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Garcia Romo E, Pfang B, Valle Borrego B, Lobo Antuña M, Noguera Tejedor A, Rubio Gomez S, Galindo Vazquez V, Prieto Rios B. Successful Use of Propofol After Failed Palliative Sedation in Patients With Refractory Symptoms. J Palliat Med 2024. [PMID: 38973718 DOI: 10.1089/jpm.2023.0672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2024] Open
Abstract
Context: Propofol is a general anesthetic used in multiple clinical scenarios. Despite growing evidence supporting its use in palliative care, propofol is rarely used in palliative sedation. Reluctance toward the adoption of propofol as a sedative agent is often associated with fear of adverse events such as respiratory arrest. Objectives: We aimed to describe efficacy and safety of palliative sedation in refractory sedation with propofol using a protocol based on low, incremental dosing. Methods: A retrospective observational study featuring inpatients receiving sedative treatment with propofol in our palliative care unit in Madrid (Spain) between March 1, 2018 and February 28, 2023, following a newly developed protocol. Results: During the study period, 22 patients underwent sedation with propofol. Propofol was used successfully to control different refractory symptoms, mainly psychoexistential suffering and delirium. All patients had undergone previous failed attempts at sedation with other medications (midazolam or lemovepromazine) and presented risk factors for complicated sedation. All patients achieved satisfactory (profound) levels of sedation measured with the Ramsay Sedation Scale, but total doses varied greatly between patients. Most patients (17, 77%) received combined therapy with propofol and other sedative medications to harness synergies. The median time between start of sedation with propofol and death was 26.0 hours. No cases of apnea or death during induction were recorded. Conclusion: A protocol for palliative sedation with propofol based on low, incremental dosing, with the option of administering an initial induction bolus, shows excellent results regarding adequate levels of sedation, without observing apnea or respiratory depression. Our results promote the use of propofol to achieve palliative sedation in patients with refractory symptoms and risk factors for complicated sedation at the end of life.
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Affiliation(s)
- Eduardo Garcia Romo
- Palliative Care Unit, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | - Bernadette Pfang
- Health Research Institute of the Jimenez Diaz Foundation, Madrid, Spain
| | | | | | | | - Silvia Rubio Gomez
- Palliative Care Unit, Beata María Ana de Hermanas Hospitalarias Hospital, Madrid, Spain
| | | | - Blanca Prieto Rios
- Palliative Care Unit, Fundación Jiménez Díaz University Hospital, Madrid, Spain
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Doi M, Hirata N, Suzuki T, Morisaki H, Morimatsu H, Sakamoto A. Safety and efficacy of remimazolam in induction and maintenance of general anesthesia in high-risk surgical patients (ASA Class III): results of a multicenter, randomized, double-blind, parallel-group comparative trial. J Anesth 2020; 34:491-501. [DOI: 10.1007/s00540-020-02776-w] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 04/04/2020] [Indexed: 12/11/2022]
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Tran A, Blinder H, Hutton B, English S. Alpha-2 agonists for sedation in mechanically ventilated neurocritical care patients: a systematic review protocol. Syst Rev 2016; 5:154. [PMID: 27609187 PMCID: PMC5016878 DOI: 10.1186/s13643-016-0331-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 09/02/2016] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Sedation is an important consideration in the care of the neurocritically ill patient. It provides anxiety and relief, facilitates procedures and nursing tasks, and minimizes intolerance of mechanical ventilation. Alpha-2 agonists such as dexmedetomidine and clonidine have been shown to be an effective alternative in the general critical care population by reducing duration of mechanical ventilation and length of stay in the intensive care unit (ICU), as compared to traditional sedative agents such as propofol or benzodiazepines. However, there is a paucity of literature detailing their utility and safety in neurocritical care, a population that presents unique considerations for management of global and cerebral hemodynamics, agitation, and facilitation of neurological assessments. The objective of this review is to assess the efficacy and safety of alpha-2 agonists for non-procedural sedation in mechanically ventilated brain-injured patients. METHODS We will search the Embase and MEDLINE databases for all randomized controlled trials, prospective and retrospective cohort studies examining neurocritically ill adult patients aged 18 years and older who are on mechanical ventilation and receiving alpha-2 agonists for non-procedural sedation. Primary outcomes of interest include effect on mean arterial pressure (MAP), intracranial pressure (ICP), and cerebral perfusion pressure (CPP). Secondary outcomes include adverse events, duration of mechanical ventilation, 30-day mortality, ICU length of stay, incidence of delirium, and quality of sedation. Continuous outcomes will be presented as means and mean differences and discrete counting events will be presented as event rates. Pre-defined criteria for heterogeneity are provided for determination of pooling eligibility. Where appropriate, we will pool estimates for individual outcomes. Planned subgroup analyses include specific alpha-2 agonist agent, study design, clinical diagnosis, dosing regimen, and use of adjunctive agents. Quality of evidence for the recommendation will be assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach where appropriate. DISCUSSION This systematic review will summarize the evidence on the efficacy and safety for the use of alpha-2 agonists as sedative agents in the neurocritical care population. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42016037045.
