Adverse Events Associated with Sedatives, Analgesics, and Other Drugs That Provide Patient Comfort in the Intensive Care Unit

Comparative analysis of dexmedetomidine, midazolam, and propofol impact on epilepsy-related mortality in the ICU: insights from the MIMIC-IV database

BACKGROUND

Dexmedetomidine (Dex), midazolam, and propofol are three distinct sedatives characterized by varying pharmacological properties. Previous literature has indicated the positive impact of each of these sedatives on ICU patients. However, there is a scarcity of clinical evidence comparing the efficacy of Dex, midazolam, and propofol in reducing mortality among people with epilepsy (PWE). This study aimed to assess the impact of Dex, midazolam, and propofol on the survival of PWE.

METHODS

The data were retrospectively retrieved from the Medical Information Mart for Intensive Care (MIMIC)-IV database (version 2.0). PWE were categorized into Dex, midazolam, and propofol groups based on the intravenously administered sedatives. PWE without standard drug therapy were included in the control group. Comparative analyses were performed on the data among the groups.

RESULTS

The Dex group exhibited a significantly lower proportion of in-hospital deaths and a markedly higher in-hospital survival time compared to the midazolam and propofol groups (p < 0.01) after propensity score matching. Kaplan-Meier curves demonstrated a significant improvement in survival rates for the Dex group compared to the control group (p = 0.025). Analysis of Variance (ANOVA) revealed no significant differences in survival rates among the Dex, midazolam, and propofol groups (F = 1.949, p = 0.143). The nomogram indicated that compared to midazolam and propofol groups, Dex was more effective in improving the survival rate of PWE.

CONCLUSION

Dex might improve the survival rate of PWE in the ICU compared to no standard drug intervention. However, Dex did not exhibit superiority in improving survival rates compared to midazolam and propofol.

Ketamine in Critically Ill Patients: Use, Perceptions, and Potential Barriers

Objective: To evaluate practitioner use of ketamine and identify potential barriers to use in acutely and critically ill patients. To compare characteristics, beliefs, and practices of ketamine frequent users and non-users. Methods: An online survey developed by members of the Society of Critical Care Medicine (SCCM) Clinical Pharmacy and Pharmacology Section was distributed to physician, pharmacist, nurse practitioner, physician assistant and nurse members of SCCM. The online survey queried SCCM members on self-reported practices regarding ketamine use and potential barriers in acute and critically ill patients. Results: Respondents, 341 analyzed, were mostly adult physicians, practicing in the United States at academic medical centers. Clinicians were comfortable or very comfortable using ketamine to facilitate intubation (80.0%), for analgesia (77.9%), procedural sedation (79.4%), continuous ICU sedation (65.8%), dressing changes (62.4%), or for asthma exacerbation and status epilepticus (58.8% and 40.4%). Clinicians were least comfortable with ketamine use for alcohol withdrawal and opioid detoxification (24.7% and 23.2%). Most respondents reported "never" or "infrequently" using ketamine preferentially for continuous IV analgesia (55.6%) or sedation (61%). Responses were mixed across dosing ranges and duration. The most common barriers to ketamine use were adverse effects (42.6%), other practitioners not routinely using the medication (41.5%), lack of evidence (33.5%), lack of familiarity (33.1%), and hospital/institutional policy guiding the indication for use (32.3%). Conclusion: Although most critical care practitioners report feeling comfortable using ketamine, there are many inconsistencies in practice regarding dose, duration, and reasons to avoid or limit ketamine use. Further educational tools may be targeted at practitioners to improve appropriate ketamine use.

Valproic acid for agitation in the intensive care unit: an observational study of psychiatric consults

BACKGROUND

Agitation is a common clinical problem encountered in the intensive care unit (ICU). Treatment options are based on clinical experience and sparse quality literature.

AIM

The aim of this study was to describe the effect of valproic acid (VPA) as adjuvant treatment for agitation in the ICU, identify predictors of response to VPA and evaluate the independent effect of VPA on agitation compared to standard of care (SOC).

METHOD

This retrospective single center observational study evaluated adult patients admitted to the ICU for whom a psychiatric consultation was requested for agitation management, with agitation defined as a Richmond Agitation Sedation Score of 2 or greater. A descriptive analysis of the proportion of agitation-free patients per day of follow-up, the incidence of agitation-related-events, as well as the evolution of co-medications use over time are presented. A logistic regression model was used to assess predictors of VPA response, defined as being agitation-free on Day 7 and generalized estimating equations were used to evaluate the independent effect of VPA as adjuvant therapy for agitation in the critically ill.

RESULTS

One hundred seventy-five patients were included in the study with 78 receiving VPA. The percentage of agitation-free patients on VPA was 6.5% (5/77) on Day 1, 14.1% (11/78) on Day 3 and 39.5% (30/76) on Day 7. Multivariate regression model for clinical and demographic variables identified female gender as predictor of response on Day 7 (OR 6.10 [1.18-31.64], p = 0.03). The independent effect of VPA was non-significant when compared to SOC.

CONCLUSION

Although VPA used as adjuvant treatment was associated with a decrease in agitation, its effect when compared to SOC did not yield significant results.

Melatonin as an Antioxidant Agent in Stroke: An Updated Review

Stroke is a devastating disease associated with high mortality and disability worldwide, and is generally classified as ischemic or hemorrhagic, which share certain similar pathophysiological processes. Oxidative stress is a critical factor involved in stroke-induced injury, which not only directly damages brain tissue, but also enhances a series of pathological signaling cascades, contributing to inflammation, brain edema, and neuronal death. To alleviate these serious secondary brain injuries, neuroprotective agents targeting oxidative stress inhibition may serve as a promising treatment strategy. Melatonin is a hormone secreted by the pineal gland, and has various properties, such as antioxidation, anti-inflammation, circadian rhythm modulation, and promotion of tissue regeneration. Numerous animal experiments studying stroke have confirmed that melatonin exerts considerable neuroprotective effects, partially via anti-oxidative stress. In this review, we introduce the possible role of melatonin as an antioxidant in the treatment of stroke based on the latest published studies of animal experiments and clinical research.

