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Louie JM, Lonardo NW, Mone MC, Stevens VW, Deka R, Shipley W, Barton RG. Outcomes When Using Adjunct Dexmedetomidine with Propofol Sedation in Mechanically Ventilated Surgical Intensive Care Patients. PHARMACY 2018; 6:pharmacy6030093. [PMID: 30154389 PMCID: PMC6164835 DOI: 10.3390/pharmacy6030093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 08/21/2018] [Accepted: 08/22/2018] [Indexed: 12/02/2022] Open
Abstract
Objective: Compare the duration of mechanical ventilation between patients receiving sedation with continuous infusions of propofol alone or combination with the use of dexmedetomidine and propofol. Design: Retrospective, propensity matched (1:1) cohort study, employing eight variables chosen a priori for matching. Timing of exposure to dexmedetomidine initiation was incorporated into a matching algorithm. Setting: Level 1, university-based, 32-bed, adult, mixed trauma and surgical intensive care unit (SICU). Continuous sedation was delivered according to a protocol methodology with daily sedation vacation and spontaneous breathing trials. Choice of sedation agent was physician directed. Patients: Between 2010 and 2014, 149 SICU patients receiving mechanical ventilation for >24 h received dexmedetomidine with propofol. Propensity matching resulted in 143 pair cohorts. Interventions: Dexmedetomidine with propofol or propofol alone. Measurements and Main Results: There was no statistical difference in SICU length of stay (LOS), with a median absolute difference of 5.3 h for propofol alone group (p = 0.43). The SICU mortality was not statistically different (RR = 1.002, p = 0.88). Examining a 14-day period post-treatment with dexmedetomidine, on any given day (excluding days 1 and 14), dexmedetomidine with propofol-treated patients had a 0.5% to 22.5% greater likelihood of being delirious (CAM-ICU positive). In addition, dexmedetomidine with propofol-treated patients had a 4.5% to 18.8% higher likelihood of being above the target sedation score (more agitated) compared to propofol-alone patients. Conclusions: In this propensity matched cohort study, adjunct use of dexmedetomidine to propofol did not show a statistically significant reduction with respect to mechanical ventilation (MV) duration, SICU LOS, or SICU mortality, despite a trend toward receiving fewer hours of propofol. There was no evidence that dexmedetomidine with propofol improved sedation scores or reduced delirium.
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Affiliation(s)
- Jessica M Louie
- Department of Pharmacy, University of Utah Health, Salt Lake City, UT 84132, USA.
- Department of Pharmacy Practice, West Coast University School of Pharmacy, Los Angeles, CA 90004, USA.
| | - Nick W Lonardo
- Department of Pharmacy, University of Utah Health, Salt Lake City, UT 84132, USA.
| | - Mary C Mone
- Department of Surgery, University of Utah Health, Salt Lake City, UT 84132, USA.
| | - Vanessa W Stevens
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT 84132, USA.
- Department of Pharmacy Practice, University of Utah College of Pharmacy, Salt Lake City, UT 84132, USA.
| | - Rishi Deka
- Department of Pharmacy Practice, University of Utah College of Pharmacy, Salt Lake City, UT 84132, USA.
| | - Wayne Shipley
- Department of Pharmacy, University of Utah Health, Salt Lake City, UT 84132, USA.
| | - Richard G Barton
- Department of Surgery, University of Utah Health, Salt Lake City, UT 84132, USA.
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Outcomes When Using Adjunct Dexmedetomidine with Propofol Sedation in Mechanically Ventilated Surgical Intensive Care Patients. PHARMACY (BASEL, SWITZERLAND) 2018. [PMID: 30154389 DOI: 10.3390/pharmacy6030093.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: Compare the duration of mechanical ventilation between patients receiving sedation with continuous infusions of propofol alone or combination with the use of dexmedetomidine and propofol. Design: Retrospective, propensity matched (1:1) cohort study, employing eight variables chosen a priori for matching. Timing of exposure to dexmedetomidine initiation was incorporated into a matching algorithm. Setting: Level 1, university-based, 32-bed, adult, mixed trauma and surgical intensive care unit (SICU). Continuous sedation was delivered according to a protocol methodology with daily sedation vacation and spontaneous breathing trials. Choice of sedation agent was physician directed. Patients: Between 2010 and 2014, 149 SICU patients receiving mechanical ventilation for >24 h received dexmedetomidine with propofol. Propensity matching resulted in 143 pair cohorts. Interventions: Dexmedetomidine with propofol or propofol alone. Measurements and Main Results: There was no statistical difference in SICU length of stay (LOS), with a median absolute difference of 5.3 h for propofol alone group (p = 0.43). The SICU mortality was not statistically different (RR = 1.002, p = 0.88). Examining a 14-day period post-treatment with dexmedetomidine, on any given day (excluding days 1 and 14), dexmedetomidine with propofol-treated patients had a 0.5% to 22.5% greater likelihood of being delirious (CAM-ICU positive). In addition, dexmedetomidine with propofol-treated patients had a 4.5% to 18.8% higher likelihood of being above the target sedation score (more agitated) compared to propofol-alone patients. Conclusions: In this propensity matched cohort study, adjunct use of dexmedetomidine to propofol did not show a statistically significant reduction with respect to mechanical ventilation (MV) duration, SICU LOS, or SICU mortality, despite a trend toward receiving fewer hours of propofol. There was no evidence that dexmedetomidine with propofol improved sedation scores or reduced delirium.