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Affiliation(s)
- Alexandre Tran
- Department of Epidemiology, University of Ottawa, Ottawa, Ontario, Canada. .,Department of General Surgery, University of Ottawa, Ottawa, Ontario, Canada. .,Department of General Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada. .,The Ottawa Hospital Civic Campus, Loeb Research Building, Main Floor 725 Parkdale Avenue, Office WM150E, Ottawa, Ontario, K1Y 4E9, Canada.
| | - Henrietta Blinder
- Department of Epidemiology, University of Ottawa, Ottawa, Ontario, Canada
| | - Brian Hutton
- Department of Epidemiology, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program (CEP) Ottawa Health Research Institute, Ottawa, Ontario, Canada
| | - Shane English
- Clinical Epidemiology Program (CEP) Ottawa Health Research Institute, Ottawa, Ontario, Canada.,Department of Medicine (Critical Care), University of Ottawa, Ottawa, Ontario, Canada
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Lonardo NW, Mone MC, Nirula R, Kimball EJ, Ludwig K, Zhou X, Sauer BC, Nechodom K, Teng C, Barton RG. Propofol is associated with favorable outcomes compared with benzodiazepines in ventilated intensive care unit patients. Am J Respir Crit Care Med 2014; 189:1383-94. [PMID: 24720509 DOI: 10.1164/rccm.201312-2291oc] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
RATIONALE Mechanically ventilated intensive care unit (ICU) patients are frequently managed using a continuous-infusion sedative. Although recent guidelines suggest avoiding benzodiazepines for sedation, this class of drugs is still widely used. There are limited data comparing sedative agents in terms of clinical outcomes in an ICU setting. OBJECTIVES Comparison of propofol to midazolam and lorazepam in adult ICU patients. METHODS Data were obtained from a multicenter ICU database (2003-2009). Patient selection criteria included age greater than or equal to 18 years, single ICU admission with single ventilation event (>48 h), and treatment with continuously infused sedation (propofol, midazolam, or lorazepam). Propensity score analysis (1:1) was used and mortality measured. Cumulative incidence and competing risk methodology were used to examine time to ICU discharge and ventilator removal. MEASUREMENTS AND MAIN RESULTS There were 2,250 propofol-midazolam and 1,054 propofol-lorazepam matched patients. Hospital mortality was statistically lower in propofol-treated patients as compared with midazolam- or lorazepam-treated patients (risk ratio, 0.76; 95% confidence interval [CI], 0.69-0.82 and risk ratio, 0.78; 95% CI, 0.68-0.89, respectively). Competing risk analysis for 28-day ICU time period showed that propofol-treated patients had a statistically higher probability for ICU discharge (78.9% vs. 69.5%; 79.2% vs. 71.9%; P < 0.001) and earlier removal from the ventilator (84.4% vs. 75.1%; 84.3% vs. 78.8%; P < 0.001) when compared with midazolam- and lorazepam-treated patients, respectively. CONCLUSIONS In this large, propensity-matched ICU population, patients treated with propofol had a reduced risk of mortality and had both an increased likelihood of earlier ICU discharge and earlier discontinuation of mechanical ventilation.
