Economic evaluation of dexmedetomidine relative to midazolam for sedation in the intensive care unit

Comparison of vital sign stability and cost effectiveness between midazolam and dexmedetomidine during third molar extraction under intravenous sedation

Objectives

To compare the vital sign stability and cost of two commonly used sedatives, midazolam (MDZ) and dexmedetomidine (DEX). Patients and.

Methods

This retrospective study targeted patients who underwent mandibular third molar extractions under intravenous sedation using MDZ or DEX. The predictor variable was the type of sedative used. The primary outcome variables were vital signs (heart rate and blood pressure), vital sign outliers, and cost of the sedatives. A vital sign outlier was defined as a 30% or more change in vital signs during sedation; the fewer changes, the higher the vital sign stability. The secondary outcome variables included the observer's assessment of alertness/sedation scale, level of amnesia, patient satisfaction, and bispectral index score. Covariates were sex, age, body mass index, sleeping time, dental anxiety score, and Pederson scale. Descriptive statistics were computed including propensity score matching (PSM). The P-value was set at 0.05.

Results

The study enrolled 185 patients, 103 in the MDZ group and 82 in the DEX group. Based on the data after PSM, the two samples had similar baseline covariates. The sedative effect of both agents was satisfactory. Heart rate outliers were more common with MDZ than with DEX (49.3% vs 22.7%, P=0.001). Heart rate was higher with MDZ (P=0.000). The cost was higher for DEX than for MDZ (29.27±0.00 USD vs 0.37±0.04 USD, P=0.000).

Conclusion

DEX showed more vital sign stability, while MDZ was more economical. These results could be used as a reference to guide clinicians during sedative selection.

Sequential use of midazolam and dexmedetomidine for long-term sedation may reduce weaning time in selected critically ill, mechanically ventilated patients: a randomized controlled study

Background

Current sedatives have different side effects in long-term sedation. The sequential use of midazolam and dexmedetomidine for prolonged sedation may have distinct advantages. We aimed to evaluate the efficacy and safety of the sequential use of midazolam and either dexmedetomidine or propofol, and the use of midazolam alone in selected critically ill, mechanically ventilated patients.

Methods

This single-center, randomized controlled study was conducted in medical and surgical ICUs in a tertiary, academic medical center. Patients enrolled in this study were critically ill, mechanically ventilated adult patients receiving midazolam, with anticipated mechanical ventilation for ≥ 72 h. They passed the spontaneous breathing trial (SBT) safety screen, underwent a 30-min-SBT without indication for extubation and continued to require sedation. Patients were randomized into group M-D (midazolam was switched to dexmedetomidine), group M-P (midazolam was switched to propofol), and group M (sedation with midazolam alone), and sedatives were titrated to achieve the targeted sedation range (RASS − 2 to 0).

Results

Total 252 patients were enrolled. Patients in group M-D had an earlier recovery, faster extubation, and more percentage of time at the target sedation level than those in group M-P and group M (all P < 0.001). They also experienced less weaning time (25.0 h vs. 49.0 h; HR1.47, 95% CI 1.05 to 2.06; P = 0.025), and a lower incidence of delirium (19.5% vs. 43.8%, P = 0.002) than patients in group M. Recovery (P < 0.001), extubation (P < 0.001), and weaning time (P = 0.048) in group M-P were shorter than in group M, while the acquisition cost of sedative drug was more expensive than other groups (both P < 0.001). There was no significant difference in adverse events among these groups (all P > 0.05).

Conclusions

The sequential use of midazolam and dexmedetomidine was an effective and safe sedation strategy for long-term sedation and could provide clinically relevant benefits for selected critically ill, mechanically ventilated patients.

Trial registration

NCT02528513. Registered August 19, 2015.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-03967-5.