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Liu W, Ge T, Pan Z, Leng Y, Lv J, Li B. The effects of herbal medicine on epilepsy. Oncotarget 2018; 8:48385-48397. [PMID: 28423368 PMCID: PMC5564656 DOI: 10.18632/oncotarget.16801] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 03/22/2017] [Indexed: 12/21/2022] Open
Abstract
Traditional herbal medicine plays a significant role in the treatment of epilepsy. Though herbal medicine is widely used in antiepileptic treatment, there is a lack of robust evidence for efficacy and toxicity of most herbs. Besides, the herbal medicine should be subject to evidence-based scrutiny. In this context, we present a review to introduce the effects of herbal medicine on epilepsy. However, hundreds of herbal medicines have been investigated in the available studies. Some commonly used herbal medicines for epilepsy have been listed in our study. The overwhelming majority of these data are based on animal experiments. The lack of clinical data places constraints on the clinical recommendation of herbal medicine. Our study may conduct further studies and provide some insight on the development of anti-epileptic drugs.
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Affiliation(s)
- Wei Liu
- Jilin Provincial Key Laboratory on Molecular and Chemical Genetic, The Second Hospital of Jilin University, Changchun 130041, PR China
| | - Tongtong Ge
- Jilin Provincial Key Laboratory on Molecular and Chemical Genetic, The Second Hospital of Jilin University, Changchun 130041, PR China
| | - Zhenxiang Pan
- Jilin Provincial Key Laboratory on Molecular and Chemical Genetic, The Second Hospital of Jilin University, Changchun 130041, PR China
| | - Yashu Leng
- Third Hospital of Jilin University, Changchun 130033, PR China
| | - Jiayin Lv
- Third Hospital of Jilin University, Changchun 130033, PR China
| | - Bingjin Li
- Jilin Provincial Key Laboratory on Molecular and Chemical Genetic, The Second Hospital of Jilin University, Changchun 130041, PR China
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Tripathi M, Kumar V, Kalashetty MB, Malviya D, Bais PS, Sanjeev OP. Comparison of Dexmedetomidine and Midazolam for Sedation in Mechanically Ventilated Patients Guided by Bispectral Index and Sedation-Agitation Scale. Anesth Essays Res 2017; 11:828-833. [PMID: 29284834 PMCID: PMC5735473 DOI: 10.4103/aer.aer_48_17] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background: Mechanical ventilation and sedation are inextricably linked components of critical care that represent, what we do for the patients during their vulnerable course in Intensive Care Unit (ICU). Aims: The aim of this study is to compare the efficacy and safety of midazolam and dexmedetomidine in patients on mechanical ventilator with the help of Bispectral Index (BIS) monitoring and correlation of BIS with Sedation-Agitation Scale (SAS). Settings and Design: Prospective, observational, and comparative study. Materials and Methods: In this study, recruited patients were allocated into two groups of 14 patients each. Group A and Group B patients received injection dexmedetomidine and injection Midazolam, respectively. Hemodynamic parameters, time of extubation, duration of mechanical ventilation, and mortality were compared between two groups. Statistical Analysis: Mean and the standard deviation were calculated. Test of analysis between two groups was performed using unpaired t-test. We applied correlation technique, that is, Pearson product-moment correlation coefficient (r) to assess the correlation between BIS and SAS. It varies from + 1–0 to −1. Results: Heart rate and blood pressure were more stable and less in Group A than Group B. Duration of mechanical ventilation was found extremely significant between Group A (77.86 ± 5.71 h) and Group B (95.64 ± 17.00 h) (P = 0.001). There was significant difference found in the time of extubation between Group A (21 ± 6.44 h) and Group B (30.4 ± 10.62 h) P = 0.008. Conclusion: It is concluded in this study that sedation with dexmedetomidine resulted in quick extubation and decreased the duration of mechanical ventilation in comparison to midazolam in ICU patients. There was found moderate to high correlation between BIS index and SAS.
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Affiliation(s)
- Manoj Tripathi
- Department of Anesthesia and Critical Care, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Virendra Kumar
- Department of Anesthesia and Critical Care, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | | | - Deepak Malviya
- Department of Anesthesia and Critical Care, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Prateek Singh Bais
- Department of Anesthesia and Critical Care, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Om Prakash Sanjeev
- Department of Anesthesia and Critical Care, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Opioid requirements in mechanically ventilated trauma patients receiving dexmedetomidine versus propofol. J Trauma Nurs 2015; 21:111-4. [PMID: 24828772 DOI: 10.1097/jtn.0000000000000041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Proponents of dexmedetomidine often cite the agent's analgesic properties as one of its main advantages over propofol and benzodiazepines. However, there are very limited studies utilizing endpoints such as analgesic requirements to provide supporting evidence for these claims. The primary purpose of this retrospective study was to compare opioid analgesic requirements in trauma patients receiving nonconcurrent dexmedetomidine and propofol for sedation while being weaned from mechanical ventilation. Total analgesic requirements were similar between dexmedetomidine and propofol within 48 hours of sedative initiation in adult trauma patients (P > .05).
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Reardon DP, Anger KE, Adams CD, Szumita PM. Role of dexmedetomidine in adults in the intensive care unit: an update. Am J Health Syst Pharm 2014; 70:767-77. [PMID: 23592359 DOI: 10.2146/ajhp120211] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
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.
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Affiliation(s)
- David P Reardon
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA 02115, USA.
