-1β, IL-6, IL-10, mixed lineage kinase domain-like protein, and receptor-interacting protein kinase-3), and histologic findings were investigated.

RESULTS

Dexmedetomidine preconditioning significantly suppressed the histologic damage. In the IR-D group, the expression of IL-6 was decreased and the Bcl-2 was increased when compared with the IR group.

CONCLUSION

Dexmedetomidine suppresses hepatic IR injury and the protective mechanism appears to involve the decrease of IL-6 and upregulation of Bcl-2 expression, which result in the attenuation of inflammatory response and the inhibition of apoptosis.

The role of dexmedetomidine in neurosurgery

Dexmedetomidine can be used for sedation and analgesia and has been approved for this use by the European Medicines Agency since 2017. It causes an arousable state of sedation, which is beneficial during neurosurgical procedures that require the patient to cooperate with neurological tests (i.e. tumor surgery or implantation of deep brain stimulators). During procedures where monitoring of somatosensory evoked potentials and/or motor evoked potentials is required, dexmedetomidine can be used as an adjunct to general anesthesia with GABAergic drugs to decrease the dose of the latter when these drugs impair the monitoring signals. The use of dexmedetomidine has also been associated with neuroprotective effects and a decreased incidence of delirium, but studies confirming these effects in the peri-operative (neuro-)surgical setting are lacking. Although dexmedetomidine does not cause respiratory depression, its hemodynamic effects are complex and careful patient selection, choice of dose, and monitoring must be performed.

Effect of Dexmedetomidine on Delirium in Elderly Surgical Patients: A Meta-analysis of Randomized Controlled Trials

OBJECTIVE

The purpose of this meta-analysis is to assess the effect of dexmedetomidine on delirium in elderly surgical patients.

DATA SOURCES

The Cochrane Library, Web of Science, PubMed, EMBASE, and Google Scholar were searched (January 1, 2000, to February 4, 2020) for randomized controlled trials (RCTs).

STUDY SELECTION AND DATA EXTRACTION

RCTs without language restrictions were included if delirium incidence was assessed in elderly surgical patients receiving dexmedetomidine. Intervention and basic information were extracted.

DATA SYNTHESIS

21 studies were included. Dexmedetomidine reduced delirium occurrence (risk ratio [RR] = 0.55; 95% CI = 0.45 to 0.67) in elderly surgical patients with sufficient evidence from trial sequential analysis. Dexmedetomidine did not prevent delirium incidence for cardiac surgery (RR = 0.71; 95% CI = 0.44 to 1.15) with insufficient evidence. Dexmedetomidine decreased mortality incidence (RR = 0.47; 95% CI = 0.25 to 0.89), shortened the length of intensive care unit (ICU; standard mean difference [SMD] = -0.46) and hospital stays (SMD = -0.41), and increased bradycardia incidence (RR = 1.60).

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

This review revealed that dexmedetomidine could reduce delirium incidence for elderly noncardiac surgical patients, and the effect of dexmedetomidine on delirium for elderly cardiac surgical patients needs further studies to guide clinicians.

CONCLUSION

Dexmedetomidine reduced delirium incidence in elderly surgical patients. The efficacy of dexmedetomidine on delirium for elderly cardiac surgical patients warrants further studies. Furthermore, dexmedetomidine was associated with an increased bradycardia incidence, shorter length of ICU/hospital stays, and a lower incidence of mortality.

Sedation, Analgesia, and Paralysis in COVID-19 Patients in the Setting of Drug Shortages

The rapid spread of the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has led to a global pandemic. The 2019 coronavirus disease (COVID-19) presents with a spectrum of symptoms ranging from mild to critical illness requiring intensive care unit (ICU) admission. Acute respiratory distress syndrome is a major complication in patients with severe COVID-19 disease. Currently, there are no recognized pharmacological therapies for COVID-19. However, a large number of COVID-19 patients require respiratory support, with a high percentage requiring invasive ventilation. The rapid spread of the infection has led to a surge in the rate of hospitalizations and ICU admissions, which created a challenge to public health, research, and medical communities. The high demand for several therapies, including sedatives, analgesics, and paralytics, that are often utilized in the care of COVID-19 patients requiring mechanical ventilation, has created pressure on the supply chain resulting in shortages in these critical medications. This has led clinicians to develop conservation strategies and explore alternative therapies for sedation, analgesia, and paralysis in COVID-19 patients. Several of these alternative approaches have demonstrated acceptable levels of sedation, analgesia, and paralysis in different settings but they are not commonly used in the ICU. Additionally, they have unique pharmaceutical properties, limitations, and adverse effects. This narrative review summarizes the literature on alternative drug therapies for the management of sedation, analgesia, and paralysis in COVID-19 patients. Also, this document serves as a resource for clinicians in current and future respiratory illness pandemics in the setting of drug shortages.

Cochlear Implantation Under Local Anesthesia With Conscious Sedation in the Elderly: First 100 Cases

OBJECTIVE

To report the outcomes on a large series of elderly patients who underwent cochlear implantation (CI) surgery under local anesthesia with conscious sedation (LA-CS).

METHODS

Retrospective chart review on 100 consecutive elderly patients (> 65 years) who underwent CI with LA-CS at a tertiary care center between August 2013 and January 2020. An age-matched control group of 50 patients who underwent CI with general anesthesia (GA) are used for comparison. Outcomes measured included time in the operating room, time in the postanesthesia care unit (PACU), and rate of adverse events.

