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Efficacy
Sedation for agitated ventilated patients
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| bet | 153/654 | | Sana | 03.01.2022 | | Hajmi | 1,5 Mb. | | #14803 |
Efficacy
Sedation for agitated ventilated patients: A Cochrane systematic review including seven studies covering 1624 participants found that compared with other sedatives, long-term sedation using dexmedetomidine in critically ill adults reduced the duration of mechanical ventilation and ICU length of stay. Dexmedetomidine doubled the incidence of bradycardia, which was the most commonly reported adverse event. Effect on other adverse event rates compared to other sedatives was heterogeneous including: hypotension; hypertension; tachycardia; first degree heart block; hyperglycaemia; and hypoglycaemia. There was no evidence that dexmedetomidine changed the overall death rate. [LOE I in adults] Children, infants and newborns were not included. [7]
A systematic review published in abstract form only reported 31 studies of prolonged dexmedetomidine sedation in paediatric patients involving a total of 3342 patients with nearly all being case series (94%) and retrospective (87%). No randomised trials were found. [8] A RCT of dexmedetomidine use in term neonates with moderate to severe hypoxic ischaemic encephalopathy is awaiting publication. [9]
A dose escalation study [10] in preterm (28-36 weeks gestation, n=18) and full-term (36-44 weeks, n=24) mechanically ventilated infants assessed the effects of 3 dosage levels of dexmedetomidine: Level 1: loading dose (LD) 0.05 microgram/kg; maintenance dose (MD) 0.05 microgram/kg/hour; Level 2: LD 0.1 microgram/kg; MD 0.1 microgram/kg/hour; Level 3: LD 0.2 microgram/kg; MD 0.2 microgram/kg/hour. Rescue sedation (midazolam) was given in 1 (7%) at level 1, 1 (7%) at level 2, and 2 (14%) at level 3. Rescue sedation was required in 4 (17%) preterm infants and 4 (10%) term infants. Rescue analgaesia (opioid) was given in 5 (36%) at level 1, and 5 (36%) at level 2; and 7 (50%) at level 3. Rescue sedation was required in 3 (17%) preterm infants and 14 (58%) term infants. Three adverse events were assessed as definitely related to dexmedetomidine: diastolic hypotension in a preterm infant at dose level 2; hypertension in a term infant at dose level 1; and significant agitation in a term infant at dose level 3. They concluded premature neonates were adequately sedated with dexmedetomidine alone, although doses up to 0.2 microgram/kg/hour were not sufficient in most term neonates.
O’Mara et al [11] reported a case control study of 48 preterm neonates requiring mechanical ventilation who received fentanyl (n=24) or dexmedetomidine (n=24) for pain or sedation. Dexmedetomidine was administered as a 0.5 microgram/kg bolus, followed by a maintenance infusion 0.3 microgram/kg/hour, increased by 0.1 microgram/kg/hour up to twice daily if there were elevated sedation scores with a need for >3 doses of adjunctive sedation during a 12-hour period. Patients in the dexmedetomidine group required less adjunctive sedation (54.1% vs. 16.5%, p<0.0001), shorter duration of mechanical ventilation, reduced time to meconium passage and reduced time to achievement of full enteral feeds. There were no differences in haemodynamic parameters between the 2 groups.
Conclusion: There are no data from RCTs supporting the use of dexmedetomidine for sedation of ventilated children, infants or newborns. RCTs are required to determine the effectiveness and safety of dexmedetomidine in ventilated newborn infants. [LOE IV newborn infants]
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