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Holliday SF, Kane-Gill SL, Empey PE, Buckley MS, Smithburger PL. Interpatient variability in dexmedetomidine response: a survey of the literature. ScientificWorldJournal 2014; 2014:805013. [PMID: 24558330 PMCID: PMC3914598 DOI: 10.1155/2014/805013] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Accepted: 10/22/2013] [Indexed: 12/28/2022] Open
Abstract
Fifty-five thousand patients are cared for in the intensive care unit (ICU) daily with sedation utilized to reduce anxiety and agitation while optimizing comfort. The Society of Critical Care Medicine (SCCM) released updated guidelines for management of pain, agitation, and delirium in the ICU and recommended nonbenzodiazepines, such as dexmedetomidine and propofol, as first line sedation agents. Dexmedetomidine, an alpha-2 agonist, offers many benefits yet its use is mired by the inability to consistently achieve sedation goals. Three hypotheses including patient traits/characteristics, pharmacokinetics in critically ill patients, and clinically relevant genetic polymorphisms that could affect dexmedetomidine response are presented. Studies in patient traits have yielded conflicting results regarding the role of race yet suggest that dexmedetomidine may produce more consistent results in less critically ill patients and with home antidepressant use. Pharmacokinetics of critically ill patients are reported as similar to healthy individuals yet wide, unexplained interpatient variability in dexmedetomidine serum levels exist. Genetic polymorphisms in both metabolism and receptor response have been evaluated in few studies, and the results remain inconclusive. To fully understand the role of dexmedetomidine, it is vital to further evaluate what prompts such marked interpatient variability in critically ill patients.
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Affiliation(s)
- Samantha F. Holliday
- University of Pittsburgh School of Pharmacy, 3501 Terrace Street, Pittsburgh, PA 15261, USA
| | - Sandra L. Kane-Gill
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, 3501 Terrace Street, Pittsburgh, PA 15261, USA
| | - Philip E. Empey
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, 3501 Terrace Street, Pittsburgh, PA 15261, USA
| | - Mitchell S. Buckley
- Banner Good Samaritan Medical Center, Department of Pharmacy, 1111 E. McDowell Road, Phoenix, AZ 85006, USA
| | - Pamela L. Smithburger
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, 3501 Terrace Street, Pittsburgh, PA 15261, USA
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MacLaren R, Preslaski CR, Mueller SW, Kiser TH, Fish DN, Lavelle JC, Malkoski SP. A Randomized, Double-Blind Pilot Study of Dexmedetomidine Versus Midazolam for Intensive Care Unit Sedation. J Intensive Care Med 2013; 30:167-75. [DOI: 10.1177/0885066613510874] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Introduction: Sedation with dexmedetomidine may facilitate ventilator liberation and limit the occurrence of delirium. No trial has assessed patient recall or the development of psychological outcomes after dexmedetomidine sedation. This pilot study evaluated whether transitioning benzodiazepine sedation to dexmedetomidine alters patient recall and the incidence of anxiety, depression, or acute stress disorder (ASD). Methods: This investigation was a randomized, double-blind, single-center study. Existing continuous benzodiazepine sedation was converted to dexmedetomidine or midazolam when patients qualified for daily awakenings. Sedation was titrated to achieve Riker sedation agitation scores of 3 to 4. The intensive care unit (ICU) Stressful Experiences Questionnaire, hospital anxiety and depression scale, and the impact of event scale-revised were administered before hospital discharge to assess recall, anxiety, depression, and manifestations of ASD. Results: A total of 11 patients received dexmedetomidine, and 12 patients received midazolam. Median dosing was 0.61 µg/kg/h for 3.5 days for dexmedetomidine and 3.7 mg/h for 3 days for midazolam. Attainment of goal sedation and analgesia was similar; however, more dexmedetomidine patients experienced agitation and pain. The median duration of mechanical ventilation from study drug initiation to extubation was 3.4 days in dexmedetomidine patients and 2.9 days in midazolam patients. Dexmedetomidine patients remembered 18.5 experiences compared with 8.5 in midazolam patients ( P = .015). Rates of anxiety and depression were similar. In all, 5 (62.5%) dexmedetomidine patients and 1 (12.5%) midazolam patient manifested ASD ( P = .063), and 1 dexmedetomidine patient and 5 midazolam patients developed new-onset delirium ( P = .07). Hypotension occurred in 10 (90.9%) dexmedotomidine patients and 6 (50%) midazolam patients ( P = .069). Conclusions: Transitioning benzodiazepine sedation to dexmedetomidine when patients qualify for daily awakenings may reduce the development of delirium and facilitate remembrance of ICU experiences but may lead to manifestations of ASD. Monitoring hypotension is required for both the sedatives. Additional comparative studies focusing on the long-term impact of ICU recall and psychological outcomes are needed.