RESULTS

Cochlear implant surgery under LA-CS was successfully performed in 99 (99%) patients. One patient requiring conversion to GA intraoperatively. No patients in the LA-CS group experienced cardiopulmonary adverse events; however, three patients (6%) in the GA group experienced minor events including atrial fibrillation and/or demand ischemia. Overnight observation in the hospital due to postoperative medical concerns or prolonged wake-up from anesthesia was required in one patient (1%) from the LA-CS cohort and 12 patients (24%) from the GA cohort. Perioperative adverse events exclusive to the LA-CS group included severe intraoperative vertigo (8%), temporary facial nerve paresis (3%), and wound infection (1%). The average amount of time spent in the operating room was 37 minutes less for procedures performed under LA-CS compared to GA (P < .05). The average amount of time in recovery was similar for both groups (P > .05).

CONCLUSION

Cochlear implant surgery under LA-CS offers many benefits and is a safe, feasible, and cost-effective alternative to GA when performed by experienced CI surgeons.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:E946-E951, 2021.

Assessment of the sedative effects of dexmedetomidine and propofol treatment in patients undergoing mechanical ventilation in the ICU and relationship between treatment and occurrence of ventilator-associated pneumonia and detection of pathogenic bacteria

The present study aimed to investigate the sedative effects of dexmedetomidine combined with propofol in patients undergoing mechanical ventilation in the intensive care unit (ICU), and to reveal the risk factors of ventilator-associated pneumonia (VAP). A retrospective analysis of 322 patients who had been subject to mechanical ventilation in the ICU ward was performed. Subjects were divided into two groups: A group treated with dexmedetomidine and propofol (combined group) and a group treated with dexmedetomidine alone (monotherapy group). Clinical data, sedative effects, the number of VAP patients and the distribution of VAP pathogens were assessed. Multivariate analysis and receiver operating characteristic (ROC) curves were used to predict VAP. Significant differences in the sedative effects between the two groups were observed (P<0.001). The incidence of VAP was significantly higher in the monotherapy group compared with the combined group (P<0.05). Multivariate logistic regression analysis demonstrated that age, acute physiology chronic health evaluation score, consciousness, invasive operations, recovery time, extubation time and sedation regimen were independent risk factors for VAP in the ICU during mechanical ventilation. ROC curves indicated that the areas under the curve for age, acute physiology chronic health score, consciousness, invasive operations, recovery time, extubation time and sedation regimen were 0.934, 0.870, 0.632, 0.677, 0.865, 0.950 and 0.603, respectively. In summary, dexmedetomidine combined with propofol can shorten the recovery and extubation times of mechanical ventilation patients in the ICU. Different sedation schemes are also independent risk factors for VAP during mechanical ventilation in the ICU.

The Role of Precedex in Post-Operative Pain Management Following Craniosynostosis Repair

The application of dexmedetomidine (precedex) in pediatric settings has increased due to its superior safety and efficacy profile and it has been specifically suggested as an adjunct to IV acetaminophen and a substitute for morphine in craniosynostosis repair. However, reports of its use in pediatrics, let alone in craniosynostosis repair, remain limited and to date there are no studies addressing its use after craniosynostosis repair in children. This study is an IRB-approved retrospective case review of the use of dexmedetomidine following pediatric craniosynostosis repair as a postoperative analgesic/sedative agent at one institution.

Physicochemical Compatibility of Dexmedetomidine With Parenteral Nutrition

BACKGROUND

Dexmedetomidine is an α2-agonist used as a sedative agent in the intensive care setting. Simultaneous administration of dexmedetomidine and parenteral nutrition (PN) may be required. The aim of this study was to evaluate the physicochemical compatibility of dexmedetomidine Y-site administered with PN.

METHODS

Three PN and 3 dexmedetomidine solutions were compounded. The tested infusion rate for PN was 66 mL/h. For dexmedetomidine, we considered the initial and maximum infusion rates (0.7 and 1.4 µg/kg/h) detailed in the data sheet. Taking this into account and considering a weight range of 55-95 kg, we tested 2 dexmedetomidine infusion rates (10 and 36 mL/h). The samples obtained were examined visually against light. pH was analyzed with a pH meter. Mean fat droplet diameter was determined by dynamic light scattering. Quantification of dexmedetomidine concentration was carried out by ultraperformance liquid chromatography-high-resolution mass spectrometry. For each PN-dexmedetomidine admixture, tests were performed in triplicate.

RESULTS

No alterations were observed by visual inspection. Average pH was 6.25 ± 0.01. Droplet diameter remained below 500 nm (298 ± 10 nm for 10-mL/h rate and 303 ± 5 nm for 36-mL/h rate). Dexmedetomidine concentrations at t = 0 were 519 ± 31 ng/mL and 1391 ± 90 ng/mL for 10- and 36-mL/h infusion rates, respectively. At t = 24 hours, the concentrations obtained were 494 ± 22 and 1332 ± 102 ng/mL, which translates into ≥90% of the initial concentrations.

CONCLUSION

Dexmedetomidine is physicochemically compatible with PN during simulated Y-site administration at the tested infusion rates.

