Enteral Sedation in Patients Requiring Mechanical Ventilation During an Intravenous Analgesic and Sedative Shortage

Background: There is a paucity of data evaluating the use of enteral sedation in mechanical ventilation. A sedative shortage resulted in the use of this approach. Purpose: To evaluate the feasibility of using enteral sedatives to decrease intravenous (IV) analgesia and sedative requirements. Materials/Methods: This single-center, retrospective, observational study compared two groups of patients admitted to the ICU who were mechanically ventilated. One group received a combination of enteral and IV sedatives and the second group received IV monotherapy. Linear mixed model (LMM) analyses were performed to assess the impact of enteral sedatives on IV fentanyl equivalents, IV midazolam equivalents, and propofol. Mann-Whitney U tests were performed on percent of days at goal for Richmond Agitation and Sedation Scale (RASS) and critical care pain observation tool (CPOT) scores. Results: One hundred and four patients were included. The average cohort age was 62 years and 58.7% were male. The median length of mechanical ventilation was 7.1 days and the median length of stay was 11.9 days. The LMM estimated that enteral sedatives reduced IV fentanyl equivalents received per patient by an average of 305.6 mcg/day (P = .04), although did not significantly decrease midazolam equivalents or propofol. There was no statistically significant difference in CPOT scores (P = .57 and P = .46 respectively), however RASS scores in the enteral sedation group were more often at goal (P = .03); oversedation occurred more in the non-enteral sedation group (P = .018). Conclusion: Enteral sedation may be a possible way to decrease IV analgesia requirements during periods of shortage.

Clinical and economic impact of substituting dexmedetomidine for propofol due to a US drug shortage: examination of coronary artery bypass graft patients at an urban medical centre

BACKGROUND

Propofol has reduced healthcare costs in coronary artery bypass graft (CABG) surgery patients by decreasing post-operative duration of mechanical ventilation. However, the US shortage of propofol necessitated the use of alternative agents.

OBJECTIVE

This study sought to evaluate clinical and economic implications of substituting dexmedetomidine for propofol in patients undergoing CABG surgery.

METHODS

This was a retrospective cohort study. Patients undergoing isolated, elective CABG surgery and sedated with either propofol or dexmedetomidine during the study period were included. The cohorts were matched 1:1 based on important characteristics. The primary outcome was the number of patients achieving a post-operative duration of mechanical ventilation ≤6 h. Secondary outcomes were post-operative intensive care unit (ICU) length of stay (LOS) ≤48 h, total post-operative LOS ≤5 days, the need for adjunctive opioid therapy and associated cost savings. Variables recorded included patient demographics, co-morbid medical conditions, health risks, sedation drug doses, post-operative medical complications and sedation-related adverse events. Univariate and multivariate analyses were completed to examine the relationship between these covariates and post-operative LOS. The cost analysis consisted of examination of the net financial benefit (or cost) of choosing dexmedetomidine versus propofol in the study population, with utilisation observed in the study converted to costs using institutional data from the Premier database.

RESULTS

Eighty-four patients were included, with 42 patients per cohort. Mechanical ventilation duration ≤6 h was achieved in 24 (57.1 %) versus 7 (16.7 %) in the dexmedetomidine and propofol cohorts, respectively (p < 0.001). More patients treated with dexmedetomidine achieved ICU LOS ≤48 h (p < 0.05) and total hospital LOS ≤5 days (p < 0.05), as compared with the propofol group. Multivariate analysis revealed that having one or more post-operative medical complication was the most significant predictor of increased post-operative LOS, whereas choosing dexmedetomidine was also significant in terms of reduced post-operative LOS. The estimated net financial benefit of choosing dexmedetomidine versus propofol was US$2,613 per patient (year 2012 value).

CONCLUSIONS

Findings suggest that use of dexmedetomidine as an alternative to propofol for sedation of CABG patients post-operatively contributes to reduced mechanical ventilation time, ICU LOS and post-operative LOS. Higher drug costs resulting from the propofol shortage were offset by savings in post-operative room and board costs. Additional savings may be possible by preventing medical complications to the extent possible.