Sedative may have better outcomes than common medication for ICU patients on respirator

Intensive care unit patients on respirators who were sedated with the drug dexmedetomidine had more days alive without delirium or coma and better sedation compared to patients treated with the recommended drug lorazepam, according to a study in the December 12 issue of JAMA: The Journal of the American Medical Association.

Benzodiazepine drugs, such as lorazepam, are routinely administered to mechanically ventilated (respirators) patients to reduce pain and anxiety and to allow patients to tolerate invasive procedures in the intensive care unit (ICU). But these medications may also increase mechanical ventilation time, ICU length of stay and the risk of developing acute brain dysfunction, i.e., delirium and coma, according to background information in the article. The medication dexmedetomidine induces sedation via different central nervous system receptors than the benzodiazepine drugs and may lower the risk of acute brain dysfunction.

Pratik P. Pandharipande, M.D., M.S.C.I., of Vanderbilt University Schools of Medicine and Nursing, Nashville, Tenn., and colleagues conducted a study to determine if dexmedetomidine, when compared with benzodiazepine drugs, reduces the duration of delirium and coma while effectively sedating mechanically ventilated ICU patients. The randomized controlled trial included 106 adult ICU patients who were mechanically ventilated between August 2004 and April 2006. Patients were sedated with dexmedetomidine or lorazepam for as many as 120 hours.

The researchers found that dexmedetomidine patients had more days alive without delirium or coma (median [midpoint], 7 vs. 3). About 30 percent fewer patients experienced coma in the dexmedetomidine group than in the lorazepam group (63 percent vs. 92 percent). Nonsignificant differences were noted between the dexmedetomidine and lorazepam groups in death at 28-days (17 percent vs. 27 percent) and ventilator-free days (22 days vs. 18 days alive and free of mechanical ventilation).

A higher but nonsignificant percentage of patients in the dexmedetomidine group were able to complete post-ICU neuropsychological testing. Patients administered dexmedetomidine spent more time near the targeted level of sedation compared with patients sedated with lorazepam (median percentage of days, 80 percent vs. 67 percent). The 12-month time to death in the dexmedetomidine vs. the lorazepam group was 363 vs. 188 days, respectively.

“In this double-blind, randomized controlled trial, dexmedetomidine was more effective than lorazepam for achieving sustained sedation of mechanically ventilated medical and surgical ICU patients. Dexmedetomidine-treated ICU patients had 4 more days alive and without delirium or coma, significantly higher accuracy at meeting the stated sedation goals, and no added cost of care, as measured using data obtained at the largest enrolling site,” the authors conclude.

http://jama.ama-assn.org/