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Liu SY, Kelly-Hedrick M, Temkin N, Barber J, Komisarow J, Hatfield J, Ohnuma T, Manley G, Treggiari MM, Colton K, Vavilala MS, Grandhi R, Laskowitz DT, Mathew JP, Hernandez A, James ML, Raghunathan K, Goldstein B, Krishnamoorthy V. Association of Early Dexmedetomidine Utilization With Clinical and Functional Outcomes Following Moderate-Severe Traumatic Brain Injury: A Transforming Clinical Research and Knowledge in Traumatic Brain Injury Study. Crit Care Med 2024; 52:607-617. [PMID: 37966330 PMCID: PMC10939970 DOI: 10.1097/ccm.0000000000006106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
OBJECTIVE To examine early sedation patterns, as well as the association of dexmedetomidine exposure, with clinical and functional outcomes among mechanically ventilated patients with moderate-severe traumatic brain injury (msTBI). DESIGN Retrospective cohort study with prospectively collected data. SETTING Eighteen Level-1 Trauma Centers, United States. PATIENTS Adult (age > 17) patients with msTBI (as defined by Glasgow Coma Scale < 13) who required mechanical ventilation from the Transforming Clinical Research and Knowledge in TBI (TRACK-TBI) study. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Using propensity-weighted models, we examined the association of early dexmedetomidine exposure (within the first 5 d of ICU admission) with the primary outcome of 6-month Glasgow Outcomes Scale Extended (GOS-E) and the following secondary outcomes: length of hospital stay, hospital mortality, 6-month Disability Rating Scale (DRS), and 6-month mortality. The study population included 352 subjects who required mechanical ventilation within 24 hours of admission. The initial sedative medication was propofol for 240 patients (68%), midazolam for 59 patients (17%), ketamine for 6 patients (2%), dexmedetomidine for 3 patients (1%), and 43 patients (12%) never received continuous sedation. Early dexmedetomidine was administered in 77 of the patients (22%), usually as a second-line agent. Compared with unexposed patients, early dexmedetomidine exposure was not associated with better 6-month GOS-E (weighted odds ratio [OR] = 1.48; 95% CI, 0.98-2.25). Early dexmedetomidine exposure was associated with lower DRS (weighted OR = -3.04; 95% CI, -5.88 to -0.21). In patients requiring ICP monitoring within the first 24 hours of admission, early dexmedetomidine exposure was associated with higher 6-month GOS-E score (OR 2.17; 95% CI, 1.24-3.80), lower DRS score (adjusted mean difference, -5.81; 95% CI, -9.38 to 2.25), and reduced length of hospital stay (hazard ratio = 1.50; 95% CI, 1.02-2.20). CONCLUSION Variation exists in early sedation choice among mechanically ventilated patients with msTBI. Early dexmedetomidine exposure was not associated with improved 6-month functional outcomes in the entire population, although may have clinical benefit in patients with indications for ICP monitoring.
