Abstract
Objective: Compare the duration of mechanical ventilation between patients receiving sedation with continuous infusions of propofol alone or combination with the use of dexmedetomidine and propofol. Design: Retrospective, propensity matched (1:1) cohort study, employing eight variables chosen a priori for matching. Timing of exposure to dexmedetomidine initiation was incorporated into a matching algorithm. Setting: Level 1, university-based, 32-bed, adult, mixed trauma and surgical intensive care unit (SICU). Continuous sedation was delivered according to a protocol methodology with daily sedation vacation and spontaneous breathing trials. Choice of sedation agent was physician directed. Patients: Between 2010 and 2014, 149 SICU patients receiving mechanical ventilation for >24 h received dexmedetomidine with propofol. Propensity matching resulted in 143 pair cohorts. Interventions: Dexmedetomidine with propofol or propofol alone. Measurements and Main Results: There was no statistical difference in SICU length of stay (LOS), with a median absolute difference of 5.3 h for propofol alone group (p = 0.43). The SICU mortality was not statistically different (RR = 1.002, p = 0.88). Examining a 14-day period post-treatment with dexmedetomidine, on any given day (excluding days 1 and 14), dexmedetomidine with propofol-treated patients had a 0.5% to 22.5% greater likelihood of being delirious (CAM-ICU positive). In addition, dexmedetomidine with propofol-treated patients had a 4.5% to 18.8% higher likelihood of being above the target sedation score (more agitated) compared to propofol-alone patients. Conclusions: In this propensity matched cohort study, adjunct use of dexmedetomidine to propofol did not show a statistically significant reduction with respect to mechanical ventilation (MV) duration, SICU LOS, or SICU mortality, despite a trend toward receiving fewer hours of propofol. There was no evidence that dexmedetomidine with propofol improved sedation scores or reduced delirium.
Highlights
Mechanical ventilation is a life-saving intervention utilized in 20–30% of intensive care unit (ICU) admissions, but it is associated with many risks
Patient data was collected at a Level 1 trauma university hospital, within a 32-bed mixed trauma and surgical intensive care unit (SICU)
Chi-Squared Test; b Fisher’s Exact Test; DXM = dexmedetomidine. In this analysis of SICU patients, we found that the use of dexmedetomidine as an adjunct sedative in patients already receiving propofol provided no obvious benefit in terms of mechanical ventilation duration, time in the SICU, and all-cause SICU mortality when compared to a propensity matched group of patients receiving propofol alone
Summary
Mechanical ventilation is a life-saving intervention utilized in 20–30% of intensive care unit (ICU) admissions, but it is associated with many risks. The use of mechanical ventilation is one of the costliest interventions in the ICU, accounting for an estimated $27 billion, or 12% of all hospital costs [1,2,3]. The delivery of sedation and analgesic agents are often necessary supportive treatments which are highly effective in providing comfort, tolerance, and improving ventilator synchrony [2]. There are known consequences to using sedative medications, including potentially prolonged duration of mechanical ventilation, increased overall. One of the major goals for critical care clinicians is achieving a balance between adequate levels of sedation without causing a concomitant prolonged need for ventilator support. In the age of evidence-based medicine, clinicians refer to society-specific guidelines for treatment direction
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