Use of Preoperative Single Dose Ivabradine for Perioperative Hemodynamic Stabilization During Non-Cardiac Elective Surgery Under General Anaesthesia: A Pilot Study

BACKGROUND

Peri-anesthetic hemodynamic fluctuations during non-cardiac surgeries are sometimes of serious consequences and associated with increased morbidity and mortality, especially in undiagnosed vulnerable patients. Currently used drugs like β-blocker, α2 agonist or sedative analgesic have their own limitations like combined negative ionotropic and chronotropic action, and unwanted bradycardia associated with hypotension, respectively. In this context, ivabradine has been used extensively in cases of cardiac failure, myocardial ischemia and cardiomyopathies for its funny channel associated dependable heart rate reducing property. Hence, for the first time, in search of a better agent for perioperative hemodynamic stabilization, the present study evaluated the role of ivabradine in patients undergoing non-cardiac surgeries.

METHODS

This was a prospective, observer blind, randomized, interventional pilot study, conducted among 50 patients belonging undergoing elective abdominal laparoscopic surgeries, under general anesthesia. The study group patients received ivabradine tablet 7.5 mg, 2 h before scheduled time of surgery with a sip of water. All the patients received standardized balanced general anesthesia as practiced in our institute with all standard monitoring with additional minimum alveolar concentration (MAC) monitoring to ensure an adequate depth of anesthesia, and neuromuscular monitoring to ensure adequate and standard muscle relaxation. Hemodynamic stability of the groups was tested by comparing them at time points like induction, incision and operation, and extubation. Mean values of heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP) were compared between groups, and also for variation with lapse of time, using RMANOVA analysis, using baseline parameters as covariate so as to standardize them.

RESULTS

On multivariate analysis using Wilk's lambda multivariate test, there was a statistically significant difference (F = 3.587, P = 0.036) in HR between the groups with time, while no significant difference of SBP, DBP and MAP between the groups with time.

CONCLUSIONS

The study revealed a significant attenuation of HR response to stressful events like laryngoscopy, intubation and surgical incision with ivabradine. Also, a good intraoperative protection against cardiovascular ischemic and arrhythmic episodes in perioperative period was achieved with this drug ivabradine.

<p>Cost-Minimization Analysis of Dexmedetomidine Compared to Other Sedatives for Short-Term Sedation During Mechanical Ventilation in the United States</p>

Purpose

Mechanical ventilation (MV) remains a substantial cost driver in intensive care units (ICU) in the United States (US). Evaluations of standard sedation treatments used to relieve pain and discomfort in this setting have found varying impacts on ICU length of stay. This cost analysis examines both length-of=stay costs and the total cost implications among MV patients receiving common sedative treatments (dexmedetomidine, propofol, or midazolam) in short-term sedation settings (<24 hours).

Methods

A cost-minimization model was conducted from the hospital provider perspective. Clinical outcomes were obtained from published literature and included ICU length of stay, MV duration, prescription of sedatives and pain medication, and the occurrence of adverse events. Outcomes costs were obtained from previously conducted ICU cost studies and Medicare payment fee schedules. All costs were estimated in 2018 US Dollars.

Results

The per patient costs associated with dexmedetomidine, propofol, and midazolam were estimated to be $21,115, $27,073, and $27,603, respectively. Dexmedetomidine was associated with a savings of $5958 per patient compared to propofol and a saving of $6487 compared to midazolam. These savings were primarily driven by a reduction in ICU length of stay and the degree of monitoring and management.

Conclusion

Dexmedetomidine was associated with reduced costs when compared to propofol or midazolam used for short-term sedation during MV in the ICU, suggesting sedative choice can have a potential impact on overall cost per episode.