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Affiliation(s)
- Sunny Yang Liu
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Duke University School of Medicine, Durham, NC
| | - Margot Kelly-Hedrick
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Duke University School of Medicine, Durham, NC
| | - Nancy Temkin
- Department of Biostatistics, University of Washington. Seattle, WA
- Department of Neurosurgery, University of Washington. Seattle, WA
| | - Jason Barber
- Department of Neurosurgery, University of Washington. Seattle, WA
| | | | - Jordan Hatfield
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Duke University School of Medicine, Durham, NC
| | - Tetsu Ohnuma
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Department of Anesthesiology, Duke University. Durham, NC
| | - Geoffrey Manley
- Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, CA
| | - Miriam M. Treggiari
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Department of Anesthesiology, Duke University. Durham, NC
| | | | - Monica S. Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington. Seattle, WA
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Utah, Salt Lake City, UT
| | - Daniel T. Laskowitz
- Department of Neurosurgery, Duke University. Durham, NC
- Department of Anesthesiology, Duke University. Durham, NC
- Department Neurology, Duke University. Durham, NC
| | | | | | - Michael L. James
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Department of Anesthesiology, Duke University. Durham, NC
- Department Neurology, Duke University. Durham, NC
| | - Karthik Raghunathan
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Department of Anesthesiology, Duke University. Durham, NC
- Department of Population Health Sciences, Duke University. Durham, NC
| | - Ben Goldstein
- Departments of Biostatistics and Bioinformatics, Duke University. Durham, NC
| | - Vijay Krishnamoorthy
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Department of Anesthesiology, Duke University. Durham, NC
- Department of Population Health Sciences, Duke University. Durham, NC
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Hatfield J, Soto AL, Kelly-Hedrick M, Kaplan S, Komisarow JM, Ohnuma T, Krishnamoorthy V. Safety, Efficacy, and Clinical Outcomes of Dexmedetomidine for Sedation in Traumatic Brain Injury: A Scoping Review. J Neurosurg Anesthesiol 2024; 36:101-108. [PMID: 36791389 PMCID: PMC10425561 DOI: 10.1097/ana.0000000000000907] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 12/28/2022] [Indexed: 02/17/2023]
Abstract
Dexmedetomidine is a promising alternative sedative agent for moderate-severe Traumatic brain injury (TBI) patients. Although the data are limited, the posited benefits of dexmedetomidine in this population are a reduction in secondary brain injury compared with current standard sedative regimens. In this scoping review, we critically appraised the literature to examine the effects of dexmedetomidine in patients with moderate-severe TBI to examine the safety, efficacy, and cerebral and systemic physiological outcomes within this population. We sought to identify gaps in the literature and generate directions for future research. Two researchers and a librarian queried PubMed, Embase, Scopus, and APA PsycINFO databases. Of 920 studies imported for screening, 11 were identified for inclusion in the review. The primary outcomes in the included studied were cerebral physiology, systemic hemodynamics, sedation levels and delirium, and the presence of paroxysmal sympathetic hyperactivity. Dexmedetomidine dosing ranged from 0.2 to 1 ug/kg/h, with 3 studies using initial boluses of 0.8 to 1.0 ug/kg over 10 minutes. Dexmedetomidine used independently or as an adjunct seems to exhibit a similar hemodynamic safety profile compared with standard sedation regimens, albeit with transient episodes of bradycardia and hypotension, decrease episodes of agitation and may serve to alleviate symptoms of sympathetic hyperactivity. This scoping review suggests that dexmedetomidine is a safe and efficacious sedation strategy in patients with TBI. Given its rapid onset of action and anxiolytic properties, dexmedetomidine may serve as a feasible sedative for TBI patients.
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Affiliation(s)
- Jordan Hatfield
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina
- Duke University School of Medicine, Durham, North Carolina
| | - Alexandria L. Soto
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina
- Duke University School of Medicine, Durham, North Carolina
| | - Margot Kelly-Hedrick
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina
- Duke University School of Medicine, Durham, North Carolina
| | | | - Jordan M. Komisarow
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina
- Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Tetsu Ohnuma
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina
- Department of Anesthesiology, Duke University, Durham, North Carolina
- Population Health Sciences, Duke University, Durham, North Carolina
| | - Vijay Krishnamoorthy
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina
- Department of Anesthesiology, Duke University, Durham, North Carolina
- Population Health Sciences, Duke University, Durham, North Carolina
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Watson DJ, Nemecek E, Bongiovanni R, Merlin MA. Dexmedetomidine Utilization During Air Medical Transport for Agitated Patients. Air Med J 2024; 43:60-62. [PMID: 38154843 DOI: 10.1016/j.amj.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 10/08/2023] [Accepted: 10/17/2023] [Indexed: 12/30/2023]
Abstract
Fixed Wing Air Ambulance providers routinely transport patients agitated from traumatic brain injury sequelae across long distances in a unique environment. The current paradigm limits options available to air medical clinicians to those routinely found on ground based, short distance vehicles, plus whatever a sending facility might be willing to provide. We postulate that dexmedetomidine offers a safe, effective alternative to improve patient care and enhance the safe operation of aircraft.
