The use of dexmedetomidine in the emergency department: A systematic review

Sedation for awake tracheal intubation: A systematic review and network meta-analysis

BACKGROUND

Different sedation regimens have been used to facilitate awake tracheal intubation, but the evidence has not been synthesised robustly, particularly with respect to clinically important outcomes. We conducted a systematic review and network meta-analysis to determine the sedation techniques most likely to be associated with successful tracheal intubation, a shorter time to successful intubation and a lower risk of arterial oxygen desaturation.

METHODS

We searched for randomised controlled trials of patients undergoing awake tracheal intubation for any indication and reporting: overall tracheal intubation success rate; tracheal intubation time; incidence of arterial oxygen desaturation; and other related outcomes. We performed a frequentist network meta-analysis for these outcomes if two or more sedation regimens were compared between included trials. We also performed a sensitivity analysis excluding trials with a high risk of bias.

RESULTS

In total, 48 studies with 2837 patients comparing 33 different regimens were included. Comparing overall awake tracheal intubation success rates (38 studies, 2139 patients), there was no evidence suggesting that any individual sedation regimen was superior. Comparing times to successful tracheal intubation (1745 patients, 24 studies), any sedation strategy was superior to placebo. When we excluded trials with a high risk of bias, we found no evidence of a difference between any interventions for time to successful tracheal intubation. Thirty-one studies (1753 patients) suggested that dexmedetomidine and magnesium sulphate were associated with a reduced risk of arterial oxygen desaturation compared with other interventions, but excluding trials with a high risk of bias suggested no relevant differences between interventions. The quality of evidence for each of our outcomes was low.

CONCLUSIONS

To maximise effective and safe awake tracheal intubation, optimising oxygenation, topical airway anaesthesia and procedural performance may have more impact than any given sedation regimen.

Impact of dexmedetomidine-assisted anesthesia in elderly patients undergoing radical resection of colon cancer

BACKGROUND

Radical resection of colon cancer under general anesthesia is one of the main treatment methods for this malignancy. However, due to the physiological characteristics of elderly patients, the safety of perioperative anesthesia needs special attention. As an α2-adrenergic receptor agonist, dexmedetomidine (Dex) has attracted much attention from anesthesiologists due to its stabilizing effect on heart rate and blood pressure, inhibitory effect on inflammation, and sedative and analgesic effects. Its application in general anesthesia may have a positive impact on the quality of anesthesia and postoperative recovery in elderly patients undergoing radical resection of colon cancer.

AIM

To investigate the anesthetic effects of Dex during radical surgery for colon cancer under general anesthesia in elderly patients.

METHODS

A total of 165 colon cancer patients who underwent radical surgery for colon cancer under general anesthesia at Qingdao University Affiliated Haici Hospital, Qingdao, China were recruited and divided into two groups: A and B. In group A, Dex was administered 30 min before surgery, while group B received an equivalent amount of normal saline. The hemodynamic changes, pulmonary compliance, airway pressure, inflammatory factors, confusion assessment method scores, Ramsay Sedation-Agitation Scale scores, and cellular immune function indicators were compared between the two groups.

RESULTS

Group A showed less intraoperative hemodynamic fluctuations, better pulmonary compliance, and lower airway resistance compared with group B. Twelve hours after the surgery, the serum levels of TLR-2, TLR-4, IL-6, and TNF-α in group A were significantly lower than those of group B (P < 0.05). After extubation, the Ramsay Sedation-Agitation Scale score of group A patients was significantly higher than that of group B patients, indicating a higher level of sedation. The incidence of delirium was significantly lower in group A than in group B (P < 0.05).

CONCLUSION

The use of Dex as an adjunct to general anesthesia for radical surgery in elderly patients with colon cancer results in better effectiveness of anesthesia.

Clinical adverse events to dexmedetomidine: a real-world drug safety study based on the FAERS database

Objective

Adverse events associated with dexmedetomidine were analyzed using data from the FDA's FAERS database, spanning from 2004 to the third quarter of 2023. This analysis serves as a foundation for monitoring dexmedetomidine's safety in clinical applications.

Methods

Data on adverse events associated with dexmedetomidine were standardized and analyzed to identify clinical adverse events closely linked to its use. This analysis employed various signal quantification analysis algorithms, including Reporting Odds Ratio (ROR), Proportional Reporting Ratio (PRR), Bayesian Confidence Propagation Neural Network (BCPNN), and Multi-Item Gamma Poisson Shrinker (MGPS).

Results

In the FAERS database, dexmedetomidine was identified as the primary suspect in 1,910 adverse events. Our analysis encompassed 26 organ system levels, from which we selected 346 relevant Preferred Terms (PTs) for further examination. Notably, adverse drug reactions such as diabetes insipidus, abnormal transcranial electrical motor evoked potential monitoring, acute motor axonal neuropathy, and trigeminal cardiac reflex were identified. These reactions are not explicitly mentioned in the drug's specification, indicating the emergence of new signals for adverse drug reactions.