Dexmedetomidine for the prevention of postoperative delirium in elderly patients undergoing noncardiac surgery: A meta-analysis of randomized controlled trials

BACKGROUND

Postoperative delirium (POD) among the elderly population that undergoes noncardiac surgery is significantly associated with adverse clinical outcomes. We conducted this meta-analysis to evaluate the effectiveness and safety of dexmedetomidine for the prophylaxis of POD among the elderly population after noncardiac surgery.

METHODS

We searched Embase, PubMed, and the Cochrane Library from inception date to March 2019 for randomized controlled trials (RCTs) that compared dexmedetomidine and placebo for the prevention of POD and evaluated the major cardiovascular outcomes among elderly people after noncardiac surgery. Two authors independently screened the studies and extracted data from the published articles. The main outcome was the incidence of POD. The secondary outcomes included the occurrence of bradycardia, hypotension, hypertension, tachycardia, myocardial infarction, stroke, hypoxaemia, and all-cause mortality.

RESULTS

A total of 6 RCTs with 2102 participants were included. Compared with placebo, dexmedetomidine significantly reduced the prevalence of POD (RR = 0.61, 95% CI 0.34-0.76, P = 0.001, I2 = 66%), and the risk of tachycardia (RR = 0.48, 95% CI 0.30-0.76, P = 0.002, I2 = 0%), hypertension (RR = 0.59, 95% CI 0.44-0.79, P < 0.001, I2 = 20%), stroke (RR = 0.22, 95% CI 0.06-0.76, P = 0.02, I2 = 0%), and hypoxaemia (RR = 0.50, 95% CI 0.32-0.78, P = 0.002, I2 = 0%) in elderly patients who underwent noncardiac surgery. However, dexmedetomidine accelerated the occurrence of bradycardia (RR = 1.36, 95% CI 1.11-1.67, P = 0.003, I2 = 0%). Furthermore, no significant differences were observed in the incidence of hypotension, myocardial infarction, and all-cause mortality between the dexmedetomidine and placebo groups.

CONCLUSIONS

Among elderly patients after noncardiac surgery, the prophylactic use of dexmedetomidine, compared with the use of placebo, was related to a decline in the incidence of POD.

Dexmedetomidine: present and future directions

Dexmedetomidine is a potent, highly selective α-2 adrenoceptor agonist, with sedative, analgesic, anxiolytic, sympatholytic, and opioid-sparing properties. Dexmedetomidine induces a unique sedative response, which shows an easy transition from sleep to wakefulness, thus allowing a patient to be cooperative and communicative when stimulated. Dexmedetomidine may produce less delirium than other sedatives or even prevent delirium. The analgesic effect of dexmedetomidine is not strong; however, it can be administered as a useful analgesic adjuvant. As an anesthetic adjuvant, dexmedetomidine decreases the need for opioids, inhalational anesthetics, and intravenous anesthetics. The sympatholytic effect of dexmedetomidine may provide stable hemodynamics during the perioperative period. Dexmedetomidine-induced cooperative sedation with minimal respiratory depression provides safe and acceptable conditions during neurosurgical procedures in awake patients and awake fiberoptic intubation. Despite the lack of pediatric labelling, dexmedetomidine has been widely studied for pediatric use in various applications. Most adverse events associated with dexmedetomidine occur during or shortly after a loading infusion. There are some case reports of dexmedetomidine-related cardiac arrest following severe bradycardia. Some extended applications of dexmedetomidine discussed in this review are promising, but still limited, and further research is required. The pharmacological properties and possible adverse effects of dexmedetomidine should be well understood by the anesthesiologist prior to use. Moreover, it is necessary to select patients carefully and to determine the appropriate dosage of dexmedetomidine to ensure patient safety.

Dexmedetomidine for the prevention of delirium in critically ill patients - A protocol for a systematic review

BACKGROUND

Delirium is a common complication in critically ill patients and carries an increased risk of mortality and morbidity. Dexmedetomidine can potentially prevent delirium by diminishing predisposing factors. The evidence regarding the use of dexmedetomidine in preventing delirium is conflicting. This protocol aims to identify the beneficial and harmful effects of dexmedetomidine in the prevention of delirium.

METHODS

This protocol uses the recommendations of the Cochrane Collaboration, the Preferred Report Items of Systematic Reviews with Meta-Analysis Protocols, and the eight-step assessment procedure suggested by Jakobsen and colleagues. We wish to assess in critically ill patients, if dexmedetomidine versus placebo can reduce the incidence of delirium and improve clinical outcomes. We will include all randomised trials assessing the use of dexmedetomidine in the prevention of delirium. To identify trials, we will search the Cochrane Central Register of Controlled Trials, Medical Literature Analysis and Retrieval System Online, Excerpta Medica database, Latin American and Caribbean Health Sciences Literature, Science Citation Index Expanded on Web of Science, Chinese Biomedical Literature Database, China National Knowledge Infrastructure, Chinese Science Journal Database, and BIOSIS. Two authors will screen the literature and extract data. We will use the Cochrane risk of bias tool to evaluate trials. Extracted data will be analysed using Review Manager 5 and Trial Sequential Analysis. We will create a "Summary of Findings"-table in which we will present our primary and secondary outcomes. We will assess the quality of evidence using GRADE.

DISCUSSION

This systematic review can potentially aid clinicians in decision-making and benefit the many critically ill patients at risk of delirium.

