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Stollings JL, Thompson JL, Ferrell BA, Scheinin M, Wilkinson GR, Hughes CG, Shintani AK, Ely EW, Girard TD, Pandharipande PP, Patel MB. Sedative Plasma Concentrations and Delirium Risk in Critical Illness. Ann Pharmacother 2018; 52:513-521. [PMID: 29363356 DOI: 10.1177/1060028017753480] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The relationship between plasma concentration of sedatives and delirium is unknown. OBJECTIVE We hypothesized that higher plasma concentrations of lorazepam are associated with increased delirium risk, whereas higher plasma concentrations of dexmedetomidine are associated with reduced delirium risk. METHODS This prospective cohort study was embedded in a double-blind randomized clinical trial, where ventilated patients received infusions of lorazepam and dexmedetomidine. Plasma concentrations of these drugs and delirium assessments were measured at least daily. A multivariable logistic regression model accounting for repeated measures was used to analyze associations between same-day plasma concentrations of lorazepam and dexmedetomidine (exposures) and the likelihood of next-day delirium (outcome), adjusting for same-day mental status (delirium, coma, or normal) and same-day fentanyl doses. RESULTS This critically ill cohort (n = 103) had a median age of 60 years (IQR: 48-66) with APACHE II score of 28 (interquartile range [IQR] = 24-32), where randomization resulted in assignment to lorazepam (n = 51) or dexmedetomidine (n = 52). After adjusting for same-day fentanyl dose and mental status, higher plasma concentrations of lorazepam were associated with increased probability of next-day delirium (comparing 500 vs 0 ng/mL; odds ratio [OR] = 13.2; 95% CI = 1.4-120.1; P = 0.02). Plasma concentrations of dexmedetomidine were not associated with next-day delirium (comparing 1 vs 0 ng/mL; OR = 1.1; 95% CI = 0.9-1.3; P = 0.45). CONCLUSIONS In critically ill patients, higher lorazepam plasma concentrations were associated with delirium, whereas dexmedetomidine plasma concentrations were not. This implies that the reduced delirium risk seen in patients sedated with dexmedetomidine may be a result of avoidance of benzodiazepines, rather than a dose-dependent protective effect of dexmedetomidine.
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Affiliation(s)
| | | | - Benjamin A Ferrell
- 1 Vanderbilt University Medical Center, Nashville, TN, USA.,3 University of Tennessee School of Medicine, Nashville, TN, USA
| | - Mika Scheinin
- 4 University of Turku, Turku, Finland.,5 Turku University Hospital, Turku, Finland
| | - Grant R Wilkinson
- 1 Vanderbilt University Medical Center, Nashville, TN, USA.,2 Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Christopher G Hughes
- 1 Vanderbilt University Medical Center, Nashville, TN, USA.,2 Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Ayumi K Shintani
- 2 Vanderbilt University School of Medicine, Nashville, TN, USA.,6 Osaka University, Suita, Japan
| | - E Wesley Ely
- 1 Vanderbilt University Medical Center, Nashville, TN, USA.,2 Vanderbilt University School of Medicine, Nashville, TN, USA.,7 Veterans Affairs, Tennessee Valley Health Care System, Nashville, TN, USA
| | | | - Pratik P Pandharipande
- 1 Vanderbilt University Medical Center, Nashville, TN, USA.,2 Vanderbilt University School of Medicine, Nashville, TN, USA.,7 Veterans Affairs, Tennessee Valley Health Care System, Nashville, TN, USA
| | - Mayur B Patel
- 1 Vanderbilt University Medical Center, Nashville, TN, USA.,2 Vanderbilt University School of Medicine, Nashville, TN, USA.,7 Veterans Affairs, Tennessee Valley Health Care System, Nashville, TN, USA
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