Dexmedetomidine sedation in ICU

Risk of Rhabdomyolysis Associated with Dexmedetomidine Use over the Past 10 Years: Insights from the EudraVigilance Database

Dexmedetomidine, a selective α2-adrenergic agonist, is favoured in intensive care for its minimal respiratory depression. This study evaluated the reporting frequency of rhabdomyolysis with dexmedetomidine compared to midazolam and propofol using the European pharmacovigilance database Eudravigilance. We conducted an observational, retrospective analysis of Individual Case Safety Reports (ICSRs) from 1 January 2013, to 31 December 2023. Primary and secondary outcomes included the reporting frequencies of rhabdomyolysis and its indicative signs and symptoms, respectively. We retrieved 19,268 ICSRs, of which 364 reported rhabdomyolysis associated with dexmedetomidine (3.8%), midazolam (10.2%), propofol (76.9%), or combinations thereof (9.1%). Dexmedetomidine showed a significantly lower reporting frequency of rhabdomyolysis compared to propofol (ROR, 0.32; 95% CI, 0.19-0.55) but no significant difference compared to midazolam. Subgroup analyses revealed higher frequencies in males, especially with propofol. Despite limitations such as underreporting, our findings suggest dexmedetomidine poses a lower rhabdomyolysis risk than propofol, supporting its safe use for sedation in high-risk patients. It is important to note that due to the retrospective design of this study our findings are indicative of correlations rather than causation. Continuous monitoring and further studies are recommended to validate these results.

Perioperative management of primary classic bladder exstrophy: A single institutional pathway to success

PURPOSE

Appropriate perioperative management is crucial in patients undergoing classic bladder exstrophy closure (CBE). Therefore, the authors sought to review their intra and postoperative management of patients with CBE undergoing primary closure and examine the impact of this pathway on patient outcomes.

METHOD

A prospectively maintained institutional approved exstrophy-epispadias complex database was reviewed for patients with CBE who had undergone primary closure between 2016 and 2022 and whose closure was performed within one year of age. Electronic medical records for eligible patients were retrospectively reviewed to examine patient demographics, use of pelvic osteotomy, immobilization status, pediatric intensive care unit (PICU) admission and management, perioperative analgesia and sedation, nutritional support, drainage tubes, blood transfusions, antibiotic coverage, hospital length of stay, postoperative complications, and closure failure.

RESULTS

A total of 25 patients were identified, 22 with CBE and 3 with variant CBE. Closure was performed at a median age of 84 days with patients ranging in age from 9 to 351 days. All patients underwent osteotomy and immobilization with modified Buck's traction and external fixation for a median duration of 41 days. A suprapubic tube was placed in all patients for a median duration of 46.5 days. All patients underwent PICU admission following closure for a median duration of 8 days. Ventilator support was required in 68 % of patients for a median of 3 days. Epidural analgesia was used in all patients and catheters were maintained for a median duration of 19 days. All patients received a blood transfusion over the course of their admission. Patient-controlled analgesia was used in most patients as an adjunct for a median duration of 38.5 days. Other commonly used analgesic adjuncts included acetaminophen, diazepam, clonidine, and dexmedetomidine. TPN was used in 80 % of patients for a median of 7 days with a return of oral feeding thereafter. Overall, the closure success rate in this cohort of patients was 100 %.

DISCUSSION

The outcome of primary bladder closure can have inauspicious consequences that can affect a child's continence for years. The incidence of failed bladder closure can be minimized with the implementation of a detailed plan for immobilization, analgesia, and nutrition guided by an experienced multi-disciplinary team.

CONCLUSION

We have identified several guiding principles for perioperative success in exstrophy patients at our center including Buck's traction with external fixation, provision of adequate postoperative analgesia and sedation, aggressive nutritional support, renal and bladder drainage, and robust antibacterial support. Our high success rate in managing this complex pathology demonstrates its validity and use as a pathway to success.