Dexmedetomidine for the management of delirium in critically ill patients-A protocol for a systematic review

BACKGROUND

Delirium is a common complication in critically ill patients and carries an increased risk of mortality and morbidity. Dexmedetomidine can potentially treat delirium by diminishing predisposing factors. The evidence regarding the use of dexmedetomidine in the management of delirium is conflicting. This protocol aims to identify the beneficial and harmful effects of dexmedetomidine in the management of delirium.

METHODS

This protocol uses the recommendations of the Cochrane Collaboration, the Preferred Report Items of Systematic reviews with Meta-Analysis Protocols, and the eight-step assessment procedure suggested by Jakobsen and colleagues. We wish to assess in critically ill patients with delirium, if dexmedetomidine vs placebo is effective in managing delirium and improving clinical outcomes. We will include all relevant randomised clinical trials assessing the use of dexmedetomidine in treating delirium. To identify trials, we will search the Cochrane Central Register of Controlled Trials, Medical Literature Analysis and Retrieval System Online, Excerpta Medica database, Latin American and Caribbean Health Sciences Literature, Science Citation Index Expanded on Web of Science, Chinese Biomedical Literature Database, China National Knowledge Infrastructure, Chinese Science Journal Database, and BIOSIS. Two authors will screen the literature and extract data. The Cochrane risk of bias tool will be used to evaluate included trials. Extracted data will be analysed using Review Manager 5 and Trial Sequential Analysis. We will create a 'Summary of Findings'-table in which we will present our primary and secondary outcomes. We will assess the quality of evidence using GRADE assessment.

DISCUSSION

This systematic review can potentially aid clinicians in decision making and benefit the many critically ill patients developing delirium.

Sedative drugs used for mechanically ventilated patients in intensive care units: a systematic review and network meta-analysis

BACKGROUND

The effects of different sedative drugs on all-cause mortality rate, duration of ICU stay, and risk of delirium in mechanically ventilated ICU patients are unclear. This meta-analysis aimed to compare the effectiveness and safety of individual sedative drugs and drug combinations in mechanically ventilated ICU patients.

MATERIALS AND METHODS

Medline, Embase, Cochrane, EBSCOhost, and ISI Web of Science databases were searched for studies that assessed sedation in ICU mechanically ventilated patients. A Bayesian random-effects model was used to combine the direct comparisons and indirect evidence.

RESULTS

Thirty-one randomized, controlled trials were included, which consisted of 4491 patients who received one of seven sedative drugs or a combination of drugs. There were no significant differences regarding the all-cause mortality rate. Compared to propofol, inhalation anesthetics (hazard ratio [HR] 0.121; 95% credible interval [CrI] -7.58 to 7.62), alpha agonists (HR 2.2; 95% CrI 0.776 to 5.22), propofol with benzodiazepines (HR 0.306; 95% CrI -6.97 to 7.65), ketamine with benzodiazepines (HR 6.57; 95% CrI -6.05 to 19.1) and placebo (HR 2.4; 95% CrI -5.37 to 10.3), benzodiazepines (HR 3.62; 95% CrI 0.834 to 6.2) may increase the duration of ICU stay. Compared to alpha agonists, propofol (HR 2.4; 95% CrI 0.304 to 21.1) and placebo (HR 6.12; 95% CrI 0.745 to 54.6), benzodiazepines (HR 2.59; 95% CrI 1.08 to 7.4) were associated with incremental risks of delirium.

CONCLUSION

Compared to propofol, benzodiazepines may increase the duration of ICU stay. Compared to alpha agonists, benzodiazepines were associated with an increased risk of delirium.

Pharmacological interventions for prevention and management of delirium in intensive care patients: a systematic overview of reviews and meta-analyses

OBJECTIVES

We assessed the evidence from reviews and meta-analyses of randomised clinical trials on the effects of pharmacological prevention and management of delirium in intensive care unit (ICU) patients.

METHODS

We searched for reviews in July 2017 in: Cochrane Library, MEDLINE, Embase, Science Citation Index, BIOSIS Previews, CINAHL and LILACS. We assessed whether reviews were systematic according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and assessed the methodological quality using ROBIS.

OUTCOME MEASURES

Primary outcomes: all-cause mortality, serious adverse events, prevention of delirium and management of delirium.

SECONDARY OUTCOMES

quality of life; non-serious adverse events and cognitive function.

RESULTS

We included 378 reviews: 369 narrative reviews, eight semisystematic reviews which failed on a maximum of two arbitrary PRISMA criteria and one systematic review fulfilling all 27 PRISMA criteria. For the prevention of delirium, we identified the one systematic review and eight semisystematic reviews all assessing the effects of alpha-2-agonists. None found evidence of a reduction of mortality (systematic review RR 0.99, 95% CI 0.79 to 1.24). The systematic review and three semisystematic reviews found no evidence of an effect for the prevention of delirium (systematic review RR 0.85, 0.63 to 1.14). Conversely, four semisystematic reviews found a beneficial effect. Serious adverse events, quality of life, non-serious adverse events and cognitive function were not assessed. We did not identify any systematic or semisystematic reviews addressing other pharmacological interventions for the prevention of delirium. For the management of manifest delirium, we did not identify any systematic or semisystematic review assessing any pharmacological agents.

CONCLUSION

Based on systematic reviews, the evidence for the use of pharmacological interventions for prevention or management of delirium is poor or sparse. A systematic review with low risk of bias assessing the effects of pharmacological prevention of delirium and management of manifest delirium in ICU patients is urgently needed.