The Impact of Signing Do-Not-Resuscitate Orders on the Use of Non-Beneficial Life-Sustaining Treatments for Intensive Care Unit Patients: A Retrospective Study

Background: Intensive care medical technology increases the survival rate of critically ill patients. However, life-sustaining treatments also increase the probability of non-beneficial medical treatments given to patients at the end of life. Objective: This study aimed to analyse whether patients with a do-not-resuscitate (DNR) order were more likely to be subject to the withholding of cardiac resuscitation and withdrawal of life-sustaining treatment in the ICU. Methods: This retrospective study collected data regarding the demographics, illness conditions, and life-sustaining treatments of ICU patients who were last admitted to the ICU between 1 January 2016 and 31 December 2017, as determined by the hospital’s electronic medical dataset. Results: We identified and collected data on 386 patients over the two years; 319 (82.6%) signed a DNR before the end. The study found that DNR patients were less likely to receive cardiac resuscitation before death than non-DNR patients. The cardiac resuscitation treatments included chest compressions, electric shock, and cardiotonic drug injections (p < 0.001). However, the life-sustaining treatments were withdrawn for only a few patients before death. The study highlights that an early-documented DNR order is essential. However, it needs to be considered that promoting discussions of time-limited trials might be the solution to helping ICU terminal patients withdraw from non-beneficial life-sustaining treatments.

Quetiapine and other antipsychotics combined with opioids in legal autopsy cases: A random finding or cause of fatal outcome?

Opioid poisoning is a frequent cause of death in drug addicts and occurs with opioid treatment. Quetiapine is often found in forensic autopsies and may increase the risk of fatal opioid poisoning by enhancing sedation, respiratory depression, hypotension and QT prolongation. We systematically searched for studies of acute toxicity of quetiapine or other antipsychotics combined with morphine or methadone. Case reports describing toxicity of quetiapine combined with morphine or methadone were also included. We retrieved one human study that observed pharmacokinetic interaction between quetiapine and methadone, and 16 other human studies. Fourteen investigated the combination of droperidol and morphine in treatment doses, and some indicated an additive sedative effect. Five animal studies with acepromazine in combination with morphine or methadone were located and indicated an additive effect on sedation and hypotension. Six forensic case reports in which death could have been caused solely by quetiapine, the opioid, or other drugs were found. Thus, acute toxicity of quetiapine combined with morphine or methadone has not been studied. Because of quetiapine's effects on alpha-adrenoceptors, muscarinic and histamine receptors, human ether-a-go-go-channels and methadone kinetics, we suggest further research to clarify if the indicated additive effects of opioids and droperidol or acepromazine are also true for quetiapine.

The effect of melatonin on reduction in the need for sedative agents and duration of mechanical ventilation in traumatic intracranial hemorrhage patients: a randomized controlled trial

Purpose

This study aimed to determine the effect of exogenous melatonin on the number of sedative drugs and the duration of mechanical ventilation in traumatic intracranial hemorrhage patients in ICU.

Methods

This double-blind randomized clinical trial study was conducted in the ICU wards of Golestan Hospital, Ahvaz, Iran, from September 2017 to March 2018. In this study, 52 patients with intracerebral hemorrhage were selected by convenient sampling (26 patients in each group) and were randomly assigned to two groups of melatonin and control. Sedation and pain management package was applied to both groups. Outcomes: Amount of the sedative and opioid drug; mechanical ventilation time; ICU staying time; Glasgow Coma Score; hemodynamic parameters.

Results

There was no significant difference between them in terms of demographic characteristics. Cumulative doses of morphine and mechanical ventilation time were significant in two groups. (P < 0.05) The mean length of ICU staying was not significant. Glasgow Coma Score on the 6th day was significant in two groups (P < 0.05). Diastolic blood pressure was significant between groups (P < 0.001).

Conclusion

This study presented that morphine consumption and mechanical ventilation time were significantly lower in the melatonin group than in the control. Also, rise in GCS in the melatonin group was faster in the melatonin group than in the control. The use of melatonin can be recommended for patients with ICH in the ICU for better outcomes.

Circulatory effects of dexmedetomidine in early sepsis: a randomised controlled experimental study

We designed this experimental study with a view to evaluate the effects of dexmedetomidine (DEX) on cardiac performance and systemic and peripheral hemodynamics in healthy and early-stage endotoxemia swine models. Our study hypothesis was that DEX can ensure hemodynamic stability during the course of endotoxemia. Thirty-two male pigs (25-27 kg) were assigned into four groups: (1) no intervention (group A), (2) DEX 0.8 μg/kg was administered in non-septic animals (group B), (3) sepsis induced by intravenous Escherichia coli endotoxin (group C) and (4) DEX 0.8 μg/kg was administered in septic animals (group D). Hemodynamic parameters such as heart rate, mean blood pressure, central venous pressure, pulmonary artery pressures, pulmonary artery occlusion pressure, pulmonary vascular resistance and cardiac output were continuously recorded. Central venous oxygen saturation was also measured in order to obtain a complete evaluation of cardiovascular response to sepsis. Heart rate was decreased, whilst mean arterial pressure decrease was alleviated after DEX administration in septic animals. In addition, central venous pressure was stable in animals with sepsis after DEX infusion. Sepsis dramatically elevated pulmonary function indicators but DEX succeeded in ameliorating this effect. The important decrease measured in central venous oxygen saturation in both sepsis groups reflected the decreased perfusion of tissues that takes place at the end of early sepsis. Our findings support the hypothesis that DEX has beneficial effects on heart rate and pulmonary artery pressure, whilst reduction in systemic blood pressure occurs at acceptable levels.

Sole use of dexmedetomidine for sedation and analgesia in patients undergoing endovenous thermal ablation for incompetent saphenous veins

Background

Dexmedetomidine have both sedative and analgesic properties without respiratory-depressant effect. This study aims to evaluate the safety and effectiveness of sedation and analgesia using dexmedetomidine for the endovenous treatment of varicose veins.

Methods

This study included 88 patients (male =38, female =50; mean age, 48.7 years) who underwent endovenous laser or radiofrequency ablation of saphenous vein. At the beginning of sedation, dexmedetomidine was administered intravenously to all patients with a loading dose of 1 µg/kg over 15 minutes, which was followed by a maintenance dose of 0.2 µg/kg/h throughout the procedure. Peripheral oxygen saturation, systolic and diastolic blood pressure, heart rate and respiratory rate, and the induction and recovery time were assessed. The degree of pain was recorded by using a 10-point visual analog scale after the procedure. Adverse events associated with sedation/analgesia were also recorded.

