Abstract
BackgroundTo determine the preventive and therapeutic effect of dexmedetomidine on intensive care unit (ICU) delirium.MethodsThe literature search using PubMed and the Cochrane Central Register of Controlled Trials was performed (August 1, 2018) to detect all randomized controlled trials (RCTs) of adult ICU patients receiving dexmedetomidine. Articles were included if they assessed the influence of dexmedetomidine compared to a sedative agent on incidence of ICU delirium or treatment of this syndrome. Accordingly, relevant articles were allocated to the following two groups: (1) articles that assessed the delirium incidence (incidence comparison) or articles that assessed the treatment of delirium (treatment comparison). Incidence of delirium and delirium resolution were the primary outcomes. We combined treatment effects comparing dexmedetomidine versus (1) placebo, (2) standard sedatives, and (3) opioids in random-effects meta-analyses. Risk of bias for each included RCT was assessed following Cochrane standards.ResultsThe literature search resulted in 28 articles (25 articles/4975 patients for the incidence comparison and three articles/166 patients for the treatment comparison). In the incidence comparison, heterogeneity was present in different subgroups. Administration of dexmedetomidine was associated with significantly lower overall incidence of delirium when compared to placebo (RR 0.52; 95% CI 0.39–0.70; I2 = 37%), standard sedatives (RR 0.63; 95% CI 0.46–0.86; I2 = 69%), as well as to opioids (RR 0.61; 95% CI 0.44–0.83; I2 = 0%). Use of dexmedetomidine significantly increased the risks of bradycardia and hypotension. Limited data were available on circulatory insufficiency and mortality. In the treatment comparison, the comparison drugs in the three RCTs were placebo, midazolam, and haloperidol. The resolution of delirium was measured differently in each study. Two out of the three studies indicated clear favorable effects for dexmedetomidine (i.e., compared to placebo and midazolam). The study comparing dexmedetomidine with haloperidol was a pilot study (n = 20) with high variability in the results.ConclusionFindings suggest that dexmedetomidine reduces incidence and duration of ICU delirium. Furthermore, our systematic searches show that there is limited evidence if a delirium shall be treated with dexmedetomidine.
Highlights
To determine the preventive and therapeutic effect of dexmedetomidine on intensive care unit (ICU) delirium
The remaining nine randomized controlled trial (RCT) consisted of six studies examining mechanically ventilated (MV) patients [32, 38, 40, 43, 44, 50] two examining noninvasively ventilated patients [35, 37] and one where dexmedetomidine was used for nightly sedation [56]
One article consisted of two separate RCTs comparing dexmedetomidine to midazolam and propofol, respectively [38]
Summary
To determine the preventive and therapeutic effect of dexmedetomidine on intensive care unit (ICU) delirium. It is a confusional state that has been described as a transient global disorder of cognition, awareness, and attention and as such is challenging for the treating medical team, and has a considerable impact on affected patients. It is associated with prolonged hospital length of stay and time on MV, deterioration in cognition, and increased morbidity and mortality causing additional health-care expenses [4,5,6]. Its pathophysiological mechanisms are highly heterogeneous—as perceived by the high number of risk factors [7]—and have yet to be fully understood. Certain hospital care characteristics (patient immobilization, bladder catheter, or sleep deprivation) further contribute to the development of delirium [8, 9]
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