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Affiliation(s)
- David J Watson
- Angel MedFlight Worldwide Air Ambulance Service, Scottsdale, AZ.
| | - Erik Nemecek
- Angel MedFlight Worldwide Air Ambulance Service, Scottsdale, AZ
| | | | - Mark A Merlin
- Angel MedFlight Worldwide Air Ambulance Service, Scottsdale, AZ
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Bauerschmidt A, Al-Bermani T, Ali S, Bass B, Dorilio J, Rosenberg J, Al-Mufti F. Modern Sedation and Analgesia Strategies in Neurocritical Care. Curr Neurol Neurosci Rep 2023; 23:149-158. [PMID: 36881257 DOI: 10.1007/s11910-023-01261-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2023] [Indexed: 03/08/2023]
Abstract
PURPOSE OF REVIEW Patients with acute neurologic injury require a specialized approach to critical care, particularly with regard to sedation and analgesia. This article reviews the most recent advances in methodology, pharmacology, and best practices of sedation and analgesia for the neurocritical care population. RECENT FINDINGS In addition to established agents such as propofol and midazolam, dexmedetomidine and ketamine are two sedative agents that play an increasingly central role, as they have a favorable side effect profile on cerebral hemodynamics and rapid offset can facilitate repeated neurologic exams. Recent evidence suggests that dexmedetomidine is also an effective component when managing delirium. Combined analgo-sedation with low doses of short-acting opiates is a preferred sedation strategy to facilitate neurologic exams as well as patient-ventilator synchrony. Optimal care for patients in the neurocritical care population requires an adaptation of general ICU strategies that incorporates understanding of neurophysiology and the need for close neuromonitoring. Recent data continues to improve care tailored to this population.
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Affiliation(s)
- Andrew Bauerschmidt
- Department of Neurology-Westchester Medical Center, New York Medical College, Valhalla, NY, USA.
- Department of Neurosurgery-Westchester Medical Center, New York Medical College, Valhalla, NY, USA.
| | - Tarik Al-Bermani
- Department of Pulmonary, Critical Care, and Sleep Medicine-Westchester Medical Center, Valhalla, NY, USA
| | - Syed Ali
- Department of Neurology-Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Brittany Bass
- Department of Pulmonary, Critical Care, and Sleep Medicine-Westchester Medical Center, Valhalla, NY, USA
| | - Jessica Dorilio
- Department of Neurology-Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Jon Rosenberg
- Department of Neurology-Westchester Medical Center, New York Medical College, Valhalla, NY, USA
- Department of Neurosurgery-Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Fawaz Al-Mufti
- Department of Neurology-Westchester Medical Center, New York Medical College, Valhalla, NY, USA
- Department of Neurosurgery-Westchester Medical Center, New York Medical College, Valhalla, NY, USA
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Zitikyte G, Roy DC, Tran A, Fernando SM, Rosenberg E, Kanji S, Engels PT, Wells GA, Vaillancourt C. Pharmacologic Interventions to Prevent Delirium in Trauma Patients: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials. Crit Care Explor 2023; 5:e0875. [PMID: 36937896 PMCID: PMC10019141 DOI: 10.1097/cce.0000000000000875] [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: 03/17/2023] Open
Abstract
To compare the relative efficacy of pharmacologic interventions in the prevention of delirium in ICU trauma patients. DATA SOURCES We searched Medical Literature Analysis and Retrieval System Online, Embase, and Cochrane Registry of Clinical Trials from database inception until June 7, 2022. We included randomized controlled trials comparing pharmacologic interventions in critically ill trauma patients. STUDY SELECTION Two reviewers independently screened studies for eligibility, extracted data, and assessed risk of bias. DATA EXTRACTION Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines for network analysis were followed. Random-effects models were fit using a Bayesian approach to network meta-analysis. Between-group comparisons were estimated using hazard ratios (HRs) for dichotomous outcomes and mean differences for continuous outcomes, each with 95% credible