Dexmedetomidine Might Help Liberate Delirious Patients from the Ventilator
Patricia Kritek, MD
Treatment with dexmedetomidine for as long as 1 week shortened delirium duration and mechanical ventilation time by nearly 1 day.
Dexmedetomidine is a sedating α-2 agonist that doesn’t impair respiratory drive. In this multicenter study, investigators randomized 74 intensive care unit (ICU) patients with agitated delirium to receive either dexmedetomidine or placebo for ≤7 days. All patients were receiving mechanical ventilation and remained intubated only because lowering sedation levels to allow extubation would have been unsafe. This determination was made by treating clinicians based on objective criteria (i.e., need for mechanical restraints or sedative medications, and presence of delirium and psychomotor agitation according to standard scales).
Dexmedetomidine recipients were extubated sooner than placebo recipients (median time to extubation, 22 vs. 44 hours) and had faster resolution of delirium (median, 23 vs. 40 hours) and more ventilator-free time during the 7 days after randomization (median, 145 vs. 128 hours). However, active treatment did not affect ICU or hospital lengths of stay. Nearly all patients were sedated with propofol; those in the dexmedetomidine group received lower quantities of propofol, benzodiazepines, and opioids. The study was stopped early because of slower-than-expected enrollment.
These results don’t convince me that dexmedetomidine has a direct effect on delirium; rather, the drug’s main effect might be to lessen use of other medications that contribute to delirium. A trial of dexmedetomidine in an intubated patient with uncontrollable agitated delirium seems reasonable, given the lack of good alternatives and the downsides of prolonged intubation. However, larger studies that demonstrate shortened ICU and hospital lengths of stay are needed before dexmedetomidine can become a “go-to” drug.
Reade MC et al. Effect of dexmedetomidine added to standard care on ventilator-free time in patients with agitated delirium: A randomized clinical trial. JAMA 2016 Apr 12; 315:1460.(http://dx.doi.org/10.1001/jama.2016.2707)
Ely EW and Pandharipande PP.The evolving approach to brain dysfunction in critically ill patients. JAMA 2016 Apr 12; 315:1455.(http://dx.doi.org/10.1001/jama.2016.2708)
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