Regional Anesthesia for Arthroscopic Knee Repair in a Patient With Hypertrophic Obstructive Cardiomyopathy (HOCM) Under Monitored Anesthesia Care With Dexmedetomidine Infusion

Patients with hypertrophic obstructive cardiomyopathy (HOCM) who are scheduled for elective, noncardiac surgery present a distinctive challenge for perioperative healthcare providers. The use of general anesthesia and neuraxial anesthesia carries the risk of unpredictable hemodynamic changes and potential complications. Regional anesthesia (RA) emerges as a prudent and effective option for HOCM patients. RA provides advantages such as minimizing hemodynamic fluctuations, avoiding intubation, reducing pharmacologic side effects, facilitating enhanced recovery after surgery, and contributing to greater patient satisfaction. We share the case of a 15-year-old individual diagnosed with HOCM and exercise intolerance, undergoing arthroscopic repair for right patellar instability. In this instance, the patient received preoperative peripheral nerve blocks for surgical anesthesia and underwent repair utilizing monitored anesthesia care (MAC) with a dexmedetomidine (DEX) infusion.

Efficacy of ultrasound guided superior laryngeal nerve block on sedation for delayed extubation in maxillofacial surgery with free flap reconstruction

OBJECTIVE

Superior laryngeal nerve block (SLNB) is a regional anesthesia technique for addressing airway response. However, SLNB on the efficacy of sedation in patients with delayed extubation is unknown, particularly for maxillofacial surgery (MS). The aim of the study was to assess whether ultrasound guided (UG) SLNB reduces the incidence of moderate to severe cough for delayed extubation in MS with free flap reconstruction.

METHODS

60 patients were randomly assigned to the GEA group (control group) and the SLNB group (UG-SLNB postoperatively, study group). During the initial two postoperative hours, the incidence of moderate and severe cough, agitation, and the number of patients requiring rescue propofol and flurbiprofen were recorded. Additionally, the time spent under the target level of sedation, postoperative hemodynamics, and the total does of propofol during the postoperative 24 h were recorded.

RESULTS

The data showed the SLNB group had a significantly lower incidence of moderate to severe cough and agitation (p < 0.05), and a longer sedation time (p < 0.05). The number of patients required rescue propofol and flurbiprofen, as well as the hemodynamic changes, were significantly different between the two groups (p < 0.05).

CONCLUSION

The use of UG-SLNB is associated with reduced incidence of postoperative cough. Moreover, SLNB can enhance the efficacy of postoperative sedation with need of fewer agents postoperatively.

CLINICAL TRIAL REGISTRATION

ChiCTR2000039982.

Advances in Anesthesia for Shoulder Surgery: A Comprehensive Review of Dexmedetomidine-Enhanced Interscalene Brachial Plexus Block

Surgical procedures on the shoulder pose distinctive challenges in managing pain during the perioperative period, underscoring the importance of exploring innovative anesthesia techniques. This comprehensive review article delves into integrating dexmedetomidine, an alpha-2 adrenergic agonist, within interscalene brachial plexus blocks for shoulder surgery. The review initiates by underscoring the pivotal role of effective anesthesia in shoulder surgery and elucidates the rationale behind investigating dexmedetomidine as an adjunct. It meticulously examines the anatomy and physiology of the brachial plexus, emphasizing its critical significance in shoulder surgery. Furthermore, the article expounds on dexmedetomidine's mechanisms of action and pharmacokinetics, encompassing its safety profile and potential side effects. The conventional interscalene brachial plexus block techniques, along with their limitations and challenges, are discussed, laying the foundation for the integration of dexmedetomidine. The review subsequently delves into exploring the role of dexmedetomidine in regional anesthesia, covering previous studies, mechanisms of action, and the potential advantages of incorporating it into nerve blocks. The review's core concentrates on the practical application of dexmedetomidine-enhanced interscalene brachial plexus blocks. This includes discussions on administration techniques, dosage guidelines, and compelling evidence supporting its utilization. Clinical scenarios where this approach proves most advantageous are thoroughly explored, comparing its effectiveness with traditional techniques in terms of pain control and patient outcomes. A comprehensive examination of relevant clinical trials and case studies highlights the evidence supporting its efficacy. The review also underscores safety considerations associated with dexmedetomidine. It proposes strategies for mitigating risks to ensure patient safety. Insights into future directions and research are provided, encompassing ongoing studies, areas necessitating further investigation, and potential refinements in technique. Finally, the article summarizes key findings, emphasizing the practicality of dexmedetomidine-enhanced interscalene brachial plexus blocks in shoulder surgery and its far-reaching implications for clinical practice and patient care.