Effect of dexmedetomidine and midazolam for flexible fiberoptic bronchoscopy in intensive care unit patients: A retrospective study

This study aimed to investigate the clinical effectiveness of dexmedetomidine and midazolam for sedation of intensive care unit (ICU) patients requiring flexible fiberoptic bronchoscopy (FFB).This retrospective cohort study included 148 patients from the third ICU ward of the Second Affiliated Hospital of Harbin Medical University (Harbin, China) who received simultaneous invasive mechanical ventilation and FFB between March 2012 and December 2014. Patients were divided into dexmedetomidine (n  =  72) and midazolam (n  =  76) groups according to sedative mode. The sedative effects, incidence of adverse events, and bronchoscopist satisfaction scores were compared between groups.During FFB, total sedation time and total time of FFB were significantly shorter in the midazolam group (P < .001, respectively), with a lower percentage of these patients requiring propofol for remedial sedation (P < .001). The incidence of FFB-related adverse events (including bronchospasm, cough, and decreased oxygen saturation) was significantly higher in dexmedetomidine group compared with midazolam group (P  =  .007, .014 and .008, respectively). However, the incidence of other adverse events was not significantly different between groups. In addition, bronchoscopist satisfaction scores were significantly higher in the midazolam compared with dexmedetomidine group (7.72 ± 1.65 vs 7.08 ± 1.77; P  =  .030).For sedation of ICU patients during FFB, combination of midazolam and dexmedetomidine demonstrated an enhanced sedative effect, lower incidence of adverse events, and higher bronchoscopist satisfaction score compared with dexmedetomidine alone, thus represents a suitable alternative sedative for FFB patients.

Alpha-2 agonists for sedation of mechanically ventilated adults in intensive care units: a systematic review

BACKGROUND

Care of critically ill patients in intensive care units (ICUs) often requires potentially invasive or uncomfortable procedures, such as mechanical ventilation (MV). Sedation can alleviate pain and discomfort, provide protection from stressful or harmful events, prevent anxiety and promote sleep. Various sedative agents are available for use in ICUs. In the UK, the most commonly used sedatives are propofol (Diprivan(®), AstraZeneca), benzodiazepines [e.g. midazolam (Hypnovel(®), Roche) and lorazepam (Ativan(®), Pfizer)] and alpha-2 adrenergic receptor agonists [e.g. dexmedetomidine (Dexdor(®), Orion Corporation) and clonidine (Catapres(®), Boehringer Ingelheim)]. Sedative agents vary in onset/duration of effects and in their side effects. The pattern of sedation of alpha-2 agonists is quite different from that of other sedatives in that patients can be aroused readily and their cognitive performance on psychometric tests is usually preserved. Moreover, respiratory depression is less frequent after alpha-2 agonists than after other sedative agents.

OBJECTIVES

To conduct a systematic review to evaluate the comparative effects of alpha-2 agonists (dexmedetomidine and clonidine) and propofol or benzodiazepines (midazolam and lorazepam) in mechanically ventilated adults admitted to ICUs.

DATA SOURCES

We searched major electronic databases (e.g. MEDLINE without revisions, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE and Cochrane Central Register of Controlled Trials) from 1999 to 2014.

METHODS

Evidence was considered from randomised controlled trials (RCTs) comparing dexmedetomidine with clonidine or dexmedetomidine or clonidine with propofol or benzodiazepines such as midazolam, lorazepam and diazepam (Diazemuls(®), Actavis UK Limited). Primary outcomes included mortality, duration of MV, length of ICU stay and adverse events. One reviewer extracted data and assessed the risk of bias of included trials. A second reviewer cross-checked all the data extracted. Random-effects meta-analyses were used for data synthesis.