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Affiliation(s)
- Robert MacLaren
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | | | - Scott W. Mueller
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Tyree H. Kiser
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Douglas N. Fish
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - James C. Lavelle
- Division of Pulmonary and Critical Care Medicine, University of Colorado School of Medicine Aurora, CO, USA
| | - Stephen P. Malkoski
- Division of Pulmonary and Critical Care Medicine, University of Colorado School of Medicine Aurora, CO, USA
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9
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Clinical practice guidelines for evidence-based management of sedoanalgesia in critically ill adult patients. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.medine.2013.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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10
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Celis-Rodríguez E, Birchenall C, de la Cal M, Castorena Arellano G, Hernández A, Ceraso D, Díaz Cortés J, Dueñas Castell C, Jimenez E, Meza J, Muñoz Martínez T, Sosa García J, Pacheco Tovar C, Pálizas F, Pardo Oviedo J, Pinilla DI, Raffán-Sanabria F, Raimondi N, Righy Shinotsuka C, Suárez M, Ugarte S, Rubiano S. Guía de práctica clínica basada en la evidencia para el manejo de la sedoanalgesia en el paciente adulto críticamente enfermo. Med Intensiva 2013; 37:519-74. [DOI: 10.1016/j.medin.2013.04.001] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 04/16/2013] [Indexed: 01/18/2023]
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MacLaren R, Krisl JC, Cochrane RE, Mueller SW. A case-based approach to the practical application of dexmedetomidine in critically ill adults. Pharmacotherapy 2013; 33:165-86. [PMID: 23386596 DOI: 10.1002/phar.1175] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Dexmedetomidine is a selective α(2) -adrenoceptor agonist that offers unique sedation because patients are readily awakened while administration continues and the drug does not suppress the respiratory center. Limitations of use include higher acquisition cost, inability to produce deep sedation, and bradycardia and hypotension. Using a case-based approach, the purpose of this review was to qualitatively assess the role of dexmedetomidine in the care of the critically ill and in the management of alcohol withdrawal, and to formulate recommendations regarding its clinical application. Sixty-six studies were identified that investigated dexmedetomidine for the provision of sedation. These studies were heterogeneous in design and patient populations; most investigated patients did not require heavy sedation, and few used propofol as the comparator. In general, though, the aggregate results of all studies demonstrate that dexmedetomidine provides comfort, possibly shortens the duration of mechanical ventilation to facilitate extubation, reduces the occurrence of acute brain dysfunction, and facilitates communication, but the drug is associated with hemodynamic instability and requires the supplemental use of traditional sedative and analgesic agents. These outcomes need to be substantiated in additional studies that include assessments of cost-effectiveness. Dexmedetomidine should be considered when patients require mild to moderate levels of sedation of short to intermediate time frames, and they qualify for daily awakenings with traditional sedative therapies. The data for dexmedetomidine in relation to alcohol withdrawal are limited to 12 retrospective reports representing a total of 127 patients. Its role for this indication requires further study, but it may be considered as adjunctive therapy when clinicians are concerned about respiratory suppression associated with escalating doses of γ-aminobutyric acid agonists. Regardless of the indication for dexmedetomidine, the practitioner must closely monitor patient comfort and the occurrence of hemodynamic deviations with the realization that as-needed administration of traditional sedatives and analgesics will be required and some degree of bradycardia and hypotension expected but intervention rarely required.
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Affiliation(s)
- Robert MacLaren
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado 80045, USA.
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12
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Asmussen S, Maybauer DM, Fraser JF, Jennings K, George S, Maybauer MO. A meta-analysis of analgesic and sedative effects of dexmedetomidine in burn patients. Burns 2013; 39:625-31. [DOI: 10.1016/j.burns.2013.01.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Revised: 12/18/2012] [Accepted: 01/04/2013] [Indexed: 11/26/2022]
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Pichot C, Longrois D, Ghignone M, Quintin L. [Dexmedetomidine and clonidine: a review of their pharmacodynamy to define their role for sedation in intensive care patients]. ACTA ACUST UNITED AC 2012; 31:876-96. [PMID: 23089375 DOI: 10.1016/j.annfar.2012.07.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Accepted: 07/12/2012] [Indexed: 11/29/2022]
Abstract
Alpha-2 adrenergic agonists ("alpha-2 agonists") present multiple pharmacodynamic effects: rousable sedation, decreased incidence of delirium in the setting of critical care, preservation of respiratory drive, decreased whole body oxygen consumption, decreased systemic and pulmonary arterial impedance, improved left ventricular systolic and diastolic function, preserved vascular reactivity to exogenous catecholamines, preserved vasomotor baroreflex with lowered set point, preserved kidney function, decreased protein catabolism. These pharmacodynamic effects explain the interest for these drugs in the critical care setting. However, their exact role for sedation in critically ill-patients remains open for further studies. Given the few double-blind randomized multicentric trials available, the present non exhaustive analysis of the literature aims at presenting the utilization of alpha-2 agonists as potential first-line sedative agents, in the critical care setting. Suggestions regarding the use of alpha-2 agonists as sedatives are detailed.
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Affiliation(s)
- C Pichot
- Physiologie (EA 4612 : neurocardiologie), campus de la Doua, université de Lyon, 8, rue R.-Dubois, 69622 Lyon-Villeurbanne, France
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Tellor BR, Arnold HM, Micek ST, Kollef MH. Occurrence and predictors of dexmedetomidine infusion intolerance and failure. Hosp Pract (1995) 2012; 40:186-192. [PMID: 22406894 DOI: 10.3810/hp.2012.02.959] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND Dexmedetomidine, a selective α2 adrenergic receptor agonist, exhibits sedative, analgesic, anxiolytic, and sympatholytic effects, and may aid in controlling agitation in the intensive care unit (ICU). At our hospital (Barnes-Jewish Hospital, St. Louis, MO), dexmedetomidine is commonly used as a sedative in the medical ICU. Predictors of dexmedetomidine intolerance or failure have not yet been defined. OBJECTIVE Describe the rate of dexmedetomidine infusion intolerance/failure and identify patient predictors of intolerance/failure. METHODS This retrospective single-center cohort study evaluated 75 mechanically ventilated adults who received dexmedetomidine infusion. Patients were included in the study if they were aged ≥ 18 years; mechanically ventilated for > 24 hours; received dexmedetomidine infusion for ≥ 1 hour following > 24 hours of continuous infusions of midazolam, fentanyl, or propofol; and were admitted to our medical ICU between August 1, 2009 and August 1, 2010. Multivariate logistic regression analysis was performed to identify independent predictors of intolerance/failure. RESULTS A total of 85 episodes of dexmedetomidine infusion were analyzed (75 total patients). Eighteen episodes (21%) met the criteria for intolerance/failure and 67 episodes (79%) met the criteria for tolerance/success. The median duration of mechanical ventilation, total dexmedetomidine infusion time, and ICU length of stay did not differ between groups. Nonblack race was the only variable independently associated with treatment failure or intolerance in the logistic regression analysis. CONCLUSION Twenty-one percent of dexmedetomidine infusion episodes met the criteria for intolerance/failure. No predictors of intolerance/failure were found to be clinically significant.