Results

Eighty-five patients responded adequately to sole use of dexmedetomidine. The mean induction time was 17.5 minutes. The mean visual analog scale pain score during the procedure was 2.3±2.0. Maximum pain scores of 4 (discomforting) or less were recorded in 69 (78.4%) patients. Six (6.8%) patients complained of pain scores in excess of 7. Systolic and diastolic blood pressure and heart rate drop between 0 and 15 minutes were 18.2/9.3 mmHg and 13.5 beat/min, respectively. Three (3.5%) patients required cessation of infusion due to significant decrease in of blood pressure or heart rate. There was no hypoxic or resuscitation event during the procedures.

Conclusions

Dexmedetomidine can provide excellent sedative and analgesic effect during endovenous thermal ablation.

Sedation and analgesia in children with cerebral palsy: a narrative review

BACKGROUND

Patients with cognitive impairment due to cerebral palsy experience pain more often than healthy peers and frequently require diagnostic and therapeutic painful procedures. Analgesia and procedural sedation outside the operating room are often required, but they may not adequately be provided because of the inability to accurately recognize and classify the state of pain and for the perceived higher risk of complications.

DATA SOURCES

We reviewed the available literature to highlight the specific risk factors and area of criticism, that should be further improved. We searched the Cochrane Library, Medline, Pubmed from 1987 to September 2018 using key words such as 'cerebral palsy and children and pain' or 'sedation and cerebral palsy and children'.

RESULTS

While different pain scales are useful in recognizing pain expressions, anxiety scales are not available. Moreover, studies on non-pharmacological techniques do not always have comparable results. Several risk factors, from anatomic abnormalities to liver and kidney functioning, should be kept in mind before proceeding with sedation.

CONCLUSIONS

Large trials are needed to assess the impact of non-pharmacological techniques and to evaluate which pain control strategy (pharmacological and non-pharmacological) should be used in different settings.

Monitored Anesthesia Care for Cardiovascular Interventions

The interventional cardiology is growing and evolving. Many complex procedures are now performed outside the operating room to manage cardiovascular pathologies which had been traditionally treated with cardiac surgery. Appropriate sedation strategy is crucial for improved patient comfort and successful procedure while ensuring safety. Sedation for cardiovascular intervention is frequently challenging, especially in critically-ill, high-risk patients. This review addresses pre-procedure evaluation and preparation of patients, proper monitoring, commonly used sedatives and analgesics, and considerations for specific procedures. Appropriate depth of sedation and analgesia should be balanced with patient, procedural and institutional factors. Understanding of the pharmacology of sedatives/analgesics, vigilant monitoring, ability and proper preparation for management of potential complications may improve outcomes in patients undergoing sedation for cardiovascular procedures.

Serious Cardiovascular Adverse Events Reported with Intravenous Sedatives: A Retrospective Analysis of the MedWatch Adverse Event Reporting System

BACKGROUND

Serious cardiovascular adverse events (SCAEs) associated with intravenous sedatives remain poorly characterized.

OBJECTIVE

The objective of this study was to compare SCAE incidence, types, and mortality between intravenous benzodiazepines (i.e., diazepam, lorazepam, and midazolam), dexmedetomidine, and propofol in the USA over 8 years regardless of the clinical setting where it was administered.

METHODS

The Food and Drug Administration's MedWatch Adverse Event Reporting System was searched between 2004 and 2011 using the Evidex^® platform from Advera Health Analytics, Inc. to identify all reports that included one or more of ten different SCAEs (package insert incidence ≥ 1%) and where an intravenous benzodiazepine, dexmedetomidine, or propofol was the primary suspected drug.

RESULTS

Among the 2326 Food and Drug Administration's MedWatch Adverse Event Reporting System cases reported, 394 (16.9%) were related to a SCAE. The presence of a SCAE (vs. a non-SCAE) is associated with higher mortality (34 vs. 8%, p < 0.001). The percentage of cases with one or more SCAE, the case mortality rate (%), and the incidence of each SCAE (per 10⁶ days of sedative exposure), respectively, were benzodiazepines (14, 26, 13) [diazepam (13, 23, 31); lorazepam (15, 43, 14); midazolam (14, 20, 11)]; dexmedetomidine (40, 15, 13); and propofol (17, 39, 7). Propofol (vs. either a benzodiazepine or dexmedetomidine) was associated with more total SCAEs (268 vs. 126, p < 0.001) but a lower incidence (per 10⁶ days of sedative exposure) of SCAE (7 vs. 13, p = 0.0001) and cardiac arrest [6.3 (benzodiazepine) vs. 6.7 (dexmedetomidine) vs. 1.4 (propofol), p < 0.0001].

CONCLUSIONS

Serious cardiac adverse events account for nearly one-fifth of intravenous sedative Food and Drug Administration's MedWatch Adverse Event Reporting System reports. These SCAEs appear to be associated with greater mortality than non-cardiac serious adverse events. Serious cardiac events may be more prevalent with either benzodiazepines or dexmedetomidine than propofol.

Efficacy of different analgesic or sedative drug therapies in pediatric patients with congenital heart disease undergoing surgery: a network meta-analysis

BACKGROUND

Surgery is an effective therapy for congenital heart disease (CHD) and the management after surgery poses challenges for the clinical workers. We performed this network meta-analysis to enhance the corresponding evidence with respect to the relative efficacy of different drug treatments applied after the CHD surgery.

METHODS

Embase and PubMed were systematically retrieved to identify all published controlled trials investigating the effectiveness of drugs for patients up to 25 August, 2018. Mean differences (MD), odds ratios and their 95% credible intervals (CrIs) were used to evaluate multi-aspect comparisons. Surface under cumulative ranking curve (SUCRA) was used to analyze the relative ranking of different treatments in each endpoint.

RESULTS

Compared to saline, all the drugs achieved better preference under the efficacy endpoints except fentanyl in JET. As for ventilator time, all drugs were more effective than saline while only the difference of dexmedetomidine was statistically obvious (MD = 6.92, 95% CrIs 1.77-12.54). Under the endpoint of ICU time, dexmedetomidine was superior to saline as well (MD = 1.26, 95% CrIs 0.11-2.45). When all the endpoints were taken into consideration and with the help of ranking probabilities and SUCRA values, fentanyl combined with dexmedetomidine was one of the recommended drugs due to its shorter time on ventilator and stay in hospital as well as lower mortality.

CONCLUSIONS

Overall, based on the comprehensive consideration of all the endpoints, fentanyl combined with dexmedetomidine was considered to be the best-recommended clinical interventions among all the methods.