RESULTS

Eighteen RCTs (2489 adult patients) were included. One trial at unclear risk of bias compared dexmedetomidine with clonidine and found that target sedation was achieved in a higher number of patients treated with dexmedetomidine with lesser need for additional sedation. The remaining 17 trials compared dexmedetomidine with propofol or benzodiazepines (midazolam or lorazepam). Trials varied considerably with regard to clinical population, type of comparators, dose of sedative agents, outcome measures and length of follow-up. Overall, risk of bias was generally high or unclear. In particular, few trials blinded outcome assessors. Compared with propofol or benzodiazepines (midazolam or lorazepam), dexmedetomidine had no significant effects on mortality [risk ratio (RR) 1.03, 95% confidence interval (CI) 0.85 to 1.24, I (2) = 0%; p = 0.78]. Length of ICU stay (mean difference -1.26 days, 95% CI -1.96 to -0.55 days, I (2) = 31%; p = 0.0004) and time to extubation (mean difference -1.85 days, 95% CI -2.61 to -1.09 days, I (2) = 0%; p < 0.00001) were significantly shorter among patients who received dexmedetomidine. No difference in time to target sedation range was observed between sedative interventions (I (2) = 0%; p = 0.14). Dexmedetomidine was associated with a higher risk of bradycardia (RR 1.88, 95% CI 1.28 to 2.77, I (2) = 46%; p = 0.001).

LIMITATIONS

Trials varied considerably with regard to participants, type of comparators, dose of sedative agents, outcome measures and length of follow-up. Overall, risk of bias was generally high or unclear. In particular, few trials blinded assessors.

CONCLUSIONS

Evidence on the use of clonidine in ICUs is very limited. Dexmedetomidine may be effective in reducing ICU length of stay and time to extubation in critically ill ICU patients. Risk of bradycardia but not of overall mortality is higher among patients treated with dexmedetomidine. Well-designed RCTs are needed to assess the use of clonidine in ICUs and identify subgroups of patients that are more likely to benefit from the use of dexmedetomidine.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42014014101.

FUNDING

The National Institute for Health Research Health Technology Assessment programme. The Health Services Research Unit is core funded by the Chief Scientist Office of the Scottish Government Health and Social Care Directorates.

Sedation and Analgesia

Patients in the cardiothoracic intensive care unit (CTICU) are subject to numerous physical and mental stresses. While most of these cannot be completely eliminated, intensivists have many tools in their armamentarium to alleviate patients' pain and suffering. This chapter will consider the importance of analgesia and sedation in the CTICU and the relevant consequences of over- or under-treatment. We will examine the tools available for monitoring and titrating analgesia and sedation in critically ill patients. The major classes of medications available will be reviewed, with particular attention to their clinical effects, metabolism and excretion, and hemodynamic characteristics. Lastly, experimental evidence will be assessed regarding the best strategies for treatment of pain and agitation in the CTICU, including use of non-pharmacologic adjuvants.

Alpha-2 agonists for sedation in mechanically ventilated neurocritical care patients: a systematic review protocol

BACKGROUND

Sedation is an important consideration in the care of the neurocritically ill patient. It provides anxiety and relief, facilitates procedures and nursing tasks, and minimizes intolerance of mechanical ventilation. Alpha-2 agonists such as dexmedetomidine and clonidine have been shown to be an effective alternative in the general critical care population by reducing duration of mechanical ventilation and length of stay in the intensive care unit (ICU), as compared to traditional sedative agents such as propofol or benzodiazepines. However, there is a paucity of literature detailing their utility and safety in neurocritical care, a population that presents unique considerations for management of global and cerebral hemodynamics, agitation, and facilitation of neurological assessments. The objective of this review is to assess the efficacy and safety of alpha-2 agonists for non-procedural sedation in mechanically ventilated brain-injured patients.

METHODS

We will search the Embase and MEDLINE databases for all randomized controlled trials, prospective and retrospective cohort studies examining neurocritically ill adult patients aged 18 years and older who are on mechanical ventilation and receiving alpha-2 agonists for non-procedural sedation. Primary outcomes of interest include effect on mean arterial pressure (MAP), intracranial pressure (ICP), and cerebral perfusion pressure (CPP). Secondary outcomes include adverse events, duration of mechanical ventilation, 30-day mortality, ICU length of stay, incidence of delirium, and quality of sedation. Continuous outcomes will be presented as means and mean differences and discrete counting events will be presented as event rates. Pre-defined criteria for heterogeneity are provided for determination of pooling eligibility. Where appropriate, we will pool estimates for individual outcomes. Planned subgroup analyses include specific alpha-2 agonist agent, study design, clinical diagnosis, dosing regimen, and use of adjunctive agents. Quality of evidence for the recommendation will be assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach where appropriate.