PROSPERO REGISTRATION NUMBER

CRD42016046628.

HIF-α/PKM2 and PI3K-AKT pathways involved in the protection by dexmedetomidine against isoflurane or bupivacaine-induced apoptosis in hippocampal neuronal HT22 cells

The present study investigated the mechanism underlying the protective effect of dexmedetomidine (Dex) on hippocampal neuronal HT22 cell apoptosis induced by the anesthetics isoflurane and bupivacaine. The cellular morphology was observed using a phase contrast microscope. The effects of anesthetics on cell proliferation were assayed using a Cell Counting Kit-8 (CCK-8). The levels of apoptosis were examined by flow cytometry utilizing Annexin V-fluorescein isothiocyanate/propidium iodide double staining, and the protein expression levels of cleaved caspase-3, phosphorylated phosphoinositide 3′-kinase (p-PI3K), p-protein kinase B (p-AKT), hypoxia inducible factor (HIF-α), pyruvate kinase M2 (PKM2), B-cell lymphoma (Bcl-2)-associated X protein (Bax), Bcl-2 and cytochrome c were detected by western blot analysis. In vitro treatment with anesthetics was identified to decrease cell proliferation (P<0.01), the effect of which was then markedly inhibited by treatment with Dex (P<0.01) or a PI3K/AKT agonist. Exposure to anesthetics induced apoptosis in HT22 cells (75.4%), which was significantly attenuated by co-treatment with Dex (26.2%) or the PI3K/AKT agonist (28.1%). Analysis of the protein expression levels revealed that exposure to anesthetics resulted in the activation of cleaved caspase-3, Bax, cytochrome c, HIF-α and PKM2 and decreased the expression levels of Bcl-2, p-PI3K and p-AKT. However, these changes were inhibited by treatment with Dex or the PI3K/AKT agonist. Dex protected hippocampal neuronal HT22 cells from anesthetic-induced apoptosis through the promotion of the PI3K/AKT pathway and inhibition of the HIF-α/PKM2 axis.

Dexmedetomidine in prevention and treatment of postoperative and intensive care unit delirium: a systematic review and meta-analysis

BACKGROUND

To determine the preventive and therapeutic effect of dexmedetomidine on intensive care unit (ICU) delirium.

METHODS

The literature search using PubMed and the Cochrane Central Register of Controlled Trials was performed (August 1, 2018) to detect all randomized controlled trials (RCTs) of adult ICU patients receiving dexmedetomidine. Articles were included if they assessed the influence of dexmedetomidine compared to a sedative agent on incidence of ICU delirium or treatment of this syndrome. Accordingly, relevant articles were allocated to the following two groups: (1) articles that assessed the delirium incidence (incidence comparison) or articles that assessed the treatment of delirium (treatment comparison). Incidence of delirium and delirium resolution were the primary outcomes. We combined treatment effects comparing dexmedetomidine versus (1) placebo, (2) standard sedatives, and (3) opioids in random-effects meta-analyses. Risk of bias for each included RCT was assessed following Cochrane standards.

RESULTS

The literature search resulted in 28 articles (25 articles/4975 patients for the incidence comparison and three articles/166 patients for the treatment comparison). In the incidence comparison, heterogeneity was present in different subgroups. Administration of dexmedetomidine was associated with significantly lower overall incidence of delirium when compared to placebo (RR 0.52; 95% CI 0.39-0.70; I² = 37%), standard sedatives (RR 0.63; 95% CI 0.46-0.86; I² = 69%), as well as to opioids (RR 0.61; 95% CI 0.44-0.83; I² = 0%). Use of dexmedetomidine significantly increased the risks of bradycardia and hypotension. Limited data were available on circulatory insufficiency and mortality. In the treatment comparison, the comparison drugs in the three RCTs were placebo, midazolam, and haloperidol. The resolution of delirium was measured differently in each study. Two out of the three studies indicated clear favorable effects for dexmedetomidine (i.e., compared to placebo and midazolam). The study comparing dexmedetomidine with haloperidol was a pilot study (n = 20) with high variability in the results.

CONCLUSION

Findings suggest that dexmedetomidine reduces incidence and duration of ICU delirium. Furthermore, our systematic searches show that there is limited evidence if a delirium shall be treated with dexmedetomidine.

Efficacy of different doses of dexmedetomidine as a rapid bolus for children: a double-blind, prospective, randomized study

Background

Dexmedetomidine (DEX), a highly sensitive α₂-adrenoceptor agonist that possesses anxiolytic, sedative, and analgesic effects, has been documented as a preventative and treatment for emergence agitation (EA). The therapeutic should be given as a loading dose that is infused during a 10 min period, but if a rapid bolus injection is deemed to be hemodynamically appropriate, it would be a more opportune route of administration. So we studied the efficacy of different doses of DEX as a rapid bolus for children to prevent and treat EA.

Methods

One hundred patients were enrolled and randomly divided into five groups: the control group (group D₁), the 0.25 μg/kg DEX group (group D₂), the 0.5 μg/kg DEX group (group D₃), the 0.75 μg/kg DEX group (group D₄), and the 1 μg/kg DEX group (group D₅). Heart rate (HR), mean blood pressure (MBP) and blood oxygen saturation (SaO₂) were recorded immediately before the study drug injection (baseline) and every minute for 5 min thereafter and at the time points of the skin cut and hernial sac pull. EA and pain were assessed in the post -anesthesia care unit, and any complementary medicine and adverse events were recorded too.

