The association of duration of mechanical ventilation and ICU stay with the use of dexmedetomidine as a single or adjuvant sedative versus other sedatives in critically ill patients in the multidisciplinary intensive care unit at the Universitas Academic Hospital in Bloemfontein, 2015 versus 2017, a retrospective cohort analysis
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Date
2019-11
Authors
Swart, Reinier
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Publisher
University of the Free State
Abstract
Background: Sedation is often used in the intensive care unit (ICU), but can be harmful if used inappropriately or excessively. Dexmedetomidine offers a favourable, co-operative sedation profile, despite a higher relative cost compared to other commonly used sedatives. Dexmedetomidine also has analgesic and opioid-sparing properties. It is, however, highly protein-bound with known haemodynamic side effects, such as bradycardia and hypertension. The multidisciplinary ICU at our central South African hospital adopted the use of dexmedetomidine over the period of 2016. This study was done to see whether this change in practice affected the ICU length of stay and duration of mechanical ventilation at this unit. Methods: This study was done as a retrospective cohort analysis and the files of patients who were sedated with midazolam and propofol in 2015 and those who were sedated with dexmedetomidine in 2017, were used to note the sedatives, demographic data, vital data and treatment. Institutional Ethics (UFS-HSD2018/0542/2808) and Free State Department of Health approval was obtained. Funding was obtained from the Research Committee of the Three Schools of Medicine, UFS to secure a research assistant who helped with collecting file numbers and files. Group 2015 and Group 2017 were also analysed for possible confounders, where appropriate, and these confounders were excluded for a re-analysis to assess for contribution to the primary or secondary outcomes. Results: There were 52 patients in Group 2015 and 60 patients in Group 2017. No difference was found in the duration of ICU length of stay (LOS) (median 5 vs 8.5 days, p = 0.1) or mechanical ventilation (median 91 vs 129 hours, p = 0.44). Those who were sedated with dexmedetomidine had better initial prognoses (median APACHE II 13 vs 18), were sedated for greater fractions of their total ICU admission times (median 46% vs 25%) and had a higher incidence of hypotension and bradycardia (36.7% vs 11.4%, p < 0.01); which did not relate to a higher mortality. The findings of more incidences of hypotension may relate to the bradycardia experienced with the use of dexmedetomidine. Spearman rank correlation coefficients also showed a weak to moderate association with longer ICU stay and ventilation duration when the duration of sedation with midazolam or propofol was shorter. Conclusion: This study did not show a reduction in ICU LOS or mechanical ventilation with the advent of dexmedetomidine in our unit. The absence of regular documentation of sedation levels and scheduled sedation breaks may have contributed to these results. Dexmedetomidine has a role to play in the ICU setting, but it should only be used when clearly indicated, with a clear protocol for its use, in order to warrant its higher cost. Vigilance for hypotension and bradycardia is required when using dexmedetomidine. More prospective research is required to validate these findings in a resource-constrained environment, but evidence from high income countries supports these findings.
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Keywords
Dissertation (M.Med (Anaesthesiology))--University of the Free State, 2019, Death, Dexmedetomidine, Discharge, Duration of mechanical ventilation, Intensive care unit / ICU, Length of stay / LOS, Midazolam, Propofol, Sole or adjuvant, Sedative