DISCUSSION

This systematic review will summarize the evidence on the efficacy and safety for the use of alpha-2 agonists as sedative agents in the neurocritical care population.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016037045.

Behavioral response and cost comparison of manual versus pharmacologic restraint protocols in healthy dogs

Although sedatives are routinely administered to dogs for diagnostic and minimally invasive procedures, manual restraint is often used. The study compared intra-procedural behavioral response, scored on a 100-point, visual analog scale, and cost of restraint in healthy dogs given 1 of 5 treatments: manual restraint, dexmedetomidine at 125 μg/m(2) (Dex 125) or 375 μg/m(2) (Dex 375), Dex 125 plus butorphanol at 0.4 mg/kg (Dex 125 + Bu), or Dex 375 plus butorphanol at 0.4 mg/kg (Dex 375 + Bu). Mean behavioral response scores in dogs declined from baseline in the manual restraint group and improved in a linear fashion in the group order Dex 125, Dex 375, Dex 125 + Bu, and Dex 375 + Bu. Dexmedetomidine at 375 μg/m(2) or at 125 μg/m(2) or at 375 μg/m(2) in combination with butorphanol produced the best intra-procedural behavioral response. The cost of sedative drugs was offset by the opportunity cost of diverting personnel from revenue-generating activity to manual restraint.

Dexmedetomidine versus standard care sedation with propofol or midazolam in intensive care: an economic evaluation

Introduction

Dexmedetomidine was shown in two European randomized double-blind double-dummy trials (PRODEX and MIDEX) to be non-inferior to propofol and midazolam in maintaining target sedation levels in mechanically ventilated intensive care unit (ICU) patients. Additionally, dexmedetomidine shortened the time to extubation versus both standard sedatives, suggesting that it may reduce ICU resource needs and thus lower ICU costs. Considering resource utilization data from these two trials, we performed a secondary, cost-minimization analysis assessing the economics of dexmedetomidine versus standard care sedation.

Methods

The total ICU costs associated with each study sedative were calculated on the basis of total study sedative consumption and the number of days patients remained intubated, required non-invasive ventilation, or required ICU care without mechanical ventilation. The daily unit costs for these three consecutive ICU periods were set to decline toward discharge, reflecting the observed reduction in mean daily Therapeutic Intervention Scoring System (TISS) points between the periods. A number of additional sensitivity analyses were performed, including one in which the total ICU costs were based on the cumulative sum of daily TISS points over the ICU period, and two further scenarios, with declining direct variable daily costs only.

Results

Based on pooled data from both trials, sedation with dexmedetomidine resulted in lower total ICU costs than using the standard sedatives, with a difference of €2,656 in the median (interquartile range) total ICU costs—€11,864 (€7,070 to €23,457) versus €14,520 (€7,871 to €26,254)—and €1,649 in the mean total ICU costs. The median (mean) total ICU costs with dexmedetomidine compared with those of propofol or midazolam were €1,292 (€747) and €3,573 (€2,536) lower, respectively. The result was robust, indicating lower costs with dexmedetomidine in all sensitivity analyses, including those in which only direct variable ICU costs were considered. The likelihood of dexmedetomidine resulting in lower total ICU costs compared with pooled standard care was 91.0% (72.4% versus propofol and 98.0% versus midazolam).

Conclusions

From an economic point of view, dexmedetomidine appears to be a preferable option compared with standard sedatives for providing light to moderate ICU sedation exceeding 24 hours. The savings potential results primarily from shorter time to extubation.

Trial registration

ClinicalTrials.gov NCT00479661 (PRODEX), NCT00481312 (MIDEX).

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-0787-y) contains supplementary material, which is available to authorized users.