Analgesic and sedative agents used in the intensive care unit: A review

Pain is a common experience for most patients in the intensive care unit (ICU). In the current study, the advantages and disadvantages of analgesic and sedative drugs used in the ICU are reviewed. An ideal sedative and analgesic agent should have features such as rapid onset of action, rapid recovery after discontinuation, predictability, minimal accumulation of the agent and metabolites in the body, and lack of toxicity. None of the sedative and analgesic agents have all of these desired characteristics; nevertheless, clinicians must be familiar with these classes of drugs to optimize pharmacotherapy and ensure as few side-effects as possible for ICU patients.

Clinical evaluation of combination of dexmedetomidine and midazolam vs. dexmedetomidine alone for sedation during spinal anesthesia

Background

Dexmedetomidine is a useful sedative agent for spinal anesthesia. However, it has been reported to decreases heart rate in a dose-dependent manner. In the present study, we compared the bolus dose of midazolam and bolus loaded dexmedetomidine over 10 min to determine additional sedation methods.

Methods

A total of 100 patients who were classified as American Society of Anesthesiologists physical status I-II undergoing spinal anesthesia were randomly divided into two groups. In the combination of midazolam and dexmedetomidine group (group MD), 10 min after bolus loading of 0.05 mg/kg midazolam, 0.5 μg/kg/h dexmedetomidine was infused. In the dexmedetomidine group (group D), 1 μg/kg bolus dose of dexmedetomidine was infused over 10 min, and then 0.5 μg/kg/h dexmedetomidine was infused continuously.

Results

At 10 min, the sedation depth of the two groups was approximately the same. In both groups, the bispectral index (BIS) was within the optimal range of 55-80 and the Ramsay Sedation Scale score was within the optimal range of 3-5. Both patient and surgeon satisfaction with sedation did not differ between groups. At 10 min, heart rate (beats/min) was significantly lower (P < .01) in group D and mean blood pressure (mm Hg) was significantly lower (P < .01) in group MD. The prevalence of bradycardia (P = .714), hypotension (P = .089), and hypoxia (P = .495) did not differ statistically between the two groups.

Conclusions

Midazolam bolus and dexmedetomidine continuous infusion may be a useful additional sedation method for patients who have severe bradycardia.

Recommendations of the Working Groups from the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) for the management of adult critically ill patients

The standardization of the Intensive Care Medicine may improve the management of the adult critically ill patient. However, these strategies have not been widely applied in the Intensive Care Units (ICUs). The aim is to elaborate the recommendations for the standardization of the treatment of critical patients. A panel of experts from the thirteen working groups (WG) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) was selected and nominated by virtue of clinical expertise and/or scientific experience to carry out the recommendations. Available scientific literature in the management of adult critically ill patients from 2002 to 2016 was extracted. The clinical evidence was discussed and summarised by the experts in the course of a consensus finding of every WG and finally approved by the WGs after an extensive internal review process that was carried out between December 2015 and December 2016. A total of 65 recommendations were developed, of which 5 corresponded to each of the 13 WGs. These recommendations are based on the opinion of experts and scientific knowledge, and are intended as a guide for the intensivists in the management of critical patients.

Dexmedetomidine Effect on Emergence Agitation and Delirium in Children Undergoing Laparoscopic Hernia Repair: a Preliminary Study

Objective To evaluate the safety and efficacy of dexmedetomidine (Dex) to prevent emergence agitation (EA) and delirium (ED) in children undergoing laparoscopic hernia repair under general anesthesia. Methods 100 children (1-5 years, 10-25 kg) were randomized into four groups: controls (saline) and intravenous Dex at 0.25, 0.5, and 1.0 µg/kg (D1, D2, D3, respectively). Dex/saline infusion was started following anesthesia. EA and ED were evaluated on a 5-point scale. Results For the C, D1, D2, and D3 groups, respectively, EA frequencies were 45.8%, 30.4%, 12%, 4%; ED frequencies 29.1%, 13%, 4%, 4%; CHIPPS scores 8, 6, 3, 3; sevoflurane doses from 13.2 ± 3.4 (controls) to 9.4 ± 3.5 ml (D3). Intervals until mask removal/spontaneous eye opening were significantly longer for D2 and D3 than controls. PACU stay was longer for D3. Conclusions There was significantly less postoperative EA and pain, with less sevoflurane required, using Dex.

Editor's Choice-The cardiovascular implications of sedatives in the cardiac intensive care unit

Patients admitted to the cardiac intensive care unit frequently develop multi-organ system dysfunction associated with their cardiac disease. In many cases, invasive mechanical ventilation is required, which often necessitates sedation for patient-ventilator synchrony, reduction of work of breathing, and patient comfort. In this paper, we describe the use of common sedatives available in the endotracheally intubated critically ill patient and emphasize the clinical and cardiovascular effects. We review γ-aminobutyric acid agonists such as etomidate, benzodiazepines, and propofol, the centrally acting α₂-agonist dexmedetomidine, and the N-methyl-D-aspartate receptor antagonist ketamine. Additionally, we outline the use of opioids and their role in potentiating other sedatives. We note that some sedatives are associated with increased delirium rates, and emphasize that judicious strategies minimizing sedative use are associated with decreases in morbidity and mortality. We also discuss standardized sedation assessment scales and highlight the importance of sedation weaning. Finally, we offer recommendations for sedation use during therapeutic hypothermia, and discuss the use of adjuvant neuromuscular blocking agents.

The Benefit of Benzodiazepine Reduction: Improving Sedation in Surgical Intensive Care

Aims:

Sedation, as it is often required in critical care, is associated with immobilization, prolonged ventilation, and increased morbidity. Most sedation protocols are based on benzodiazepines. The presented study analyzes the benefit of benzodiazepine-free sedation.

Methods:

In 2008, 134 patients were treated according to a protocol using benzodiazepine and propofol (Group 1). In 2009, we introduced a new sedation strategy based on sufentanil, nonsteroidal anti-inflammatory drugs, neuroleptics, and antidepressants, which was applied in 140 consecutive patients (Group 2). Depth of sedation, duration of mechanical ventilation, duration of Intensive Care Unit, and hospital stay were analyzed.

Results:

Group 1 had both a longer duration of deep sedation (18.7 ± 2.5 days vs. 12.6 ± 1.85 days, P = 0.031) and a longer duration of controlled ventilation (311, 35 ± 32.69 vs. 143, 96 ± 20.76 h, P < 0.0001) than Group 2. Ventilator days were more frequent in Group 1 (653, 66 ± 98.37 h vs. 478, 89 ± 68.92 h, P = 0.128).