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Affiliation(s)
- Bethany R Tellor
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, MO 63110, USA
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15
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Affiliation(s)
- C. Pichot
- Critical Care Unit, Memorial Hospital, St Lô, France
| | - M. Ghignone
- Critical Care Unit, Columbia Hospital, WPalm Beach, FL, USA
| | - L. Quintin
- Physiology (CNRS UMR 5123), University of Lyon, Lyon, France
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16
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Shapiro PA, Fedoronko DA, Epstein LA, Mirasol EGE, Desai CV. Psychiatric aspects of heart and lung disease in critical care. Heart Fail Clin 2011; 7:109-25. [PMID: 21109214 DOI: 10.1016/j.hfc.2010.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Psychiatric issues are important in the management of patients with heart and lung disease in acute, intensive, and critical care. Adjustment disorders, anxiety disorders, depression, and delirium, sometimes in association with substance abuse and withdrawal problems, are the most common issues, and may affect risk and prognosis of the associated general medical conditions and management in the acute care setting. In children with lung and heart diseases requiring critical care, appreciation of cognitive and social-psychologic developmental milestones is necessary to provide adequate care.
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Affiliation(s)
- Peter A Shapiro
- Department of Psychiatry, Columbia University, 622 West 168 Street, New York, NY 10032, USA.
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17
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Anger KE, Szumita PM, Baroletti SA, Labreche MJ, Fanikos J. Evaluation of dexmedetomidine versus propofol-based sedation therapy in mechanically ventilated cardiac surgery patients at a tertiary academic medical center. Crit Pathw Cardiol 2010; 9:221-226. [PMID: 21119342 DOI: 10.1097/hpc.0b013e3181f4ec4a] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Management of pain and sedation therapy is a vital component of optimizing patient outcomes; however, the ideal pharmacotherapy regimen has not been identified in the postoperative cardiac surgery population. We sought to evaluate efficacy and safety outcomes between postoperative mechanically ventilated cardiac surgery patients receiving dexmedetomidine versus propofol therapy upon arrival to the intensive care unit (ICU). We conducted a single center, descriptive study of clinical practice at a 20-bed cardiac surgery ICU in a tertiary academic medical center. Adult mechanically ventilated postcardiac surgery patients who received either dexmedetomidine or propofol for sedation therapy upon admission to the ICU between October 20, 2006 and December 15, 2006 were evaluated. A pharmacy database was used to identify patients receiving dexmedetomidine or propofol therapy for perioperative sedation during cardiac surgery. Patients were matched according to surgical procedure type. Fifty-six patients who received either dexmedetomidine (n = 28) or propofol (n = 28) were included in the analysis. No differences in the ICU length of stay (58.67 ± 32.61 vs. 61 ± 33.1 hours; P = 0.79) and duration of mechanical ventilation (16.21 ± 6.05 vs. 13.97 ± 4.62 hours; P = 0.13) were seen between the propofol and dexmedetomidine groups, respectively. Hypotension (17 [61%] vs. 9 [32%]; P = 0.04), morphine use (11 [39.3%] vs. 1 [3.6%]; P = 0.002), and nonsteroidal anti-inflammatory use (7 [25%] vs. 1 [3.6%]; P = 0.05) occurred more during dexmedetomidine therapy versus propofol. Dexmedetomidine therapy resulted in a higher incidence of hypotension and analgesic consumption compared with propofol-based sedation therapy. Further evaluation is needed to assess differences in clinical outcomes of propofol and dexmedetomidine-based therapy in mechanically ventilated cardiac surgery patients.
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Affiliation(s)
- Kevin E Anger
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA.
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Abstract
INTRODUCTION Dexmedetomidine is a highly selective alpha(2)-adrenoreceptor agonist that produces dose-dependent sedation, anxiolysis, and analgesia without respiratory depression. Dexmedetomidine has been used in critically ill medical, surgical, and pediatric patients, as an adjunct to sedation and/or for treating drug or alcohol withdrawal. Information regarding the dosing and utilization of dexmedetomidine has been derived primarily from studies in critically ill patients in the medical intensive care unit. There has been no study designed specifically to evaluate dexmedetomidine for these therapeutic uses in the neurocritical care population. The primary and secondary objectives were to evaluate the starting dose of dexmedetomidine for neurocritical care patients and to assess the effect on hemodynamic parameters, respectively. METHODS This was a prospective, observational study conducted from October 2007 to March 2008. Patients were included if they were admitted to the Neuro-Intensive Care Unit and received dexmedetomidine infusion. RESULTS Six patients met the criteria for the study. The mean initial dexmedetomidine infusion rate and mean maximum infusion rate were 0.67 +/- 0.2 and 1.3 +/- 0.5 mcg/kg/h, respectively. The mean duration of dexmedetomidine infusion was 66 +/- 10 h. Two patients (33%) experienced a significant change in mean heart rate and systolic blood pressure after starting dexmedetomidine infusion. CONCLUSION Neurocritically ill patients may require high doses of dexmedetomidine to achieve desired levels of sedation. The high rates and long duration of dexmedetomidine infusion had a statistically, but not clinically, significant impact on hemodynamic parameters.