Minimizing Motion Artifacts in Intravital Microscopy Using the Sedative Effect of Dexmedetomidine

Among intravital imaging instruments, the intravital two-photon fluorescence excitation microscope has the advantage of enabling real-time 3D fluorescence imaging deep into cells and tissues, with reduced photobleaching and photodamage compared with conventional intravital confocal microscopes. However, excessive motion of organs due to involuntary movement such as breathing may result in out-of-focus images and severe fluorescence intensity fluctuations, which hinder meaningful imaging and analysis. The clinically approved alpha-2 adrenergic receptor agonist dexmedetomidine was administered to mice during two-photon fluorescence intravital imaging to alleviate this problem. As dexmedetomidine blocks the release of the neurotransmitter norepinephrine, pain is suppressed, blood pressure is reduced, and a sedation effect is observed. By tracking the quality of focus and stability of detected fluorescence in two-photon fluorescence images of fluorescein isothiocyanate-sensitized liver vasculature in vivo, we demonstrated that intravascular dexmedetomidine can reduce fluorescence fluctuations caused by respiration on a timescale of minutes in mice, improving image quality and resolution. The results indicate that short-term dexmedetomidine treatment is suitable for reducing involuntary motion in preclinical intravital imaging studies. This method may be applicable to other animal models.

The Current Role of Dexmedetomidine as Neuroprotective Agent: An Updated Review

Dexmedetomidine, selective α2-adrenergic agonist dexmedetomidine, has been widely used clinically for sedation and anesthesia. The role of dexmedetomidine has been an interesting topic of neonatological and anesthetic research since a series of advantages of dexmedetomidine, such as enhancing recovery from surgery, reducing opioid prescription, decreasing sympathetic tone, inhibiting inflammatory reactions, and protecting organs, were reported. Particularly, an increasing number of animal studies have demonstrated that dexmedetomidine ameliorates the neurological outcomes associated with various brain and spinal cord injuries. In addition, a growing number of clinical trials have reported the efficacy of dexmedetomidine for decreasing the rates of postoperative neurological dysfunction, such as delirium and stroke, which strongly highlights the possibility of dexmedetomidine functioning as a neuroprotective agent for future clinical use. Mechanism studies have linked dexmedetomidine’s neuroprotective properties with its modulation of neuroinflammation, apoptosis, oxidative stress, and synaptic plasticity via the α2-adrenergic receptor, dependently or independently. By reviewing recent advances and preclinical and clinical evidence on the neuroprotective effects of dexmedetomidine, we hope to provide a complete understanding of the above mechanism and provide insights into the potential efficacy of this agent in clinical use for patients.

Comparative Effects of Dexmedetomidine and Midazolam on Dreaming of Patients Undergoing Flexible Bronchoscopy During General Anesthesia

Background

The aim of this study was to compare the effects of dexmedetomidine versus midazolam on the dreaming of patients undergoing flexible bronchoscopy during general anesthesia.

Material/Methods

Patients undergoing flexible bronchoscopy under general anesthesia were randomly divided into a dexmedetomidine group (Group D, n=40) and a midazolam group (Group M, n=40). In group D, patients received 0.5 μg/kg dexmedetomidine and in group M patients received 0.05 mg/kg midazolam intravenously 10 min prior to induction. After bronchoscopy and recovery, a modified Brice questionnaire was used to immediately evaluate the incidence of dreaming of patients. Dreamers were required to complete a 5-point Likert scale survey regarding the contents of their dreams (emotion, voice and movement, memorability) if dreaming was reported. Ramsay Sedation Scale score (Ramsay score) and Visual Analogue Scale (VAS) score were assessed and recorded.

Results

Patients in group D had higher Ramsay scores and VAS scores (2.9±0.6 and 79.4±4.0, respectively) than group M (2.4±0.7 and 75.0±6.0, respectively), with a statistically significant difference (P<0.05) between groups. The incidence and memorability of dreaming were significantly lower in group D (17.5%) than group M (37.5%, P<0.05), whereas no significant difference was found in emotion, voice, and movement scores of dreaming.