Results

The incidence of EA was significantly decreased in group D₄ and group D₅ compared with D₁.All groups exhibited similar baseline HR and MBP. After administered, HR and MBP were significantly decreased in all DEX group compared with group D_1.In groups D₃, D₄ and D₅, the minimal HR was decreased significantly compared with the groups D₁ and duration time of minimal HR significantly prolonged in group D₅, but no patient needed treatment. As the dosage increased, the recovery time was significantly prolonged. There were no significant differences in occurrence time of minimal HR, the incidence of complementary medicine and adverse events among groups.

Conclusion

Rapid intravenous injection (IV) bolus administration of 0.75 and 1.0 μg/kg of DEX could improve the recovery profile by reducing the incidence of EA in children. Although its use resulted in a transient decreases in HR and MBP, DEX was clinically well-tolerated in children.

Trial registration

No. ChiCTR-IPR-17010658. Registered 17 February 2017.

Introduction to systematic review and meta-analysis

Systematic reviews and meta-analyses present results by combining and analyzing data from different studies conducted on similar research topics. In recent years, systematic reviews and meta-analyses have been actively performed in various fields including anesthesiology. These research methods are powerful tools that can overcome the difficulties in performing large-scale randomized controlled trials. However, the inclusion of studies with any biases or improperly assessed quality of evidence in systematic reviews and meta-analyses could yield misleading results. Therefore, various guidelines have been suggested for conducting systematic reviews and meta-analyses to help standardize them and improve their quality. Nonetheless, accepting the conclusions of many studies without understanding the meta-analysis can be dangerous. Therefore, this article provides an easy introduction to clinicians on performing and understanding meta-analyses.

Dexmedetomidine Decreases Postoperative Pain and Narcotic Use in Children Undergoing Alveolar Bone Graft Surgery

Objective:

Dexmedetomidine is a parenteral agent that combines the benefits of cooperative sedation, anxiolysis, and analgesia without the risks of respiratory depression. Off-label use has been reported in children. We have introduced dexmedetomidine for use in patients having undergone alveolar bone graft (ABG). The objective is to demonstrate the value and safety of postoperative dexmedetomidine infusion in a non-ICU setting following ABG.

Design:

A retrospective review was performed on patients who underwent ABG by the senior author. Patients were divided into 2 groups: those who received postoperative dexmedetomidine and those who received patient-controlled anesthesia.

Main Outcome Measure(s):

The primary study outcome measures included patient demographics, adverse events, length of stay, pain scores, and doses of narcotics during admission were collected.

Results:

Inclusion criteria were met by 54 patients; 39 received dexmedetomidine whereas 15 did not. There were no significant differences between groups in age, gender, and length of stay. The patients who received dexmedetomidine used oral narcotics less often ( P = .01). In addition, more patients reported no pain after surgery ( P = .05) and at the time of discharge if they received dexmedetomidine ( P < .01). There were no reported adverse effects.

Conclusions:

Dexmedetomidine provided superior pain control after surgery and at the time of discharge, as well as a significant decrease in the use of oral narcotics. In our institution, it has since replaced the PCA as a postoperative pain control modality. Absent the risk for respiratory depression, dexmedetomidine has demonstrated a safe option for postoperative pain control in our focused group of pediatric patients.

Use of Dexmedetomidine in Cardiothoracic and Vascular Anesthesia

Dexmedetomidine is a highly selective α₂-adrenergic agonist with analgesic and sedative properties. In the United States, the Food and Drug Administration approved the use of the drug for short-lasting sedation (24 h) in intensive care units (ICUs) in patients undergoing mechanical ventilation and endotracheal intubation. In October 2008, the Food and Drug Administration extended use of the drug for the sedation of nonintubated patients before and during surgical and nonsurgical procedures. In the European Union, the European Medicine Agency approved the use of dexmedetomidine in September 2011 with a single recognized indication: ICU adult patients requiring mild sedation and awakening in response to verbal stimulus. At present, the use of dexmedetomidine for sedation outside the ICU remains an off-label indication. The benefits of dexmedetomidine in critically ill patients and in cardiac, electrophysiology-related, vascular, and thoracic procedures are discussed.

Risk Factors of Delirium in Sequential Sedation Patients in Intensive Care Units

Background

Delirium is a primary adverse event in ventilated patients who receive long-term monosedative treatment. Sequential sedation may reduce these adverse effects. This study evaluated risk factors for delirium in sequential sedation patients.

Methods

A total of 141 patients who underwent sequential sedation were enrolled. Delirium was diagnosed using Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) scale. Univariate and multivariate Cox proportional hazards regressions were used to predict risk factors.

Results

Older age (≥51) (RR = 2.432, 95% CL 1.316–4.494, p = 0.005), higher SOFA score (≥14) (RR = 2.022, 95% CL 1.076–3.798, p = 0.029), regular smoking (RR = 2.366, 95% CL 1.277–4.382, p = 0.006), and higher maintenance dose of midazolam (RR = 1.052, 95% CL 1.000–1.107, p = 0.049) and fentanyl (RR = 1.045, 95% CL 1.019–1.072, p = 0.001) when patients met sequential criteria, were independent risk factors of delirium. Sequential sedation with dexmedetomidine (RR = 0.448, 95% CL 0.209–0.963, p = 0.040) was associated with a lower risk of delirium.