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Zhang X, Schmidt U, Wain JC, Bigatello L. Bradycardia leading to asystole during dexmedetomidine infusion in an 18 year-old double-lung transplant recipient. J Clin Anesth 2010; 22:45-9. [DOI: 10.1016/j.jclinane.2009.06.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2008] [Revised: 06/11/2009] [Accepted: 06/24/2009] [Indexed: 12/01/2022]
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Shehabi Y, Nakae H, Hammond N, Bass F, Nicholson L, Chen J. The Effect of Dexmedetomidine on Agitation during Weaning of Mechanical Ventilation in Critically ill Patients. Anaesth Intensive Care 2010; 38:82-90. [DOI: 10.1177/0310057x1003800115] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Ventilated patients receiving opioids and/or benzodiazepines are at high risk of developing agitation, particularly upon weaning towards extubation. This is often associated with an increased intubation time and length of stay in the intensive care unit and may cause long-term morbidity. Anxiety, fear and agitation are amongst the most common non-pulmonary causes of failure to liberate from mechanical ventilation. This prospective, open-label observational study examined 28 ventilated adult patients in the intensive care unit (30 episodes) requiring opioids and/or sedatives for >24 hours, who developed agitation and/or delirium upon weaning from sedation and failed to achieve successful extubation with conventional management. Patients were ventilated for a median (interquartile range) of 115 [87 to 263] hours prior to enrolment, Dexmedetomidine infusion was commenced at 0.4 μg/kg/hour for two hours, after which concurrent sedative therapy was preferentially weaned and titrated to obtain target Motor Activity Assessment Score score of 2 to 4. The median (range) maximum dose and infusion time of dexmedetomidine was 0.7 μg/kg/hour (0.4 to 1.0) and 62 hours (24 to 252) respectively. The number of episodes at target Motor Activity Assessment Score score at zero, six and 12 hours after commencement of dexmedetomidine were 7/30 (23.3%), 28/30 (93.3%) and 26/30 (86.7%), respectively (P <0.001 for 6 and 12 vs 0 hours). Excluding unrelated clinical deterioration, 22 episodes (73.3%) achieved successful weaning from ventilation with a median (interquartile range) ventilation time of 70 (28 to 96) hours after dexmedetomidine infusion. Dexmedetomidine achieved rapid resolution of agitation and facilitated ventilatory weaning after failure of conventional therapy. Its role as first-line therapy in ventilated, agitated patients warrants further investigation.
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Affiliation(s)
- Y. Shehabi
- Acute Care Program, Intensive Care Department, Prince of Wales Hospital, Sydney, New South Wales, Australia
- Medical Director, Acute Care Program, Director, Intensive Care Services and Research and Associate Professor, University of New South Wales Clinical School, Prince of Wales Hospital
| | - H. Nakae
- Acute Care Program, Intensive Care Department, Prince of Wales Hospital, Sydney, New South Wales, Australia
- Consultant in Anaesthesia and Intensive Care. Department of Integrated Medicine, Division of Emergency and Critical Care Medicine, Akita University School of Medicine, Akita, Japan
| | - N. Hammond
- Acute Care Program, Intensive Care Department, Prince of Wales Hospital, Sydney, New South Wales, Australia
- ICU Clinical Research Nurse. The Prince Charles Hospital, Brisbane, Queensland
| | - F. Bass
- Acute Care Program, Intensive Care Department, Prince of Wales Hospital, Sydney, New South Wales, Australia
- Research Co-ordinator, Intensive Care Unit
| | - L. Nicholson
- Acute Care Program, Intensive Care Department, Prince of Wales Hospital, Sydney, New South Wales, Australia
- Acting Nurse Educator, Intensive Care Unit
| | - J. Chen
- Acute Care Program, Intensive Care Department, Prince of Wales Hospital, Sydney, New South Wales, Australia
- Senior Research Fellow, Simpson Centre for Health Services Research, The University of New South Wales
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Jackson DL, Proudfoot CW, Cann KF, Walsh TS. The incidence of sub-optimal sedation in the ICU: a systematic review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:R204. [PMID: 20015357 PMCID: PMC2811948 DOI: 10.1186/cc8212] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2009] [Revised: 10/12/2009] [Accepted: 12/16/2009] [Indexed: 11/10/2022]
Abstract
Introduction Patients in intensive care units (ICUs) are generally sedated for prolonged periods. Over-sedation and under-sedation both have negative effects on patient safety and resource use. We conducted a systematic review of the literature in order to establish the incidence of sub-optimal sedation (both over- and under-sedation) in ICUs. Methods We searched Medline, Embase and CINAHL (Cumulative Index to Nursing and Allied Health Literature) online literature databases from 1988 to 15 May 2008 and hand-searched conferences. English-language studies set in the ICU, in sedated adult humans on mechanical ventilation, which reported the incidence of sub-optimal sedation, were included. All abstracts were reviewed twice by two independent reviewers, with all conflicts resolved by a third reviewer, to check that they met the review inclusion criteria. Full papers of all included studies were retrieved and were again reviewed twice against inclusion criteria. Data were doubly extracted. Study aims, design, population, comparisons made, and data on the incidence of sub-optimal, optimal, over-sedation or under-sedation were extracted. Results There was considerable variation between included studies in the definition of optimal sedation and in the scale or method used to assess sedation. Across all included studies, a substantial incidence of sub-optimal sedation was reported, with a greater tendency toward over-sedation. Conclusions Our review suggests that improvements in the consistent definition and measurement of sedation may improve the quality of care of patients within the ICU.
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Affiliation(s)
- Daniel L Jackson
- GE Healthcare, Pollards Wood, Nightingales Lane, Chalfont St, Giles, Bucks, HP8 4SP, UK.