Conclusions

Compared to midazolam, pre-injection of dexmedetomidine before induction significantly decreased the incidence of dreaming in patients undergoing flexible bronchoscopy during general anesthesia, without producing undesirable effects on the content of dreams (most of them were pleasant), produces a more efficacious sedation effect during the recovery period and improves the comfort level and satisfaction of patients.

Critical Review and Meta-Analysis of Postoperative Sedation after Adult Cardiac Surgery: Dexmedetomidine Versus Propofol

OBJECTIVE

To evaluate reports from the published literature of all randomized clinical trials (RCT) comparing postoperative sedation with dexmedetomidine versus propofol in adult patients, after open cardiac surgery.

DESIGN

A computerized search on Medline, EMBASE, Web of Science, and Agency for Healthcare Research and Quality databases was completed through June 2020. Meta-analysis of all published RCT comparing dexmedetomidine versus propofol utilization in the postoperative phase, using the standard Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist.

SETTING

Assemblage and critical discussion of 11 RCTs comparing postoperative sedation from standard published reports from 2003 to 2019.

PARTICIPANTS

The study comprised 1,184 patients and analyzed critical discussion of time-based parameters (time to extubation, intensive care unit length of stay, and hospital length of stay) and nontime-dependent factors (delirium, bradycardia, and hypotension).

MEASUREMENTS AND MAIN RESULTS

Time to extubation was significantly reduced in the dexmedetomidine group (standardized mean difference [SMD] = -0.70, 95% confidence interval [CI] -0.98 to -0.42, p < 0.001); however, no difference in mechanical ventilation time was observed (SMD = -0.72, 95% CI -1.60 to 0.15, N.S.). Dexmedetomidine significantly reduced the intensive care unit length of stay (SMD = 0.23, 95% CI -1.06 to -0.16, p = 0.008), but this did not translate into a reduced hospital length of stay (SMD = -1.13, 95% CI -2.43 to 0.16, N.S). For nontime-dependent factors, incidence of delirium was unaffected between groups (odds ratio [OR]: 0.68, 95% CI 0.43-1.06, N.S), and higher rates of bradycardia (OR: 3.39, 95% CI: 1.20-9.55, p = 0.020) and hypotension (OR: 1.68, 95% CI 1.09-2.58, p = 0.017) were reported with propofol.

CONCLUSIONS

Despite the ICU time advantages afforded by dexmedetomidine over propofol, the former did not seem to contribute to an overall reduction in hospital length of stay or improvement in postoperative outcomes of heart valve surgery and CABG patients.

Safety of dexmedetomidine in the cardiac intensive care unit

AIMS

Dexmedetomidine is one of the sedative agents recommended by the Society of Critical Care Medicine as a preferred option over benzodiazepines in critically ill, mechanically ventilated patients. Little data exists describing sedation in the cardiac intensive care unit (CICU). The purpose of this study was to determine the prevalence of adverse events in CICU patients treated with dexmedetomidine.

METHODS AND RESULTS

This was a retrospective cohort analysis of patients >18 years old admitted to the University of Michigan CICU from June 2014 to October 2019 who received dexmedetomidine therapy. The primary outcome was the composite of adverse events including bradycardia, hypotension, increasing vasopressor/inotrope requirements, and asystole. Secondary outcomes included individual components of the primary outcome. Patients that experienced adverse events were compared to those that did not experience adverse events to identify risk factors for adverse events. A total of 197 patients were included. There were 116 adverse events in 106 patients. Hypotension was the most common adverse event, making up 60.3% of adverse events reported. Increased vasopressor requirement and bradycardia both occurred in 22 patients (18.9%). Asystole occurred in two patients. B-type natriuretic peptide (BNP) levels were significantly higher in those experiencing an adverse event (848 pg/mL vs. 431 pg/mL; P = 0.03).

CONCLUSIONS

Patients admitted to the CICU experienced a high rate of adverse events with dexmedetomidine use. Those experiencing adverse events were more likely to have a higher BNP. Future studies should explore the safety of alternative sedative agents to ascertain safe pharmacological options for patients admitted to the CICU.