intervals. Treatment rankings were estimated for each outcome in the form of surface under the cumulative ranking curve values. DATA SYNTHESIS A total 3,541 citations were screened; six randomized clinical trials (n = 382 patients) were included. Compared with combined propofol-dexmedetomidine, there may be no difference in delirium prevalence with dexmedetomidine (HR 1.44, 95% CI 0.39-6.94), propofol (HR 2.38, 95% CI 0.68-11.36), nor haloperidol (HR 3.38, 95% CI 0.65-21.79); compared with dexmedetomidine alone, there may be no effect with propofol (HR 1.66, 95% CI 0.79-3.69) nor haloperidol (HR 2.30, 95% CI 0.88-6.61). CONCLUSIONS The results of this network meta-analysis suggest that there is no difference found between pharmacologic interventions on delirium occurrence, length of ICU stay, length of hospital stay, or mortality, in trauma ICU patients.
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Affiliation(s)
- Gabriele Zitikyte
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Danielle C Roy
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Alexandre Tran
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, ON, Canada
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Shannon M Fernando
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Erin Rosenberg
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Salmaan Kanji
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Department of Pharmacy, The Ottawa Hospital, Ottawa, ON, Canada
| | - Paul T Engels
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - George A Wells
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Christian Vaillancourt
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
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Neurosurgical Anesthesia: Optimizing Outcomes with Agent Selection. Biomedicines 2023; 11:biomedicines11020372. [PMID: 36830909 PMCID: PMC9953550 DOI: 10.3390/biomedicines11020372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 01/22/2023] [Indexed: 01/31/2023] Open
Abstract
Anesthesia in neurosurgery embodies a vital element in the development of neurosurgical intervention. This undisputed interest has offered surgeons and anesthesiologists an array of anesthetic selections to utilize, though with this allowance comes the equally essential requirement of implementing a maximally appropriate agent. To date, there remains a lack of consensus and official guidance on optimizing anesthetic choice based on operating priorities including hemodynamic parameters (e.g., CPP, ICP, MAP) in addition to the route of procedure and pathology. In this review, the authors detail the development of neuroanesthesia, summarize the advantages and drawbacks of various anesthetic classes and agents, while lastly cohesively organizing the current literature of randomized trials on neuroanesthesia across various procedures.
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Soto-Edwards A, Kawamoto A, Peters A. Effective Use of Ketamine-Dexmedetomidine Following Propofol-Induced Hyperlactatemia: A Case Report. Cureus 2022; 14:e25764. [PMID: 35812601 PMCID: PMC9270096 DOI: 10.7759/cureus.25764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2022] [Indexed: 11/05/2022] Open
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Kayambankadzanja RK, Samwel R, Baker T. Pragmatic sedation strategies to prevent secondary brain injury in low‐resource settings. Anaesthesia 2022; 77 Suppl 1:43-48. [DOI: 10.1111/anae.15621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2021] [Indexed: 01/22/2023]
Affiliation(s)
- R. K. Kayambankadzanja
- School of Public Health Kamuzu University of Health Science Blantyre Malawi
- Department of Anaesthesia and Intensive Care Queen Elizabeth Central Hospital Blantyre Malawi
| | - R. Samwel
- Department of Anaesthesia and Intensive Care Bugando Medical Centre Mwanza Tanzania
| | - T. Baker
- Muhimbili University of Health and Allied Sciences Dar es Salaam Tanzania
- Department of Clinical Research London School of Hygiene and Tropical Medicine London UK
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Kapoor I, Mahajan C, Prabhakar H. Dexmedetomidine in Modern Neuroanesthesia Practice. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-021-00450-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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