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Page VJ. Tackling agitated delirium--the tip of the iceberg. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:158. [PMID: 19591644 PMCID: PMC2717458 DOI: 10.1186/cc7912] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Reade et al. studied 20 agitated intubated patients in a pilot open-label trial comparing the efficacy of dexmedetomidine versus haloperidol in facilitating extubation. While the study design had limitations, which are outlined by the authors themselves in the paper published in this issue of Critical Care, the study demonstrated an impressive reduction in time to extubation and length of stay. Dexmedetomidine is a promising sedative agent that acts via α2-receptors and has been shown to decrease prevalence and duration of delirium in mechanically ventilated patients. Haloperidol is the recommended and standard drug to treat delirium, largely based on large case series and reports. Delirium is a common, underdiagnosed and serious problem in intensive care unit patients. Agitated delirious patients are at risk of immediate adverse events as well as prolonged respiratory support. All delirious patients are at risk of poor cognitive outcomes. Further research is needed into the pharmacological management of delirium, including the use of dexmedetomidine in the management of agitation and the clinical efficacy of haloperidol.
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Affiliation(s)
- Valerie J Page
- Department of Anaesthetics, Watford General Hospital, Vicarage Road, Watford, WD19 4DZ, UK.
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Gregoretti C, Decaroli D, Piacevoli Q, Mistretta A, Barzaghi N, Luxardo N, Tosetti I, Tedeschi L, Burbi L, Navalesi P, Azzeri F. Analgo-sedation of patients with burns outside the operating room. Drugs 2009; 68:2427-43. [PMID: 19016572 DOI: 10.2165/0003495-200868170-00003] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Following the initial resuscitation of burn patients, the pain experienced may be divided into a 'background' pain and a 'breakthrough' pain associated with painful procedures. While background pain may be treated with intravenous opioids via continuous infusion or patient-controlled analgesia (PCA) and/or less potent oral opioids, breakthrough pain may be treated with a variety of interventions. The aim is to reduce patient anxiety, improve analgesia and ensure immobilization when required. Untreated pain and improper sedation may result in psychological distress such as post-traumatic stress disorder, major depression or delirium. This review summarizes recent developments and current techniques in sedation and analgesia in non-intubated adult burn patients during painful procedures performed outside the operating room (e.g. staple removal, wound-dressing, bathing). Current techniques of sedation and analgesia include different approaches, from a slight increase in background pain therapy (e.g. morphine PCA) to PCA with rapid-onset opioids, to multimodal drug combinations, nitrous oxide, regional blocks, or non-pharmacological approaches such as hypnosis and virtual reality. The most reliable way to administer drugs is intravenously. Fast-acting opioids can be combined with ketamine, propofol or benzodiazepines. Adjuvant drugs such as clonidine or NSAIDs and paracetamol (acetaminophen) have also been used. Patients receiving ketamine will usually maintain spontaneous breathing. This is an important feature in patients who are continuously turned during wound dressing procedures and where analgo-sedation is often performed by practitioners who are not specialists in anaesthesiology. Drugs are given in small boluses or by patient-controlled sedation, which is titrated to effect, according to sedation and pain scales. Patient-controlled infusion with propofol has also been used. However, we must bear in mind that burn patients often show an altered pharmacokinetic and pharmacodynamic response to drugs as a result of altered haemodynamics, protein binding and/or increased extracellular fluid volume, and possible changes in glomerular filtration. Because sedation and analgesia can range from minimal sedation (anxiolysis) to general anaesthesia, sedative and analgesic agents should always be administered by designated trained practitioners and not by the person performing the procedure. At least one individual who is capable of establishing a patent airway and positive pressure ventilation, as well as someone who can call for additional assistance, should always be present whenever analgo-sedation is administered. Oxygen should be routinely delivered during sedation. Blood pressure and continuous ECG monitoring should be carried out whenever possible, even if a patient is undergoing bathing or other procedures that may limit monitoring of vital pulse-oximetry parameters.
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Affiliation(s)
- Cesare Gregoretti
- Intensive Care Unit, Azienda Ospedaliera CTO-CRF-ICORMA, Turin, Italy
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Abstract
Psychiatric issues are important in the management of patients with heart and lung disease in acute, intensive, and critical care. Adjustment disorders, anxiety disorders, depression, and delirium, sometimes in association with substance abuse and withdrawal problems, are the most common issues, and may affect risk and prognosis of the associated general medical conditions and management in the acute care setting. In children with lung and heart diseases requiring critical care, appreciation of cognitive and social-psychologic developmental milestones is necessary to provide adequate care.