Dexmedetomidine in cancer surgeries: Present status and consequences with its use

Dexmedetomidine is a centrally acting α2 adrenoreceptor agonist used in perioperative medicine due to its sedative, analgesic and sympatholytic properties. Recently animal data has pointed towards potential role of dexmedetomidine in promoting cancer recurrence and metastasis when used perioperatively especially after breast surgeries. This is because of presence of α2 adrenoreceptors in breast cancer tissue. We reviewed existing literature in which dexmedetomidine was used in cancer surgeries and investigated its role in recurrence and metastasis.

Delirium in the Intensive Care Unit: Is Dexmedetomidine Effective?

Delirium in the intensive care unit affects approximately 30% of patients despite vigorous efforts to encourage the use of effective screening tools and preventive strategies. The success of pharmacological treatment of delirium remains equivocal; moreover, a paucity of research supports the use of atypical antipsychotic medications. However, dexmedetomidine appears to have a promising role in delirium management. This review includes an overview of the pathophysiology and types of delirium and describes 2 established tools used to screen for delirium. Published research related to the use of dexmedetomidine in the management of delirium is also discussed. The authors make recommendations for critical care nurses on dexmedetomidine use in the context of providing evidence-based nursing care to intensive care unit patients with delirium.

Extubation in the Emergency Department and Resuscitative Unit Setting

A subset of intubated patients can safely be extubated in the emergency department (ED). The emergency medicine provider should be prepared for both common and life-threatening complications if considering ED extubation. Patients selected for extubation in the ED should have a low or near zero risk of reintubation or extubation failure. Intensive nursing care, close monitoring, and the ability to reintubate are minimum requirements for EDs considering ED extubation. This article provides a framework for determining appropriate patients for extubation and a practical approach on how to safely perform the procedure.

Combination of Dexmedetomidine and Ketamine for Magnetic Resonance Imaging Sedation

Objectives: The use of dexmedetomidine and ketamine (DEX-KET) combination for magnetic resonance imaging (MRI) sedation has not been evaluated. We investigated the efficacy and safety of DEX-KET for sedation of patients undergoing MRI of the brain. Methods: This quasi-experimental study was conducted to compare the DEX-KET combination and midazolam for MRI sedation. We included 72 patients undergoing brain MRI following bolus injection of midazolam or DEX-KET. In August 1, 2016 a new MRI sedation protocol was implemented. After protocol implementation, bolus doses of DEX-KET were administered (DEX-KET group). Thirty-six patients from the MIDA group and 36 patients from the DEX-KET group underwent MRI sequences and were compared regarding the MRI scan time and sedation-related complications (desaturation, hypotension, cardiorespiratory arrest, and aspiration pneumonia). Results: All MRI sequences were completed for 30 patients (83.3%) from the MIDA group and for 33 patients (91.7%) from the DEX-KET group (P = 0.476). The median MRI scan time was 100.0 min (interquartile range, 87.0-111.5 min) in the MIDA group and 53.5 min (interquartile range, 45.0-60.5 min) in the DEX-KET group (P < 0.001). Complications occurred in 24 (66.7%) and 8 (22.2%) patients of the MIDA and DEX-KET group, respectively (P < 0.001). Conclusions: The efficacy of DEX-KET sedation was comparable to that of midazolam for MRI examination. DEX-KET was related to shorter scan time and lower occurrence of complications compared to midazolam.

Psychogenic stress in hospitalized veterinary patients: Causation, implications, and therapies

OBJECTIVE

To review the sources, adverse effects, diagnosis, treatment, and prevention of psychogenic stress in hospitalized human and veterinary patients.

DATA SOURCES

Data were collected by searching PubMed for veterinary and human literature from the past 10 years.

HUMAN DATA SYNTHESIS

Psychogenic stress has been linked to immune suppression; gastrointestinal, cardiovascular, and cutaneous diseases; delayed wound healing; alterations in pain perception; and neurologic impairment. Sources of psychogenic stress include environmental alterations such as excessive noise and light, social and physical factors, sleep disruption, drugs, and underlying disease. Nonpharmacologic options for stress reduction include environmental and treatment modifications, music therapy, and early mobilization. Pharmacologic options include sedation with benzodiazepines and dexmedetomidine. Trazodone and melatonin have been examined for use in sleep promotion but are not currently recommended as standard treatments in ICU.