Conclusions:

The benzodiazepine-free sedation protocol has been shown to significantly reduce depth of sedation and controlled ventilation. Additional evidence is needed to ascertain reduction of ventilator days which would not only be of benefit for the patient but also for the hospital Management.

Melatonin Supplementation May Improve the Outcome of Patients with Hemorrhagic Stroke in the Intensive Care Unit

Objective:

Although mechanical ventilation is frequently a life-saving therapy, its use can result in unwanted side effects. It has been well documented that the choice of sedating agent may influence the duration of mechanical ventilation. Melatonin is a sedative and analgesic agent without any respiratory depressant effect which makes it an attractive adjuvant for sedation in the intubated patients. The aim of this study is to evaluate the effect of melatonin on the duration of mechanical ventilation in patients with hemorrhagic stroke.

Methods:

Forty adult intubated patients with hemorrhagic stroke, who were admitted to the Intensive Care Unit (ICU) within 24 h of onset, were enrolled in this randomized double-blind study. Subjects in the melatonin group received 30 mg of melatonin every night throughout the nasogastric tube. Length of ICU stay, mortality, and duration of mechanical ventilation were recorded for all patients.

Findings:

The duration of mechanical ventilation and length of ICU stay were shorter in patients who received melatonin in comparison with the control group, and this difference was statistically significant for the length of ICU stay and marginally significant for the duration of mechanical ventilation. Although not statistically significant, the mortality rate of the control group was 30%, almost double that of the study group (15%).

Conclusion:

Melatonin possesses hypnotic, analgesic, anti-inflammatory, and anti-oxidative properties that distinguish it as an attractive adjuvant in patients under mechanical ventilation. In conclusion, the administration of melatonin may facilitate the weaning process through decreasing the consumption of sedatives with respiratory depressant properties as well as preventing ventilator-associated lung injury.

Comparison of block characteristics of spinal anesthesia following intravenous dexmedetomidine and clonidine

Background and Aims:

Different routes of administration of α2 adrenergic receptor agonists have been found to prolong the duration of spinal block.

Material and Methods:

One hundred and twenty patients, aged 18-60 years, of ASA physical status I or II posted for elective fixation of fractures of lower limb under spinal anesthesia were selected. Spinal anesthesia was administered with 2.5 ml of 0.5% bupivacaine mixed with 10 μg fentanyl. The patients were randomized to receive intravenous (IV) dexmedetomidine 1 μg/kg/h for 15 min followed by infusion of 0.3 μg/kg/h (Group I), IV Clonidine 2 μg/kg/h for 15 min followed by infusion of 0.5 μg kg/h (Group II) or 15 ml of normal saline for 15 min followed by infusion at 50 ml/h (Group III). Motor and sensory blockade was evaluated using bromage score and pin prick method respectively.

Results:

The median block height in all groups was T8. Time to achieve block height was fastest in Group I. Time of regression of sensory block to T12/L1 dermatome was 230.75 ± 21.25 min (Group I), 196.25 ± 20.27 min (Group II) and 163.88 ± 15.46 min (Group III) respectively. Regression of motor blocks to Bromage 0/1 was 274 ± 21.25 min, 234.25 ± 32.41 min and 130.12 ± 20.70 min in Groups I, II and III respectively. Bradycardia was seen in one patient in Group I and two patients in Group II. Hypotension was seen in five patients in Group I and seven patients in Group II. First requirement for postoperative analgesic was after 353.13 ± 39.60 min, 314.38 ± 30.64 min and 193.25 ± 17.74 min in Groups I, II and III respectively.

Conclusion:

IV α2 agonists are useful adjuvants for prolongation of the duration of spinal block. IV dexmedetomidine produces a better clinical profile compared to clonidine.

Valproate for agitation in critically ill patients: A retrospective study

PURPOSE

The purpose was to describe the use of valproate therapy for agitation in critically ill patients, examine its safety, and describe its relationship with agitation and delirium.

MATERIALS AND METHODS

This retrospective cohort study evaluated critically ill adults treated with valproate for agitation from December 2012 through February 2015. Information on valproate prescribing practices and safety was collected. Incidence of agitation, delirium, and concomitant psychoactive medication use was compared between valproate day 1 and valproate day 3. Concomitant psychoactive medication use was analyzed using mixed models.

RESULTS

Fifty-three patients were evaluated. The median day of valproate therapy initiation was ICU day 7, and it was continued for a median of 7 days. The median maintenance dose was 1500 mg/d (23 mg/kg/d). The incidence of agitation (96% vs 61%, P < .0001) and delirium (68% vs 49%, P = .012) significantly decreased by valproate day 3. Treatment with opioids (77% vs 65%, P = .02) and dexmedetomidine (47% vs 24%, P = .004) also decreased. In mixed models analyses, valproate therapy was associated with reduced fentanyl equivalents (-185 μg/d, P = .0003) and lorazepam equivalents (-2.1 mg/d, P = .0004). Hyperammonemia (19%) and thrombocytopenia (13%) were the most commonly observed adverse effects.

CONCLUSIONS

Valproate therapy was associated with a reduction in agitation, delirium, and concomitant psychoactive medication use within 48 hours of initiation.

Dexmedetomidine combined with midazolam vs. dexmedetomidine alone for sedation during spinal anesthesia

Background

Dexmedetomidine is a useful sedative agent for spinal anesthesia. However, it has been reported that dexmedetomidine decreases heart rate in a dose-dependent manner. In the current study, we compared the administration of a bolus dose of midazolam and bolus loading of dexmedetomidine over 10 min with the goal of identifying an additional method of sedation.

Methods

Ninety patients classified as American Society of Anesthesiologists physical status I–II who were undergoing spinal anesthesia were divided into two groups. In the midazolam and dexmedetomidine combined group (group MD), 10 min after bolus loading of 0.05 mg/kg midazolam, 0.5 µg/kg/h dexmedetomidine was continuously infused. In the dexmedetomidine group (group D), 1 µg/kg dexmedetomidine was infused over 10 min, and then 0.5 µg/kg/h dexmedetomidine was continuously infused.

Results

At 10 min, the sedation depth of the two groups was almost equal. In both groups, the bispectral index was within the optimal score range of 55–80 and the Ramsay Sedation Scale score was within the optimal range of 3–5. Satisfaction with sedation for both patient and surgeon did not differ between the two groups. At 10 min, heart rate was significantly lower (P < 0.010) in group D and mean blood pressure was significantly lower (P < 0.010) in group MD. The prevalence of bradycardia, hypotension, and hypoxia did not differ statistically between the two groups (P = 0.714, P = 0.089, P = 0.495, respectively).