Conclusions

Older age, higher SOFA score, regular smoking, and higher maintenance dose of midazolam and fentanyl when patients met sequential criteria were independent risk factors of delirium in sequential sedation patients. Sequential sedation with dexmedetomidine reduced risk of delirium.

Cochlear implantation under conscious sedation with local anesthesia; Safety, Efficacy, Costs, and Satisfaction

OBJECTIVE

To evaluate the safety, efficiency, cost effectiveness, and satisfaction of patients undergoing cochlear implantation under conscious sedation versus general anesthesia.

STUDY DESIGN

Retrospective case review of 20 patients who underwent cochlear implantation under conscious sedation which was compared to 20 age-matched patients where surgery was performed under general anesthesia.

METHODS

Perioperative times, length of stay, anesthesia drug costs, postoperative complications, and patient satisfaction were compared between the two groups.

RESULTS

Conscious sedation was associated with decreased drug costs, surgery time, and anesthesia time. Length of stay was significantly longer for patients undergoing general anesthesia. Patient satisfaction was superior with conscious sedation. Perioperative morbidity was not significantly different between the two groups.

CONCLUSION

Conscious sedation for cochlear implantation is a safe, efficient, and cost-effective alternative to general anesthesia. The efficacy of conscious sedation for cochlear implant surgery may expand the treatment of profound hearing loss to the elderly who are deemed too sick for general anesthesia or are fearful of the cognitive or medical consequences of general anesthesia.

Sedation After Cardiac Surgery: Is One Drug Better Than Another?

The classic high-dose narcotic-based cardiac anesthetic has been modified to facilitate a fast-track, rapid recovery in the intensive care unit (ICU). Postoperative sedation is consequently now an essential component in recovery of the patient undergoing cardiac surgery. It must facilitate the patient's unawareness of the environment as well as reduce the discomfort and anxiety caused by surgery, intubation, mechanical ventilation, suction, and physiotherapy. Benzodiazepines seem well suited for this role, but propofol, opioids, and dexmedetomidine are among other agents commonly used for sedation in the ICU. However, what is an ideal sedative for this application? When compared with benzodiazepine-based sedation regimens, nonbenzodiazepines have been associated with shorter duration of mechanical ventilation and ICU length of stay. Current sedation guidelines recommend avoiding benzodiazepine use in the ICU. However, there are no recommendations on which alternatives should be used. In postcardiac surgery patients, inotropes and vasoactive medications are often required because of the poor cardiac function. This makes sedation after cardiac surgery unique in comparison with the requirements for most other ICU patient populations. We reviewed the current literature to try to determine if 1 sedative regimen might be better than others; in particular, we compare outcomes of propofol and dexmedetomidine in postoperative sedation in the cardiac surgical ICU.

Incidence and factors related to delirium in an intensive care unit

OBJECTIVES

To identify the incidence of delirium, compare the demographic and clinical characteristics of patients with and without delirium, and verify factors related to delirium in critical care patients.

METHOD

Prospective cohort with a sample made up of patients hospitalized in the Intensive Care Unit (ICU) of a university hospital. Demographic, clinical variables and evaluation with the Confusion Assessment Method for Intensive Care Unit to identify delirium were processed to the univariate analysis and logistic regression to identify factors related to the occurrence of delirium.

RESULTS

Of the total 149 patients in the sample, 69 (46.3%) presented delirium during ICU stay, whose mean age, severity of illness and length of ICU stay were statistically higher. The factors related to delirium were: age, midazolam, morphine and propofol.

CONCLUSION

Results showed high incidence of ICU delirium associated with older age, use of sedatives and analgesics, emphasizing the need for relevant nursing care to prevent and identify early, patients presenting these characteristics.

OBJETIVOS

Identificar a incidência de delirium, comparar as características demográficas e clínicas dos pacientes com e sem delirium e verificar os fatores relacionados ao delirium em pacientes internados em Unidade de Terapia Intensiva (UTI).

MÉTODO

Coorte prospectiva, cuja amostra foi constituída de pacientes internados em UTI de um hospital universitário. Variáveis demográficas, clínicas e da avaliação com o Confusion Assessment Method for Intensive Care Unit para identificação de delirium foram processadas para análise univariada, e regressão logística para identificar fatores relacionados à ocorrência do delirium.

RESULTADOS

Do total de 149 pacientes da amostra, 69 (46,3%) apresentaram delirium durante a internação na UTI, observando-se que a média da idade, o índice de gravidade e o tempo de permanência nas UTI foram estatisticamente maiores. Os fatores relacionados ao delirium foram: idade, midazolam, morfina e propofol.

CONCLUSÃO

Os resultados mostraram elevada incidência de delirium na UTI e sua ocorrência associada às idades mais avançadas e o uso de sedativos e analgésicos, ressaltando-se a importância da atuação do enfermeiro na prevenção e identificação precoce do quadro nos pacientes com essas características.

