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Critical Care

, 23:340 | Cite as

The place of dexmedetomidine light sedation in patients with acute brain injury

  • Simone CarelliEmail author
  • Gennaro De Pascale
  • Nicoletta Filetici
  • Maria Grazia Bocci
  • Gian Marco Maresca
  • Salvatore Lucio Cutuli
  • Cecilia Maria Pizzo
  • Giuseppe Bello
  • Luca Montini
  • Anselmo Caricato
  • Giorgio Conti
  • Massimo Antonelli
Open Access
Letter
  • 1.1k Downloads

To the Editor,

An individualized titration of sedative and analgesic drugs is pivotal in the late phase management of acute brain injury (ABI) patients, when weaning from mechanical ventilation (MV) needs to be implemented [1]. Due to its pharmacologic profile, dexmedetomidine (Dex) represents a drug of choice in such setting. Nevertheless, its use in ABI patients has been recently debated mainly as a consequence of its hemodynamic effects [2, 3]. The present study aimed to evaluate clinical outcomes and safety profile of Dex administration in this patients’ category.

We retrospectively analysed prospectively collected data on the main clinical features and adverse events observed during light sedation with dexmedetomidine (Dex-LS) in ICU patients with ABI. Light sedation was defined by the maintenance of a Richmond Agitation and Sedation Scale (RASS) score between 1 and − 2. The rate of potential side effects during Dex-LS was compared with the 6-h period before Dex initiation (see Additional file 1 for further details).

The main clinical and analgosedation characteristics of the 101 included patients are listed in Table 1. Traumatic ABI (77.2%) was the main admission diagnosis, and haemorrhage (59.4% of the cohort) was the most common admission feature (see Additional file 1: Table S1). Out of 101 patients, 80 were mechanically ventilated during Dex-LS. In most cases, dexmedetomidine was administered in association with other sedatives, opioids or antipsycotic drugs, for a median duration and dosage of 64 h and 0.6 μg/kg/h, respectively.
Table 1

Features of 101 patients undergoing Dex-LS

Clinical characteristics

 Age, years

53 [35–68]

 Male

84 (83.2)

 Neuro-psychiatric comorbidities

24 (23.8)

- Preesistent psychosis

12 (11.9)

- Preesistent dementia

5 (5)

- Preesistent epilepsy

7 (6.9)

 Traumatic brain injury (TBI)

78 (77.2)

- Isolated traumatic brain injury

14 (13.8)

- Polytrauma with traumatic brain injury

64 (63.4)

 Non-traumatic brain injury

23 (22.8)

 ISS at admission (TBI only)

23 [17–29]

 Head-AIS at admission (TBI only)

3 [2–4]

 GCS at admission*

10 [7–14]

 SAPS II at Dex-LS start

34 [26–44]

 SOFA at Dex-LS start

4 [3–7]

 MV at admission

91 (90.1)

 MV at Dex-LS start

80 (79.2)

 ICU LOS pre-Dex-LS, days

4 [2–8]

 ICU LOS post-Dex-LS, days

8 [3–15]

 ICU mortality

4 (4)

 Hospital mortality

8 (7.9)

 Hours of MV#

39 [12–72]

 MV in assisted mode#

71 (88.8)

 MV in assisted mode, hours#

24 [6–48]

 Successful weaning#

56 (70)

 Successful weaning in pts with previous weaning failure##

16 (57.1)

 Spontaneous breathing, hours#

25 [0–72]

Analgosedation details

 RASS

0 [− 1/0]

 Propofol co-infusion

35 (34.7)

 Midazolam co-infusion

0

 Remifentanil co-infusion

59 (58.4)

 Other opioids co-infusion**

15 (14.9)

 Antipsychotic drugs co-administration***

40 (39.6)

 Dex length of infusion, hours

64 [33–120]

 Dex start dosage, μg/kg/h

0.7 [0.5–0.9]

 Dex median dosage, μg/kg/h

0.6 [0.5–0.9]

 Dex maximum dosage, μg/kg/h

0.9 [0.6–1.2]

 Dex dosage at suspension, μg/kg/h

0.5 [0.3–0.8]

Hemodynamic parameters and adverse events (n = 101)

 

Pre-Dex infusion###

Dex-LS

P value

 RASS

− 2 [− 3/0]

0 [− 1/0]

< 0.001

 HR, bpm

78 [70–89]

80 [66–91]

0.165

 SAP, mmHg

133 [124–146]