Conclusions

Midazolam bolus and dexmedetomidine continuous infusion (the regimen of group MD) may be an additional sedation method for patients who have severe bradycardia.

A retrospective comparison of dexmedetomidine versus midazolam for pediatric patients with congenital heart disease requiring postoperative sedation

We hypothesized that postoperative sedation with dexmedetomidine/fentanyl would be effective in infants and neonates with congenital heart disease and pulmonary arterial hypertension (PAH). Children who were <36 months of age, had congenital heart disease with PAH, and had been treated at our hospital between October 2011 and April 2013 (n = 187) were included in this retrospective study. Either dexmedetomidine/fentanyl (Group Dex) or midazolam/fentanyl (Group Mid) was used for postoperative sedation. The main outcome variables included delirium scores, supplemental sedative/analgesic drugs, ventilator use, and sedation time. Baseline demographics and clinical characteristics were similar between the two groups. The Pediatric Anesthesia Emergence Delirium scale (5.2 ± 5.3 vs. 7.1 ± 5.2 in the Dex and Mid groups, respectively; P = 0.016) and the incidence of delirium (18.2 vs. 32.0 % in the Dex and Mid groups, respectively; P = 0.039) were significantly lower in the Dex group than in the Mid group. Total sufentanil, midazolam, and propofol doses given during the operation did not differ between the two groups. Group Dex patients required significantly lower doses of adjunctive sedative/analgesic drugs than group Mid patients in the cardiac intensive care unit (CICU; midazolam, P = 0.007; morphine, P < 0.001). In conclusion, we found no differences between dexmedetomidine/fentanyl and midazolam/fentanyl in terms of the duration of sedation, mechanical ventilator use, and CICU stay in children with PAH. However, patients in the Dex group required a lower additional sedative/analgesic drugs and had a lower incidence of delirium than patients in the Mid group.

The pharmacologic management of delirium in children and adolescents

Delirium is a serious and common problem in severely medically ill patients of all ages. It has been less addressed in children and adolescents. Treatment of delirium is predicated on addressing its underlying cause. The management of its symptoms depends on the off-label use of antipsychotics, while avoiding agents that precipitate or worsen delirium. Olanzapine, quetiapine, and risperidone are presently considered first-line drugs, usually replacing haloperidol. Other agents have shown promise, including melatonin to address the sleep disturbance characteristic of delirium, and dexmedetomidine, an α2-agonist, that may facilitate lower doses of benzodiazepines and opioids that may worsen delirium.

Monitored anesthesia care with dexmedetomidine in transfemoral percutaneous trans-catheter aortic valve implantation: two cases report

Percutaneous trans-catheter aortic valve implantation (TAVI) is recommended for inoperable patients with severe aortic stenosis at high risk for conventional aortic valve replacement. Originally, TAVI was mostly performed under general anesthesia. Here we describe two cases of transfemoral TAVI performed under monitored anesthesia care (MAC) with dexmedetomidine. Dexmedetomidine provides sedation, analgesia with minimal respiratory depression. Although MAC during transfemoral TAVI has limitations, such as unexpected patient movement and difficulty in intra-procedural use of transesophageal echocardiography, MAC with dexmedetomidine is feasible with close monitoring, fluoroscopic guidance and the participation of experienced anesthesiologists.

Is propofol a friend or a foe of the pediatric intensivist? Description of propofol use in a PICU*

OBJECTIVE

The primary objective is to describe the practice patterns of nonprocedural propofol use in a single-center referral PICU. The secondary objective is to describe the rate of concordance of propofol use with the PICU local practice of a maximum mean rate of 4 mg/kg/hr and a maximum duration of 24 hours and to assess for signs and symptoms of propofol infusion syndrome.

DESIGN

Retrospective descriptive cohort study.

SETTING

PICU of a tertiary care teaching hospital and referral hospital for the Western Canada.

PATIENTS

Children 1 month to 17 years old who received a nonprocedural propofol infusion between January 1, 2009, and December 31, 2009.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Two hundred twenty-three infusions (representing 210 unique patients) were included in the study. The median average infusion rate (interquartile range) including boluses was 2.7 mg/kg/hr (1.9-3.6 mg/kg/hr), and the mean infusion duration (SD) was 10.3 hours (6.7 hr). Eighty-seven percent and 98% of infusions were concordant with PICU intensivists self-reported practice maximum rate and duration, respectively. No cases of propofol-related infusion syndrome or deaths associated with propofol infusions were identified.

CONCLUSIONS

The use of propofol infusions was in concordance with PICU local practice, and propofol infusion syndrome did not developed in patients. In agreement with previous recommendations, propofol infusions in the PICU appear to be safe when limiting doses to 4 mg/kg/hr and for less than 24 hours; however, appropriate monitoring of adverse effects is still warranted due to absence of robust evidence.

Role of dexmedetomidine in adults in the intensive care unit: an update

PURPOSE

The role of dexmedetomidine for the management of pain, agitation, and delirium in adult patients in the intensive care unit (ICU) is reviewed and updated.

SUMMARY

Searches of MEDLINE (July 2006-March 2012) and an extensive manual review of journals were performed. Relevant literature with a focus on data published since our last review in 2007 was evaluated for topic relevance and clinical applicability. Optimal management of pain, agitation, and delirium in ICUs requires a systematic and multimodal approach aimed at providing comfort while maximizing outcomes. Dexmedetomidine is among multiple agents, including opioids, propofol, benzodiazepines, and antipsychotics, used to facilitate and increase patients' tolerability of mechanical ventilation. This article reviews the newest evidence available for dexmedetomidine use for sedation and analgesia in medical-surgical ICUs. Adverse effects associated with dexmedetomidine were similar among the studies examined herein. The most common adverse effects with dexmedetomidine were bradycardia and hypotension, in some cases severe enough to warrant the use of vasoactive support. Due to the adverse events associated with rapid dosage adjustment and bolus therapy, dexmedetomidine may not be the best agent for treating acute agitation.

CONCLUSION

In medical-surgical ICUs, dexmedetomidine may be a viable non-benzodiazepine option for patients with a need for light sedation. In cardiac surgery patients, dexmedetomidine appears to offer no advantage over propofol as the initial sedative. The role of dexmedetomidine in unique patient populations such as neurosurgical, trauma, and obstetrics is yet to be established.