VETERINARY DATA SYNTHESIS

Activation of the stress response in veterinary patients is largely the same as in people, as are the affected body systems. Possible sources of stress can include social, physical, and environmental factors. No gold standard currently exists for the identification and quantification of stress. A combination of physical examination findings and the results of serum biochemistry, CBC, and biomarker testing can be used to support the diagnosis. Stress scales can be implemented to identify stressed patients and assess severity. Nonpharmacologic treatment options include low-stress handling, pheromones, environmental modifications, and sleep promotion. Pharmacologic options include trazodone, benzodiazepines, dexmedetomidine, and melatonin.

CONCLUSION

The prevalence and clinical significance of psychogenic stress in hospitalized veterinary patients is unknown. Future studies are needed to specifically examine the causative factors of psychogenic stress and the effects of various therapies on stress reduction. The recognition and reduction of psychogenic stress in veterinary patients can lead to improvements in patient care and welfare.

Pharmacologic Considerations of Anesthetic Agents in Pediatric Patients: A Comprehensive Review

Acute pain in the pediatric population has important differences in terms of biology, intrapopulation variation, and epidemiology. Discussion as to the pharmacologic considerations of anesthetic agents, such as induction agents, neuromuscular blockers, opioids, local anesthetics, and adjuvant agents, is presented in this article. Special considerations and concerns, such as risk for propofol infusion syndrome and adverse potential side effects of anesthesia agents, are discussed. Anesthesiologists managing pediatric patients need to have a firm understanding of physiologic and pharmacologic differences compared with the adult population. Future studies to improve the understanding of pharmacokinetics in the pediatric population are needed.

Risks and benefits of pre-operative dexmedetomidine in oral and maxillofacial surgeries: a systematic review

INTRODUCTION

Oral and maxillofacial surgeries might induce anxiety and pain to the patients. Sedative agents are one of the best ways for eliminating such consequences. Dexmedetomidine (DEX) is a recent sedative agent which presents higher sedative quality with greater specificity than other drugs. The aim of present paper is to evaluate the risks and benefits of administrating DEX during oral and maxillofacial surgeries by reviewing high quality released articles. Areas covered: Searches on PubMed, Scopus and Web of Science databases were completed with focus on randomized controlled trials (RCT). Related articles, from 2000 to 2015, were selected based on inclusion criteria and quality assessments factors. Full texts of the selected articles were screened and their significant information were gathered for judgments. Expert opinion: 17 RCTs on a total of 765 patients were screened. Some of the difficulties during reviewing the articles were: different pharmacokinetic and pharmacodynamics of drugs when combined with DEX, different time spots and method of monitoring, including studies on both minor and major surgeries for better data collection. Recent researches are going to focus on application of DEX for in-office procedures because of its desirable properties. Nevertheless, the analgesic and amnesic features of DEX are still questionable.

Comparison of Dexmedetomidine and Midazolam for Sedation in Mechanically Ventilated Patients Guided by Bispectral Index and Sedation-Agitation Scale

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.

Perioperative stroke in a patient undergoing surgery for oral cancer: A case report

Carotid artery stenosis is a significant risk factor for stroke. In elderly patients with carotid atherosclerosis and stenosis, it is not unusual for oral, head and neck cancer surgery to be performed. The present study describes a case of stroke that occurred during a neck dissection for the treatment of cervical lymph node metastasis of a left maxillary gingival carcinoma. The patient was an 84-year-old female who was considered to be at high risk of a stroke based on pre-operative head and neck computed tomography scans, which detected severe carotid atherosclerosis and stenosis. There was no possible stroke prophylaxis available during the performance of the neck dissection in the present case. However, if patients are evaluated to be high-risk pre-operatively, statin agents should be administered, the surgery should be carefully performed, adequate sedation should be maintained post-operatively and the patient should be followed up, aiming to achieve the early detection of a possible stroke.