139 [126–150]

0.136

 DAP, mmHg

65 [56–72]

69 [62–78]

< 0.001

 MAP, mmHg

85 [78–98]

90 [84–99]

0.039

 Bradycardia

2 (2)

23 (22.8)

< 0.001

- Bradycardia in pts receiving remifentanil co-infusion^

12 (20.3)

- Dex median dosage in pts with bradycardia, μg/kg/h^^

0.6 [0.4–0.9]

 Arterial hypotension requiring vasopressors

42 (41.6)

27 (26.7)

0.037

 Seizures

3 (3)

3 (3)

1

 ICP, mmHg*

9 [8–14]

8 [7–10]

0.164

Dex dexmedetomidine, LS light sedation, ISS Injury Severity Score, AIS Abbreviated Injury Scale, GCS Glasgow Coma Scale, SAPS II Simplified Acute Physiology Score II, SOFA Sequential Organ Failure Assessment, MV mechanical ventilation, LOS length of stay, RASS Richmond Agitation-Sedation Scale, HR heart rate, SAP systolic arterial pressure, DAP diastolic arterial pressure, MAP mean arterial pressure, ICP intracranial pressure, pts patients

Data are shown as median [IQR] or N (%)

*GCS at admission was available in 96 patients. ICP was monitored in 10 patients

**Sufentanil, morphine

***Haloperidol, quetiapine, chlorpromazine

#Eighty out of 101 patients were mechanically ventilated during Dex-LS

##Twenty-eight patients failed at least a weaning attempt before Dex-LS

###Data of 6-h pre-Dex infusion period were analysed

^Fifty-nine patients received remifentanil co-infusion

^^Twenty-three patients had bradycardia event(s)

Dexmedetomidine has been administered safely in our population of ABI patients. Dex infusion rate and duration were comparable with those previously described [2, 3]. The rate of systemic arterial hypotension was consistent with available findings [2, 3] and lower compared with the pre-infusion period. The 23% rate of bradycardia takes place in the wide range of occurrence reported in ABI patients [2]. Nevertheless, bradycardia never imposed dexmedetomidine interruption. These findings should be interpreted in the light of the relatively young age and low severity scores of our population, where Dex was frequently co-infused with other sedatives or opioids. Neither seizure rate nor intracranial pressure increased during Dex-LS, supporting the clinical absence of Dex impact on cerebral physiology [4].

During Dex-LS, the majority of patients were weaned from MV, including more than half who previously failed a weaning attempt. These observations are in line with the available evidence comparing Dex sedation with midazolam and propofol use, even though in ICU patients without ABI [5].

In conclusion, despite the intrinsic limitations of our retrospective design lacking a control group, this study suggests that when used to target light sedation in our cohort of ABI patients, dexmedetomidine was safe and enabled the weaning from MV and the maintenance of spontaneous breathing.

Notes

Acknowledgements

Not applicable.

Authors’ contributions

MA, GDP and SC conceived and designed the study. All the authors significantly contributed to acquire, analyse and interpret the data and cooperated to draft the manuscript. They all read and approved the present final version.

Funding

None

Ethics approval and consent to participate

The study was approved by the ethics committee of the Catholic University of the Sacred Heart (Prot. UCSC34998/18). Due to its observational, non-interventional design, informed consent was waived.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Supplementary material

13054_2019_2637_MOESM1_ESM.docx (25 kb)
Additional file 1. Electronic Supplementary Material.

References

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Copyright information

© The Author(s). 2019

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors and Affiliations

  • Simone Carelli
    • 1
    • 2
    Email author
  • Gennaro De Pascale
    • 1
    • 2
  • Nicoletta Filetici
    • 1
    • 2
  • Maria Grazia Bocci
    • 1
    • 2
  • Gian Marco Maresca
    • 1
    • 2
  • Salvatore Lucio Cutuli
    • 1
    • 2
  • Cecilia Maria Pizzo
    • 1
    • 2
  • Giuseppe Bello
    • 1
    • 2
  • Luca Montini
    • 1
    • 2
  • Anselmo Caricato
    • 1
    • 2
  • Giorgio Conti
    • 1
    • 2
  • Massimo Antonelli
    • 1
    • 2
  1. 1.Istituto di Anestesiologia e RianimazioneUniversità Cattolica del Sacro CuoreRomeItaly
  2. 2.Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della RianimazioneFondazione Policlinico Universitario A. Gemelli IRCCSRomeItaly

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