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Gu JW, Yang T, Kuang YQ, Huang HD, Kong B, Shu HF, Yu SX, Zhang JH. Comparison of the safety and efficacy of propofol with midazolam for sedation of patients with severe traumatic brain injury: a meta-analysis. J Crit Care 2013; 29:287-90. [PMID: 24360821 DOI: 10.1016/j.jcrc.2013.10.021] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 10/22/2013] [Accepted: 10/24/2013] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To perform a meta-analysis to compare the safety and efficacy of propofol with midazolam for sedation of patients with severe traumatic brain injury. MATERIALS AND METHODS Studies were included in the meta-analysis if they met the following criteria: randomized controlled trial of sedative-hypnotic agents including propofol and midazolam; patients had severe traumatic brain injury; the primary outcome was the Glasgow Outcome Scale score; secondary outcomes included mortality, therapeutic failure, intracranial pressure, and cerebral perfusion pressure. The data were analyzed using software for meta-analysis. RESULTS Seven relevant studies were identified. Three of these studies were excluded: one was a single-arm study, one compared morphine and propofol, and for one the full text article could not be obtained. The remaining 4 studies were included in the meta-analysis. The results of the meta-analysis showed that propofol and midazolam have similar effects on the Glasgow Outcome Scale score, mortality, intracranial pressure, and cerebral perfusion pressure. CONCLUSION Our meta-analysis of 4 studies showed that there are no important differences between propofol and midazolam when administered to provide sedation for patients with severe traumatic brain injury. Further randomized, controlled trials comparing propofol with midazolam for sedation of such patients are needed.
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Affiliation(s)
- Jian-wen Gu
- Department of Neurosurgery, Chengdu Military General Hospital, Chengdu 610083, China.
| | - Tao Yang
- Department of Neurosurgery, Chengdu Military General Hospital, Chengdu 610083, China
| | - Yong-qin Kuang
- Department of Neurosurgery, Chengdu Military General Hospital, Chengdu 610083, China
| | - Hai-dong Huang
- Department of Neurosurgery, Chengdu Military General Hospital, Chengdu 610083, China
| | - Bin Kong
- Department of Neurosurgery, Chengdu Military General Hospital, Chengdu 610083, China
| | - Hai-feng Shu
- Department of Neurosurgery, Chengdu Military General Hospital, Chengdu 610083, China
| | - Si-xun Yu
- Department of Neurosurgery, Chengdu Military General Hospital, Chengdu 610083, China
| | - Jun-hai Zhang
- Department of Neurosurgery, Chengdu Military General Hospital, Chengdu 610083, China
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Roberts DJ, Haroon B, Hall RI. Sedation for critically ill or injured adults in the intensive care unit: a shifting paradigm. Drugs 2012; 72:1881-916. [PMID: 22950534 DOI: 10.2165/11636220-000000000-00000] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
As most critically ill or injured patients will require some degree of sedation, the goal of this paper was to comprehensively review the literature associated with use of sedative agents in the intensive care unit (ICU). The first and selected latter portions of this article present a narrative overview of the shifting paradigm in ICU sedation practices, indications for uninterrupted or prolonged ICU sedation, and the pharmacology of sedative agents. In the second portion, we conducted a structured, although not entirely systematic, review of the available evidence associated with use of alternative sedative agents in critically ill or injured adults. Data sources for this review were derived by searching OVID MEDLINE and PubMed from their first available date until May 2012 for relevant randomized controlled trials (RCTs), systematic reviews and/or meta-analyses and economic evaluations. Advances in the technology of mechanical ventilation have permitted clinicians to limit the use of sedation among the critically ill through daily sedative interruptions or other means. These practices have been reported to result in improved mortality, a decreased length of ICU and hospital stay and a lower risk of drug-associated delirium. However, in some cases, prolonged or uninterrupted sedation may still be indicated, such as when patients develop intracranial hypertension following traumatic brain injury. The pharmacokinetics of sedative agents have clinical importance and may be altered by critical illness or injury, co-morbid conditions and/or drug-drug interactions. Although use of validated sedation scales to monitor depth of sedation is likely to reduce adverse events, they have no utility for patients receiving neuromuscular receptor blocking agents. Depth of sedation monitoring devices such as the Bispectral Index (BIS©) also have limitations. Among existing RCTs, no sedative agent has been reported to improve the risk of mortality among the critically ill or injured. Moreover, although propofol may be associated with a shorter time to tracheal extubation and recovery from sedation than midazolam, the risk of hypertriglyceridaemia and hypotension is higher with propofol. Despite dexmedetomidine being linked with a lower risk of drug-associated delirium than alternative sedative agents, this drug increases risk of bradycardia and hypotension. Among adults with severe traumatic brain injury, there are insufficient data to suggest that any single sedative agent decreases the risk of subsequent poor neurological outcomes or mortality. The lack of examination of confounders, including the type of healthcare system in which the investigation was conducted, is a major limitation of existing pharmacoeconomic analyses, which likely limits generalizability of their results.