Conclusion

Data mining in the FAERS database has elucidated the characteristics of dexmedetomidine-related adverse drug reactions. This analysis enhances our understanding of dexmedetomidine's drug safety, aids in the clinical management of pharmacovigilance studies, and offers valuable insights for refining drug-use protocols.

Dream of the Endless: Updates in Agents for Procedural Sedation

Procedural sedation and analgesia is an essential activity in the emergency department for managing pain and anxiety during a variety of medical procedures. Various pharmacotherapy options, including opioid analgesics, antiemetics, anticholinergics, sedatives, and ketamine have been utilized, all with their unique efficacy and safety profiles. This review highlights the challenges associated with using certain agents and discusses emerging trends such as the use of newer synthetic opioids and the expanding use of dexmedetomidine. Overall, the selection of the optimal agents for procedural sedation and analgesia should be guided based on the unique characteristics of each agent tailored to the needs of the specific procedure, along with consideration for individual patient characteristics.

Efficacy and safety of ketamine alone and ketamine-dexmedetomidine combination for sedation for brain computed tomography in paediatric patients with head injuries: A retrospective study

OBJECTIVE

To compare the efficacy and safety of ketamine alone with those of ketamine-dexmedetomidine combination for sedation during brain CT in paediatric patients with head injuries.

METHODS

We retrospectively analysed the data of paediatric patients who underwent sedation for brain CT at the ED. We included patients aged 6 months to 6 years with American Society of Anesthesiologists physical status I or II. The sedative protocol involved the administration of intramuscular (IM) ketamine 3 mg/kg (K), ketamine 2 mg/kg with dexmedetomidine 1.5 μg/kg (KD) or ketamine 1.5 mg/kg with dexmedetomidine 1.5 μg/kg (low-KD). The primary and secondary outcomes were sedation failure and adverse events, respectively.

RESULTS

We included 77 patients; among them, 28, 23 and 26 were in the K, KD and low-KD groups, respectively. In multivariable analysis, the combination groups (KD and low-KD groups) were significantly associated with a lower possibility of sedation failure compared to the K group (adjusted odds ratio, 0.12; 95% confidence interval, 0.02-0.56). Moreover, there were no significant differences in adverse events between the groups, and the sedation-related time variables also did not significantly differ among the three groups.

CONCLUSIONS

Our findings indicated that a combination of IM ketamine-dexmedetomidine provides effective sedation for paediatric patients undergoing brain CT without significant adverse events. Further research is needed to investigate the potential benefits of using lower doses of ketamine in combination.

Dexmedetomidine in the emergency department: A prospective observational cohort study

BACKGROUND

Dexmedetomidine (DEX) is a centrally acting sympatholytic sedative. Abundant evidence from the intensive care unit and other settings demonstrates that the use of DEX is associated with improved sedation-related outcomes. There is a paucity of data on the use and efficacy of DEX in the emergency department (ED).

METHODS

We performed a prospective single-center observational cohort study of patients treated with intravenous DEX for any indication in the ED. We performed serial bedside evaluations of sedation depth and delirium and administered standardized questionnaires to ED physicians about their use of DEX. We assessed the incidence of hemodynamic adverse events (HAEs; bradycardia or hypotension), clinically significant HAEs (HAEs accompanied by clinical intervention or discontinuation of DEX), sedation-related ED outcomes, and clinician perception of DEX effectiveness.

RESULTS

We enrolled 75 patients treated with DEX in the ED during our study period. The most common indication for DEX was noninvasive positive pressure ventilation (32 patients, 43%). DEX was administered in the ED for a median of 2.6 h (interquartile range [IQR] 1.6-4.9 h), with a median infusion rate of 0.3 μg/kg/h (IQR 0.2-0.4 μg/kg/h). Clinically significant HAE occurred in nine patients (12%, 95% CI 6%-22%). Other sedative or analgesic infusions were administered in the ED to 21 patients (28%). Clinicians felt DEX was highly effective (median [IQR] effectiveness score of 5 [3-5] on a 5-point Likert scale). The median (IQR) ED Richmond Agitation Sedation Scale post-DEX was -1 (-4 to 0).

CONCLUSIONS

DEX is used in the ED for diverse indications. Additional data from larger cohorts and comparative studies are required to determine the precise incidence of clinically significant HAE associated with DEX use in the ED. ED clinicians have a positive perception of the effectiveness of DEX.