Dexmedetomidine reduces the risk of delirium, agitation and confusion in critically Ill patients: a meta-analysis of randomized controlled trials

OBJECTIVES

Delirium frequently is observed in critically ill patients in the intensive care unit (ICU) and is associated strongly with a poor outcome. Dexmedetomidine seems to reduce time to extubation and ICU stay without detrimental effects on mortality. The objective of the authors' study was to evaluate the effect of this drug on delirium, agitation, and confusion in the ICU setting.

DESIGN

Meta-analysis of all the randomized clinical trials ever performed on dexmedetomidine versus any comparator in the ICU setting.

SETTING

Intensive care units.

PARTICIPANTS

Critically ill patients.

INTERVENTIONS

None

MEASUREMENTS AND MAIN RESULTS

Pertinent studies were independently searched in BioMedCentral, PubMed, Embase, and the Cochrane Central Register of clinical trials. Primary endpoint was the rate of delirium, including the adverse events, agitation and confusion. The 13 included manuscripts (14 trials) randomized 3,029 patients. Overall analysis showed that the use of dexmedetomidine was associated with significant reductions in the incidence of delirium, agitation and confusion (298/1,565 [19%] in the dexmedetomidine group v 337/1,464 [23%] in the control group, RR = 0.68 [0.49 to 0.96], p = 0.03). Results were confirmed in subanalyses performed on patients undergoing noninvasive ventilation (1/53 [2%] in the dexmedetomidine group v 7/49 [14%] in the control group, RR=0.18 [0.03 to 1.01], p = 0.05), receiving midazolam as a comparator (268/1,164 [23%] in the dexmedetomidine group v 277/1,025 [27%] in the control group, RR = 0.68 [0.47 to 1.00], p = 0.05) and in general ICU setting patients (204/688 [30%] in the dexmedetomidine group v 204/560 [36%] in the control group, RR = 0.68 [0.45 to 0.81], p < 0.01).

CONCLUSIONS

This meta-analysis of randomized controlled studies suggests that dexmedetomidine could help to reduce delirium in critically ill patients.

Sleep in the Intensive Care Unit

Patients in the intensive care unit (ICU) are susceptible to sleep deprivation. Disrupted sleep is associated with increased morbidity and mortality in the critically ill patients. The etiology of sleep disruption is multifactorial. The article reviews the literature on sleep in the ICU, the effects of sleep deprivation, and strategies to promote sleep in the ICU. Until the impact of disrupted sleep is better explained, it is appropriate to provide critically ill patients with consolidated, restorative sleep.

Comparison of clinical outcomes in nonintubated patients with severe alcohol withdrawal syndrome treated with continuous-infusion sedatives: dexmedetomidine versus benzodiazepines

STUDY OBJECTIVE

To compare efficacy and safety outcomes in nonintubated patients with severe alcohol withdrawal syndrome (AWS) who required a continuous infusion of a benzodiazepine or dexmedetomidine in addition to standard medical therapy for AWS.

DESIGN

Retrospective cohort study.

SETTING

Two hospitals within the same network that used different treatment strategies for AWS.

PATIENTS

A total of 61 nonintubated adults who received a continuous infusion of either a benzodiazepine (BZD) (lorazepam or midazolam; 33 patients) or dexmedetomidine (DEX) (28 patients) for severe AWS between April 1, 2011, and October 31, 2012, as well as standard medical therapy for AWS.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was a composite end point including rates of respiratory distress requiring endotracheal intubation or occurrence of alcohol withdrawal seizures. No significant differences in the composite end point were noted between the BZD and DEX groups (9.1% and 7.1%, respectively, p>0.99) or its individual components of respiratory distress (9.1% and 7.1%, respectively, p>0.99) or alcohol withdrawal seizures (0% and 3.6%, respectively, p=0.46). The DEX group received a lower median total dose of lorazepam equivalents after initiation of the study drug (median [interquartile range] 105 [60-199.5] mg in the BZD group vs 3.5 [0-12] mg in the DEX group), but this did not translate into a reduced requirement for endotracheal intubation or decreased length of stay. DEX was associated with more adverse drug events including hypotension and bradycardia. Of concern, DEX may impair the ability to assess symptoms appropriately and administer BZDs in a symptom-triggered fashion. Although the total cost of hospitalization was similar between groups, DEX was associated with a higher study drug cost per patient.