Safety and efficacy of dexmedetomidine for long-term sedation in critically ill patients

Purpose

We evaluated the safety and efficacy of long-term administration of dexmedetomidine in patients in the intensive care unit (ICU). Primary endpoint was the incidence of hypotension, hypertension, and bradycardia. Secondary endpoints were withdrawal symptoms, rebound effects, the duration of sedation with Richmond Agitation-Sedation Scale (RASS) ≤ 0 relative to the total infusion time of dexmedetomidine, and the dose of additional sedatives or analgesics.

Methods

Dexmedetomidine 0.2–0.7 μg/kg/h was continuously infused for maintaining RASS ≤ 0 in patients requiring sedation in the ICU. Safety and efficacy of short-term (≤24 h) and long-term (>24 h) dexmedetomidine administration were compared.

Results

Seventy-five surgical and medical ICU patients were administered dexmedetomidine. The incidence of hypotension, hypertension, and bradycardia that occurred after 24 h (long-term) was not significantly different from that occurring within 24 h (short-term) (P = 0.546, 0.513, and 0.486, respectively). Regarding withdrawal symptoms, one event each of hypertension and headache occurred after the end of infusion, but both were mild in severity. Increases of mean arterial blood pressure and heart rate after terminating the infusion of dexmedetomidine were not associated with the increasing duration of its infusion. The ratio of duration with RASS ≤ 0 was ≥ 85 % until day 20, except day 9 (70 %) and day 10 (75 %). There was no increase in the dose of additional sedatives or analgesics after the first 24-h treatment period.

Conclusions

Long-term safety of dexmedetomidine compared to its use for 24 h was confirmed. Dexmedetomidine was useful to maintain an adequate sedation level (RASS ≤ 0) during long-term infusion.

Use of bispectral index to monitor the depth of sedation in mechanically ventilated patients in the prehospital setting

BACKGROUND

Sedative drug administration is a challenging aspect of the management of mechanically ventilated patients in the out-of-hospital critical care medicine. We hypothesised that the bispectral index of the EEG (BIS) could be a helpful tool in evaluating the depth of sedation in this difficult environment. The main objective of the present study was to assess the agreement of BIS with the clinical scales in the out-of-hospital setting.

METHODS

This prospective study included mechanically ventilated patients. BIS values were blindly recorded continuously. A Ramsay score was performed every 5 min. The main judgement criterion was the correlation between BIS values and the Ramsay score.

RESULTS

72 patients were included, mostly presenting with toxic coma (36%) or neurological coma (21%). The median (IQR) BIS value was 85 (84-86) when the Ramsay score was 3, 80 (76-84) when the Ramsay score was 4, 61 (55-80) when the Ramsay score was 5 and 45 (38-60) when the Ramsay score was 6. According to Receiver operating characteristic (ROC) curves, BIS was categorised into three classes (BIS<54 corresponding to Ramsay score 6, 54≤BIS<72 for Ramsay score 5 and BIS≥73 for Ramsay score ≤4). Based on these categories, the proportion of appropriate BIS values was 67% (217/323). The concordance correlation coefficient for repeated measurements was 0.54 (0.43-0.64). The agreement between BIS and the Ramsay score is moderate.

CONCLUSIONS

Prehospital measured BIS values appear poorly correlated with clinical assessment of the depth of sedation. For this reason, the use of BIS to guide prehospital sedation cannot be recommended.

Enteral vs. intravenous ICU sedation management: study protocol for a randomized controlled trial

Background

A relevant innovation about sedation of long-term Intensive Care Unit (ICU) patients is the ‘conscious target’: patients should be awake even during the critical phases of illness. Enteral sedative administration is nowadays unusual, even though the gastrointestinal tract works soon after ICU admission. The enteral approach cannot produce deep sedation; however, it is as adequate as the intravenous one, if the target is to keep patients awake and adapted to the environment, and has fewer side effects and lower costs.

Methods/Design

A randomized, controlled, multicenter, single-blind trial comparing enteral and intravenous sedative treatments has been done in 12 Italian ICUs. The main objective was to achieve and maintain the desired sedation level: observed RASS = target RASS ± 1. Three hundred high-risk patients were planned to be randomly assigned to receive either intravenous propofol/midazolam or enteral melatonin/hydroxyzine/lorazepam. Group assignment occurred through online minimization process, in order to balance variables potentially influencing the outcomes (age, sex, SAPS II, type of admission, kidney failure, chronic obstructive pulmonary disease, sepsis) between groups. Once per shift, the staff recorded neurological monitoring using validated tools. Three flowcharts for pain, sedation, and delirium have been proposed; they have been designed to treat potentially correctable factors first, and, only once excluded, to administer neuroactive drugs. The study lasted from January 24 to December 31, 2012. A total of 348 patients have been randomized, through a centralized website, using a specific software expressly designed for this study. The created network of ICUs included a mix of both university and non-university hospitals, with different experience in managing enteral sedation. A dedicated free-access website was also created, in both Italian and English, for continuous education of ICU staff through CME courses.

Discussion

This ‘educational research’ project aims both to compare two sedative strategies and to highlight the need for a profound cultural change, improving outcomes by keeping critically-ill patients awake.

Trial registration number

Clinicaltrials.gov #NCT01360346

Sedation for critically ill or injured adults in the intensive care unit: a shifting paradigm

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.

The 90% effective dose of a sufentanil bolus for the management of painful positioning in intubated patients in the ICU

CONTEXT

Pain and discomfort arising from the routine care of intubated patients in the ICU is managed by continuous infusion of narcotic and sedative drugs. There is benefit in keeping infusion rates low because lightening sedation improves clinical outcome, but this risks breakthrough pain. Management of this discomfort by bolus administration could permit lower background infusion rates, but the lowest effective bolus dose of sufentanil to achieve this is unknown.

OBJECTIVE

The aim of this study was to determine the effective analgesic dose in 90% of intubated patients (ED90) in the ICU given bolus sufentanil. Pain was assessed using a Behavioural Pain Scale (BPS) requiring a score of 3-4 during moving to the lateral decubitus position.

DESIGN

Prospective, dose response study.

SETTING

A 16-bed multidisciplinary ICU in a French university hospital. Study period was from January to June 2010.

PATIENTS

Intubated and ventilated patients were eligible for the study once they had reached a BPS of 3 or 4 and Ramsay score of 3-5 within 48 h of admission to the ICU.

INTERVENTION

The analgesic efficacy of a sufentanil bolus was measured during successive lateral decubitus positioning over a 72-h study period, using the BPS scale. The dose was increased with each subsequent turn to lateral decubitus until a BPS score of 3-4 was obtained (dose escalation, starting at zero).