Factors that contribute to underrecognition of delirium by registered nurses in acute care settings: a scoping review of the literature to explain this phenomenon

AIMS AND OBJECTIVES

In order to obtain more information regarding this phenomenon, a scoping review of the literature was undertaken to analyse current research on the recognition of delirium by registered nurses in acute care settings.

BACKGROUND

Delirium is often manifested as a sign of an underlying undiagnosed condition that requires immediate intervention and is frequently manifested in acute care settings. Unfortunately, registered nurses often do not recognise delirium and its occurrence goes under-reported.

DESIGN/METHODS

Based on six inclusion criteria, a search in numerous databases using terms such as delirium detection, recognition and diagnosis by registered nurses was undertaken. Eight quantitative studies were deemed relevant and analysed for this scoping review.

RESULTS

Seven major categories emerged: the fluctuating nature of delirium, the impact of delirium education on its recognition, communication barriers, inadequate use of delirium assessment tools, lack of conceptual understanding of delirium, delirium as a burden and the likeness of delirium and dementia. A brief summary of the findings in each category is reported here.

CONCLUSIONS

The scoping review revealed that delirium remains underrecognised by registered nurses, which potentially contributes to reduced quality of nursing care for clients experiencing this condition. Further research on delirium and the processes that registered nurses use to recognise it is timely and will facilitate the development of evidence-based interventions to manage it.

RELEVANCE TO CLINICAL PRACTICE

While acute care registered nurses have historically reported dramatic changes in cognitive and neuro-biological functions in ill older adults, the literature highlighted in this scoping review revealed the following: (1) the need for further research to validate delirium assessment tools and, (2) the need for education and training for registered nurses on the use of these assessment tools to promote early recognition and thereby decrease the incidence of delirium in older adults.

Safety and Effectiveness of Dexmedetomidine in the Pediatric Intensive Care Unit (SAD-PICU)

BACKGROUND

Critically ill children require sedation for comfort and to facilitate mechanical ventilation and interventions. Dexmedetomidine is a newer sedative with little safety data in pediatrics, particularly for therapy lasting longer than 48 h.

OBJECTIVE

To quantify the frequency of adverse events and withdrawal syndromes associated with dexmedetomidine and to describe the use of this drug for continuous sedation in critically ill children.

METHODS

In this retrospective study of patients who received dexmedetomidine for sedation in the pediatric intensive care unit, adverse events were assessed with the Naranjo scale to determine the likelihood of association with dexmedetomidine. Interventions in response to adverse events were also recorded.

RESULTS

One hundred and forty-four patients (median age 34 months, range 0 - 17.7 years) who underwent a total of 153 treatment courses were included. The mean infusion rate of dexmedetomidine was 0.42 μg/kg per hour (standard deviation 0.17 μg/kg per hour, range 0.05-2 μg/kg per hour). The median duration of therapy was 20.50 h (range 0.75-854.75 h), and 70 infusions (46%) lasted more than 24 h. At least one adverse event was observed in 115 (75%) of the treatment courses. Hypotension (81 [53%]) and bradycardia (38 [25%]) were the most common adverse events and were deemed "probably" attributable to dexmedetomidine in 17 (11%) and 9 (6%) of the treatment courses, respectively. In 55 of the 66 treatment courses with infusions lasting longer than 24 h for which post-infusion data were available, at least one withdrawal symptom was observed; agitation (41 [62%]) and hypertension (22 [33%]) were the most common withdrawal symptoms.

CONCLUSIONS

Dexmedetomidine was commonly administered for longer than 24 h in the authors' institution. Dexmedetomidine was generally well tolerated; however, the majority of patients experienced withdrawal symptoms. Patients receiving dexmedetomidine for more than 24 h should be monitored for withdrawal following discontinuation, and interventions should be provided if needed. Prospective, controlled studies are needed to characterize the safety of long-term dexmedetomidine therapy in critically ill children.