CONCLUSION

DEX demonstrated a BZD-sparing effect in the treatment of AWS; however, this surrogate end point should be interpreted with caution. Although this study cannot disprove the possibility of a protective effect of DEX in preventing the requirement for endotracheal intubation in patients with AWS, an increased rate of adverse drug events and increased study drug costs were observed. If DEX is used in clinical practice, it should only be used as adjunctive therapy with BZDs that have a proven benefit in AWS.

Effect of intraoperative Dexmedetomidine infusion on Sevoflurane requirement and blood glucose levels during entropy-guided general anesthesia

Background:

Dexmedetomidine has been shown to blunt the stress response to surgery. Hence a study was designed to evaluate the effect of intravenous (IV) Dexmedetomidine infusion during general anesthesia for abdominal surgeries on blood glucose levels and on Sevoflurane requirements during anesthesia.

Materials and Methods:

Forty patients scheduled for abdominal surgery under general anesthesia were divided into Dexmedetomidine (D) group and Placebo (P) group of 20 each. Group D received a loading dose of Inj. Dexmedetomidine at 1 μg/kg/10 min diluted to 20 mL, followed by maintenance with 0.5 μg/kg/h., till the end of surgery. Group P received similar volume of IV normal saline. Anesthesia was maintained with nitrous oxide in oxygen and Sevoflurane keeping entropy between 40 and 60. Data were analyzed using students t test, chi square test and Fisher Exact test as applicable.

Results:

During the first postoperative hour, Dexmedetomidine group showed blood glucose levels of 118.2 ± 16.24 mg/dL, compared to placebo group which was 136.95 ± 19.76 mg/dL and it was statistically significant (P < 0.01). Mean hourly Sevoflurane requirement in Group D was 11.10 ± 2.17 mL, compared to 15.45 ± 3.97 mL in placebo group. In peri-operative period, the heart rate and MAP were significantly lower in Group D, when compared to placebo. Patients in Group D were better sedated and post-operative pain score was better in Group D compared to Group P.

Conclusion:

IV Dexmedetomidine was effective in blunting stress response to surgical trauma as indicated by lower blood glucose levels, and reduces Sevoflurane requirements during entropy guided general anesthesia without affecting time for extubation.

Interpatient variability in dexmedetomidine response: a survey of the literature

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.

Role of Dexmedetomidine for the Prevention and Treatment of Delirium in Intensive Care Unit Patients

OBJECTIVE:

To review recent clinical studies regarding the role of dexmedetomidine for prevention and treatment of delirium in intensive care unit (ICU) patients.

DATA SOURCES:

MEDLINE and PubMed searches (1988-Feburary 2013) were conducted, using the key words delirium, dexmedetomidine, Precedex, agitation, α-2 agonists, critical care, and intensive care. References from relevant articles were reviewed for additional information.

STUDY SELECTION AND DATA EXTRACTION:

Clinical trials comparing dexmedetomidine with other sedatives/analgesics or with antipsychotics for delirium were selected. Studies that evaluated the use of dexmedetomidine for sedation for more than 6 hours were included in this review.

DATA SYNTHESIS:

Dexmedetomidine is a highly selective α-2 receptor agonist that provides sedation, anxiolysis, and modest analgesia with minimal respiratory depression. Its mechanism of action is unique compared with that of traditional sedatives because it does not act on γ-aminobutyric acid receptors. In addition, dexmedetomidine lacks anticholinergic activity and promotes a natural sleep pattern. These pharmacologic characteristics may explain the possible antidelirium effects of dexmedetomidine. Eight clinical trials, including 5 double-blind randomized trials, were reviewed to evaluate the impact of dexmedetomidine on ICU delirium.

CONCLUSIONS:

Currently available evidence suggests that dexmedetomidine is a promising agent, not only for prevention but also for treatment of ICU-associated delirium. However, larger, well-designed trials are warranted to define the role of dexmedetomidine in preventing and treating delirium in the ICU.