Nebulized dexmedetomidine for attenuating hemodynamic response to laryngoscopy and endotracheal intubation in adult patients undergoing surgeries under general anaesthesia: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Sympathetic stimulation associated with laryngoscopy and endotracheal intubation (ETI) may lead to adverse cardio-/cerebro-vascular events in susceptible patients. Nebulization is a novel route for dexmedetomidine administration providing a large surface area for absorption while avoiding bradycardia and hypotension associated with intravenous route. We aimed to evaluate the efficacy and safety of dexmedetomidine nebulization for attenuating hemodynamic response to ETI in adult patients undergoing surgery under general anaesthesia.

METHODS

This systematic review was registered prospectively in the International Prospective Register of Systematic Reviews (CRD42023403624). PubMed, Embase (OvidSP), Cochrane library, Scopus (Elsevier), Web of Science (Clarivate) and Google Scholar were systematically searched from database inception until March 31, 2023. Two reviewers independently screened titles, abstracts and then full text against pre-specified eligibility criteria. Randomized controlled trials (RCTs) assessing effect of dexmedetomidine nebulization on hemodynamic response to ETI in adult patients undergoing surgeries under general anaesthesia were included. All studies reporting heart rate and systolic blood pressure at baseline and various time points after ETI were included. A pre-piloted data extraction form, Cochrane revised risk-of-bias tool (ROB 2) tool, GRADE approach and RevMan 5.4.1 (Cochrane Collaboration, Copenhagen, Denmark) were used for data extraction, risk of bias assessment, rating certainty of evidence and data synthesis respectively. Mean difference and relative risk with 95% Confidence Interval (CI) were used for continuous and dichotomous variables respectively.

RESULTS

Six RCTs randomized 480 patients with ASA I/II patients aged < 60 years of age and undergoing elective surgeries to receive either dexmedetomidine (n = 240) or saline nebulization (n = 240). Except for one RCT which used 2 μg/kg, all other RCTs used dexmedetomidine dose of 1 μg /kg. Heart rate, systolic, diastolic and mean blood pressure were significantly lower in the dexmedetomidine group at all the measured time points after laryngoscopy and ETI with the only exception being systolic blood pressure at 3 min [mean difference -13.86 (95% CI -30.01 to 2.99), p = 0.09]. Bradycardia and hypotension as adverse effects were absent across the included studies. However, only one-third of the included studies had a low risk of bias and strength of evidence was very low according to the GRADE assessment.

CONCLUSIONS

Compared to placebo, premedication with dexmedetomidine nebulization was associated with lower HR and BP following ETI without any risk of bradycardia and hypotension. However, the strength of evidence was very poor and came from just one country. Future well designed and conducted studies in different populations are warranted.

TRIAL REGISTRATION

PROSPERO Registration number: CRD42023403624.

RNA-sequencing approach for exploring the protective mechanisms of dexmedetomidine on pancreatic injury in severe acute pancreatitis

Background: Severe acute pancreatitis (SAP) is a severe form of acute pancreatitis with the potential to cause life-threatening complications. Patients with acute SAP require surgical intervention and are admitted to the intensive care unit for non-invasive ventilation. Dexmedetomidine (Dex) is currently used by intensive care clinicians and anaesthesiologists as an adjunctive sedative. Therefore, the clinical availability of Dex makes it easier to implement in SAP treatment than developing new drugs. Methods: Randomly dividing thirty rats into sham-operated (Sham), SAP, and Dex groups. The severity of pancreatic tissue injury in each rat was assessed by Hematoxylin and eosin (HE) staining. Serum amylase activity and inflammatory factor levels were measured using commercially available kits. The expressions of necroptosis-related proteins, myeloperoxidase (MPO), CD68, and 4-hydroxy-trans-2-nonenal (HNE) were detected using immunohistochemistry (IHC). Transferase-mediated dUTP nick-end labeling (TUNEL) staining was utilized to identify pancreatic acinar cell apoptosis. The subcellular organelle structure of pancreatic acinar cells was observed using transmission electron microscopy. The regulatory effect of Dex on the gene expression profile of SAP rat pancreas tissue was investigated using RNA sequencing. We screened for differentially expressed genes (DEGs). Quantitative real-time PCR (qRT-PCR) measured critical DEG mRNA expression in rat pancreatic tissues. Results: Dex attenuated SAP-induced pancreatic injury, infiltration of neutrophils and macrophages, and oxidative stress. Dex inhibited the expression of necroptosis-associated proteins RIPK1, RIPK3, and MLKL and alleviated apoptosis in acinar cells. Dex also mitigated the structural damage caused by SAP to mitochondria and endoplasmic reticulum. Dex inhibited SAP-induced 473 DEGs, as determined by RNA sequencing. Dex may regulate SAP-induced inflammatory response and tissue damage by inhibiting the toll-like receptor/nuclear factor κB (TLR/NF-κB) signaling pathway and neutrophil extracellular trap formation. Conclusion: This study elucidated the remarkable effect of Dex against SAP and investigated the potential mechanism of action, providing an experimental base for the future clinical application of Dex in the treatment of SAP.