Alpha-2 agonists for sedation of mechanically ventilated adults in intensive care units: a systematic review

BACKGROUND

Care of critically ill patients in intensive care units (ICUs) often requires potentially invasive or uncomfortable procedures, such as mechanical ventilation (MV). Sedation can alleviate pain and discomfort, provide protection from stressful or harmful events, prevent anxiety and promote sleep. Various sedative agents are available for use in ICUs. In the UK, the most commonly used sedatives are propofol (Diprivan(®), AstraZeneca), benzodiazepines [e.g. midazolam (Hypnovel(®), Roche) and lorazepam (Ativan(®), Pfizer)] and alpha-2 adrenergic receptor agonists [e.g. dexmedetomidine (Dexdor(®), Orion Corporation) and clonidine (Catapres(®), Boehringer Ingelheim)]. Sedative agents vary in onset/duration of effects and in their side effects. The pattern of sedation of alpha-2 agonists is quite different from that of other sedatives in that patients can be aroused readily and their cognitive performance on psychometric tests is usually preserved. Moreover, respiratory depression is less frequent after alpha-2 agonists than after other sedative agents.

OBJECTIVES

To conduct a systematic review to evaluate the comparative effects of alpha-2 agonists (dexmedetomidine and clonidine) and propofol or benzodiazepines (midazolam and lorazepam) in mechanically ventilated adults admitted to ICUs.

DATA SOURCES

We searched major electronic databases (e.g. MEDLINE without revisions, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE and Cochrane Central Register of Controlled Trials) from 1999 to 2014.

METHODS

Evidence was considered from randomised controlled trials (RCTs) comparing dexmedetomidine with clonidine or dexmedetomidine or clonidine with propofol or benzodiazepines such as midazolam, lorazepam and diazepam (Diazemuls(®), Actavis UK Limited). Primary outcomes included mortality, duration of MV, length of ICU stay and adverse events. One reviewer extracted data and assessed the risk of bias of included trials. A second reviewer cross-checked all the data extracted. Random-effects meta-analyses were used for data synthesis.

RESULTS

Eighteen RCTs (2489 adult patients) were included. One trial at unclear risk of bias compared dexmedetomidine with clonidine and found that target sedation was achieved in a higher number of patients treated with dexmedetomidine with lesser need for additional sedation. The remaining 17 trials compared dexmedetomidine with propofol or benzodiazepines (midazolam or lorazepam). Trials varied considerably with regard to clinical population, type of comparators, dose of sedative agents, outcome measures and length of follow-up. Overall, risk of bias was generally high or unclear. In particular, few trials blinded outcome assessors. Compared with propofol or benzodiazepines (midazolam or lorazepam), dexmedetomidine had no significant effects on mortality [risk ratio (RR) 1.03, 95% confidence interval (CI) 0.85 to 1.24, I (2) = 0%; p = 0.78]. Length of ICU stay (mean difference -1.26 days, 95% CI -1.96 to -0.55 days, I (2) = 31%; p = 0.0004) and time to extubation (mean difference -1.85 days, 95% CI -2.61 to -1.09 days, I (2) = 0%; p < 0.00001) were significantly shorter among patients who received dexmedetomidine. No difference in time to target sedation range was observed between sedative interventions (I (2) = 0%; p = 0.14). Dexmedetomidine was associated with a higher risk of bradycardia (RR 1.88, 95% CI 1.28 to 2.77, I (2) = 46%; p = 0.001).

LIMITATIONS

Trials varied considerably with regard to participants, type of comparators, dose of sedative agents, outcome measures and length of follow-up. Overall, risk of bias was generally high or unclear. In particular, few trials blinded assessors.

CONCLUSIONS

Evidence on the use of clonidine in ICUs is very limited. Dexmedetomidine may be effective in reducing ICU length of stay and time to extubation in critically ill ICU patients. Risk of bradycardia but not of overall mortality is higher among patients treated with dexmedetomidine. Well-designed RCTs are needed to assess the use of clonidine in ICUs and identify subgroups of patients that are more likely to benefit from the use of dexmedetomidine.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42014014101.

FUNDING

The National Institute for Health Research Health Technology Assessment programme. The Health Services Research Unit is core funded by the Chief Scientist Office of the Scottish Government Health and Social Care Directorates.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

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

Risk factors for agitation in critically ill patients

OBJECTIVE:

To evaluate the incidence of agitation in the first 7 days after intensive care unit admission, its risk factors and its associations with clinical outcomes.

METHODS:

This single-center prospective cohort study included all patients older than 18 years with a predicted stay > 48 hours within the first 24 hours of intensive care unit admission. Agitation was defined as a Richmond Agitation Sedation Scale score ≥ +2, an episode of agitation or the use of a specific medication recorded in patient charts.

RESULTS:

Agitation occurred in 31.8% of the 113 patients. Multivariate analysis showed that delirium [OR = 24.14; CI95% 5.15 - 113.14; p < 0.001], moderate or severe pain [OR = 5.74; CI95% 1.73 - 19.10; p = 0.004], mechanical ventilation [OR = 10.14; CI95% 2.93 - 35.10; p < 0.001], and smoking habits [OR = 4.49; CI95% 1.33 - 15.17; p = 0.015] were independent factors for agitation, while hyperlactatemia was associated with a lower risk [OR = 0.169; CI95% 0.04 - 0.77; p = 0.021]. Agitated patients had fewer mechanical ventilation-free days at day 7 (p = 0.003).

CONCLUSION:

The incidence of agitation in the first 7 days after admission to the intensive care unit was high. Delirium, moderate/severe pain, mechanical ventilation, and smoking habits were independent risk factors. Agitated patients had fewer ventilator-free days in the first 7 days.