MAIN OUTCOME MEASURES

BPS, Ramsay score, heart rate and mean arterial pressure were collected before and during each procedure.

RESULTS

A total of 25 patients were enrolled over 6 months. The ED90 bolus for sufentanil was 0.15 μg kg, but 40% of the patients subsequently demonstrated increased BPS with this dose.

CONCLUSION

The effective dose in 90% was 0.15 μg kg during the first 5 days of sedation. There were no adverse effects. A pre-emptive sufentanil bolus can be used to treat anticipated pain in the ICU. Regular and frequent assessments of acute pain and sedation are essential for adjusting the dose, on a case-by-case basis. This strategy may help clinicians to keep background infusions of sedatives and narcotics as low as possible and may improve clinical outcome.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01356732.

Perceived versus actual sedation practices in adult intensive care unit patients receiving mechanical ventilation

BACKGROUND

With drug shortages, newer sedative medications, and updates in research, management of sedation and delirium in patients receiving mechanical ventilation continues to evolve.

OBJECTIVE

To compare perceived and actual sedation practices for adults receiving mechanical ventilation in intensive care units (ICUs).

METHODS

This was a multicenter, 2-part study conducted in adult ICUs in US hospitals. It included a sedation practice survey completed by ICU pharmacists and an observational study evaluating actual sedation practices over a 24-hour period.

RESULTS

Surveys were completed for 85 ICUs; observational data for 496 patients were collected. Preferred sedatives from the survey data were propofol (short-term); propofol, midazolam, or lorazepam (intermediate); and lorazepam (long-term). Propofol was the most commonly used agent overall during the observational period (primarily for short-term and intermediate-length sedation); midazolam was the most commonly used for long-term sedation. Fentanyl was the preferred analgesic, and haloperidol and quetiapine were the preferred antipsychotics. Sedation treatment algorithms were used in only 50% of observed ICUs. Use of daily interruption of sedation was perceived to be 66% but was only observed in 36% of patients. Monitoring for delirium was reported among 25% of those surveyed but was observed in only 10% of patients. Targeted sedation goals were most frequently achieved when a treatment algorithm was used or when an opiate infusion was the single agent used for sedative management.

CONCLUSIONS

These data suggest differences in perceived and actual sedation practice in the US, as well as underutilization of evidence-based interventions. Most notable was the limited use of sedation treatment algorithms, daily interruption of sedation, and monitoring for delirium. Individual sedation and delirium protocols should be evaluated and updated based on evidence-based recommendations.

Evaluation of dexmedetomidine: safety and clinical outcomes in critically ill trauma patients

BACKGROUND

To compare safety and clinical outcomes of prolonged infusions with standard-dose (≤0.7 μg/kg/h) dexmedetomidine (SDD) or high-dose (>0.7 μg/kg/h) dexmedetomidine (HDD) to propofol in critically ill trauma patients.

METHODS

This was a retrospective review of 127 adult mechanically ventilated trauma patients between 2008 and 2009, who received propofol, SDD, or HDD for >24 hours. Primary outcomes were significant changes in blood pressure or heart rate. Secondary outcomes included hospital and intensive care unit (ICU) length of stay (LOS), ventilator time, and any concomitant analgesic, sedative, and antipsychotic use. Pairwise comparisons were based on Wilcoxon rank-sum test for continuous data and Pearson's chi-square test for categorical data. Statistical significance was defined as p value <0.05.

RESULTS

Patients in HDD group had higher rate of hypotension (98% vs. 78%; p = 0.02) but no significant differences in heart rate compared with propofol group. These patients had median longer hospital LOS (25 days vs. 12 days; p < 0.001), ICU LOS (20 days vs. 12 days; p = 0.004), and longer ventilator time (14 days vs. 7 days; p = 0.008). They also had increased requirements for oxycodone (74% vs. 40%; p = 0.003), midazolam (36% vs. 8%; p = 0.004), and haloperidol (50% vs. 24%; p = 0.02). Patients in SDD group had longer hospital LOS compared with propofol group (21 days vs. 13 days; p < 0.001).

CONCLUSION

Higher doses of dexmedetomidine may result in higher incidence of hypotension, longer LOS, and increased concomitant analgesic, sedative, and antipsychotic use, requiring further evaluation in trauma patients.

Current sedation practices: lessons learned from international surveys

Limitations are inherent to surveys. Most surveys have low response rates, which raises the issue of responder bias. Another limitation of self-report surveys stems from the possible differences between stated and actual practice. That is, what physicians report that they do in surveys often contrasts significantly with what they do in observational studies, as highlighted by the Canadian surveys conducted in 2002 and 2008. Some surveys report estimates provided by ICU nurse managers or physician directors, potentially resulting in inaccurate estimates or data reflecting the individuals practice rather than the entire ICU. Surveys may not reflect how different specialists practice; for example, the German surveys collected data only in ICUs run by anesthesiologists.Notwithstanding these limitations, surveys provide a wealth of information on current practice and determinants of practice, and serve as a useful tool to guide future research and educational interventions. The authors identified substantial international variation in the use of sedative and analgesic drugs, and marked changes over the last 10 years. Overall, there is a trend toward lighter sedation, along with a shift from benzodiazepines toward propofol, and from morphine toward fentanyl and remifentanil. Despite the publication of numerous studies and guidelines for sedation and analgesia, actual practice differs from recommended practice, suggesting that the impact of clinical trials and guidelines on physician practice is quite low. It is clear that there remain substantial barriers to the incorporation of sedation scales, protocols,and daily interruption into routine ICU care.

Pharmacology of commonly used analgesics and sedatives in the ICU: benzodiazepines, propofol, and opioids

The ideal sedative or analgesic agent should have a rapid onset of activity, a rapid recovery after drug discontinuation, a predictable dose response, a lack of drug accumulation,and no toxicity. Unfortunately, none of the earlier analgesics, the benzodiazepines,or propofol share all of these characteristics. Patients who are critically ill experience numerous physiologic derangements and commonly require high doses and long durations of analgesic and sedative therapy. There is a paucity of well designed clinical trials evaluating the safety and efficacy of earlier sedative and analgesic agents in the ICU. In addition, the ever-changing dynamics of patients who are critically ill makes the use of sedation a continual challenge during the course of each patient’s admission. To optimize care, clinicians should be familiar with the many pharmacokinetic, pharmacodynamic, and pharmacogenetic variables that can affect the safety and efficacy of sedatives and analgesics.