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Affiliation(s)
- Derek J Roberts
- Departments of Surgery, Community Health Sciences (Division of Epidemiology) and Critical Care Medicine, University of Calgary and the Foothills Medical Centre, Calgary, AB, Canada
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Esmaoglu A, Ulgey A, Akin A, Boyaci A. Comparison between dexmedetomidine and midazolam for sedation of eclampsia patients in the intensive care unit. J Crit Care 2009; 24:551-5. [DOI: 10.1016/j.jcrc.2009.02.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2008] [Revised: 12/31/2008] [Accepted: 02/09/2009] [Indexed: 10/21/2022]
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Huey-Ling L, Chun-Che S, Jen-Jen T, Shau-Ting L, Hsing-I C. Comparison of the effect of protocol-directed sedation with propofol vs. midazolam by nurses in intensive care: efficacy, haemodynamic stability and patient satisfaction. J Clin Nurs 2008; 17:1510-7. [DOI: 10.1111/j.1365-2702.2007.02128.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Quenot JP, Ladoire S, Devoucoux F, Doise JM, Cailliod R, Cunin N, Aubé H, Blettery B, Charles PE. Effect of a nurse-implemented sedation protocol on the incidence of ventilator-associated pneumonia*. Crit Care Med 2007; 35:2031-6. [PMID: 17855817 DOI: 10.1097/01.ccm.0000282733.83089.4d] [Citation(s) in RCA: 171] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To determine whether the use of a nurse-implemented sedation protocol could reduce the incidence of ventilator-associated pneumonia in critically ill patients. DESIGN Two-phase (before-after), prospective, controlled study. SETTING University-affiliated, 11-bed medical intensive care unit. PATIENTS Patients requiring mechanical ventilation for >or=48 hrs and sedative infusion with midazolam or propofol alone. INTERVENTIONS During the control phase, sedatives were adjusted according to the physician's decision. During the protocol phase, sedatives were adjusted according to a protocol developed by a multidisciplinary team including nurses and physicians. The protocol was based on the Cambridge scale, and sedation level was adjusted every 3 hrs by the nurses. Standard practices, including weaning from the ventilator and diagnosis of VAP, were the same during both study phases. MEASUREMENTS AND MAIN RESULTS A total of 423 patients were enrolled (control group, n = 226; protocol group, n = 197). The incidence of VAP was significantly lower in the protocol group compared with the control group (6% and 15%, respectively, p = .005). By univariate analysis (log-rank test), only use of a nurse-implemented protocol was significantly associated with a decrease of incidence of VAP (p < .01). A nurse-implemented protocol was found to be independently associated with a lower incidence of VAP after adjustment on Simplified Acute Physiology Score II in the multivariate Cox proportional hazards model (hazard rate, 0.81; 95% confidence interval, 0.62-0.95; p = .03). The median duration of mechanical ventilation was significantly shorter in the protocol group (4.2 days; interquartile range, 2.1-9.5) compared with the control group (8 days; interquartile range, 2.2-22.0; p = .001), representing a 52% relative reduction. Extubation failure was more frequently observed in the control group compared with the protocol group (13% and 6%, respectively, p = .01). There was no significant difference in in-hospital mortality (38% vs. 45% in the protocol vs. control group, respectively, p = .22). CONCLUSIONS In patients receiving mechanical ventilation and requiring sedative infusions with midazolam or propofol, the use of a nurse-implemented sedation protocol decreases the rate of VAP and the duration of mechanical ventilation.
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Affiliation(s)
- Jean-Pierre Quenot
- Department of Critical Care Medicine, Bocage University Hospital, Dijon, France.
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Abstract
PURPOSE OF REVIEW To evaluate the rationale and the pharmacologic options for sedating neurointensive care patients. RECENT FINDINGS Sedation is a fundamental element in the neurointensive care unit. Even if the sedative strategy in the neurointensive care unit shares the same general aims with intensive care, the characteristics of the patients in the neurointensive care unit pose other unique challenges and some specific indications. The primary aim of neurointensive care is to maintain adequate cerebral perfusion pressure, to control intracranial pressure, and to maintain an adequate mean arterial pressure. Reducing the brain's metabolic demand is an important treatment strategy, and analgesic and sedative agents are used to prevent undesirable increases in intracranial pressure. There are many different pharmacologic agents available, each with distinct advantages and disadvantages. SUMMARY The pharmacokinetic and pharmacologic effects of the available sedatives used in neurointensive care patients are reviewed.
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Affiliation(s)
- Giuseppe Citerio
- Dipartimento di Anestesia e Rianimazone, Nuovo Ospedale San Gerardo, Monza, Italy.
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