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Ruokonen E, Parviainen I, Jakob SM, Nunes S, Kaukonen M, Shepherd ST, Sarapohja T, Bratty JR, Takala J. Dexmedetomidine versus propofol/midazolam for long-term sedation during mechanical ventilation. Intensive Care Med 2008; 35:282-90. [DOI: 10.1007/s00134-008-1296-0] [Citation(s) in RCA: 166] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2008] [Accepted: 08/14/2008] [Indexed: 12/15/2022]
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Abstract
STUDY OBJECTIVE To determine the safety, effectiveness, and dosing of dexmedetomidine in intensive care infants and children who require sedation, and the rationale for patient selection. DESIGN Prospective observational study. SETTING Eleven-bed pediatric intensive care unit in a university-affiliated children's hospital. PATIENTS Seventeen infants and children who received dexmedetomidine consecutively between May 4, 2005, and May 4, 2006. MEASUREMENTS AND MAIN RESULTS Data were collected on demographics, blood pressure and heart rate measurements, and adverse effects. The rationale for dexmedetomidine use, its dosing, use of other sedatives, and treatment duration were also recorded. Twenty treatment courses in 17 patients (median age 5 mo, range 1 mo-17 yrs) were evaluated. Ten patients (59%) had chronic neurologic impairments (including Down syndrome in nine [53%]). Thirteen (76%) had undergone cardiac surgery, two (12%) had respiratory failure, one (6%) had endocarditis, and one (6%) had undergone scoliosis repair. In 15 (75%) of 20 cases, dexmedetomidine was started to minimize the use of midazolam before extubation; in 13 (87%) of these cases, the patients were extubated within 24 hours. The remaining patients could not tolerate midazolam, and dexmedetomidine was used as an alternative. No loading doses were given. The mean +/- SD starting dose was 0.2 +/- 0.2 microg/kg/hour, with a maximum of 0.5 +/- 0.2 microg/kg/hour. Mean +/- SD duration was 32 +/- 21 hours (range 3-75 hrs); 10 courses exceeded 24 hours. Mean arterial pressures before and after starting treatment were not significantly different (p=0.76), nor were values at discontinuation (p=0.31) or 12 hours later (p=0.29). No significant differences were noted in heart rate at the start (p=0.09), at discontinuation (p=0.06), or 12 hours later (p=0.17). One patient (6%) developed hypotension; no other adverse effects were noted. CONCLUSION With careful patient selection and a conservative approach to dosing, dexmedetomidine was a useful sedative in children requiring mechanical ventilation. It allowed for a reduction or elimination of other sedatives, and it was particularly useful in children with chronic neurologic impairments. Dexmedetomidine was well tolerated, with no clinically significant effects on blood pressure or heart rate.
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Affiliation(s)
- Marcia L Buck
- Department of Pharmacy Services, University of Virginia Children's Hospital, Charlottesville, Virginia 22908, USA.
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Muller S, Borowics SM, Fortis EAF, Stefani LC, Soares G, Maguilnik I, Breyer HP, Hidalgo MPL, Caumo W. Clinical efficacy of dexmedetomidine alone is less than propofol for conscious sedation during ERCP. Gastrointest Endosc 2008; 67:651-9. [PMID: 18291396 DOI: 10.1016/j.gie.2007.09.041] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2007] [Accepted: 09/17/2007] [Indexed: 02/07/2023]
Abstract
BACKGROUND Propofol is an accepted method of sedation for an ERCP and generally achieves deep sedation rather than conscious sedation, and dexmedetomidine has sedative properties of equivalent efficacy. OBJECTIVE To examine the hypothesis that dexmedetomidine is as effective as propofol combined with fentanyl for providing conscious sedation during an ERCP. DESIGN AND SETTING Randomized, blind, double-dummy clinical trial. PATIENTS Twenty-six adults, American Society of Anesthesiologists status I to III, underwent an ERCP. INTERVENTIONS Patients were randomized to receive either propofol (n = 14) (target plasma concentration range 2-4 microg/mL) combined with fentanyl 1 microg/kg, or dexmedetomidine (n = 12) 1 microg/kg for 10 minutes, followed by 0.2 to 0.5 microg/kg/min. Additional sedatives were used if adequate sedation was not achieved at the maximum dose allowed. MAIN OUTCOMES MEASUREMENTS The sedation level was assessed by the Richmond alertness-sedation scale and the demand for additional sedatives. Furthermore, heart rate, blood pressure, oxygen saturation, and respiratory rate were continuously assessed. RESULTS The relative risk (RR) was 2.71 (95% CI, 1.31-5.61) and the number of patients that needed to be treated (NNT) was 1.85 (95% CI, 1.19-4.21) to observe one additional patient with drowsiness 15 minutes after sedation in the dexmedetomidine group. Also, the RR was 9.42 (95% CI, 1.41-62.80), and the NNT was 1.42 (95% CI, 1.0-2.29) to require additional analgesic. However, there was also a greater reduction in blood pressure, a lower heart rate, and greater sedation after the procedure. CONCLUSIONS Dexmedetomidine alone was not as effective as propofol combined with fentanyl for providing conscious sedation during an ERCP. Furthermore, dexmedetomidine was associated with greater hemodynamic instability and a prolonged recovery.
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Affiliation(s)
- Suzana Muller
- Anesthesia and Perioperative Medicine Service, Gastroenterology Division, Hospital de Clínicas de Porto Alegre, Institute of Basic Health Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
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Affiliation(s)
- Curtis N Sessler
- Division of Pulmonary and Critical Care Medicine, Box 980050, Virginia Commonwealth University Health System, Richmond, VA 23298, USA.
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Klimek M, Lacroix MM. The Safety and Effectiveness of Dexmedetomidine When Used for More Than 24 Hours in an Adult Intensive Care Setting. J Pharm Pract 2007. [DOI: 10.1177/0897190007311672] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Dexmedetomidine is a new analgesic and anxiolytic used in the intensive care setting. It has been indicated for use for less than 24 hours to aid in intubation or extubation of a patient. The advantages for dexmedetomidine compared with propofol or benzodiazepines are that it has fewer sedating effects and a short half-life. Several retrospective studies and case reports have reported its use longer than the indicated 24 hours. They reported that dexmedetomidine is safe to use past the 24-hour indicated time of use, with the same or fewer adverse side effects reported.
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Affiliation(s)
| | - Matthew M. Lacroix
- St John's University College of Pharmacy and Health Professions, Department of Clinical Pharmacy Practice, Queens, New York, Clinical Pharmacist Preceptor, North Shore University Hospital, Manhasset, New York,
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