Comparative Effectiveness of Midazolam, Propofol, and Dexmedetomidine in Patients With or at Risk for Acute Respiratory Distress Syndrome: A Propensity Score-Matched Cohort Study

Abstract

Background: Sedatives are commonly used in patients with or at risk for acute respiratory distress syndrome (ARDS) during mechanical ventilation. To systematically compare the outcomes of sedation with midazolam, propofol, and dexmedetomidine in patients with or at risk for ARDS.Methods: We developed a dataset of real-world data to enable the comparison of the effectiveness and safety of sedatives and the associated outcomes from the MIMIC-III database and the eICU Collaborative Research database. We performed a systematic study with six cohorts to estimate the relative risks of outcomes among patients administered different sedatives. Propensity score matching was performed to generate a balanced 1:1 matched cohort and to identify potential prognostic factors. The outcomes included hospital mortality, duration of mechanical ventilation, length of intensive care unit stay, length of hospitalization, and likelihood of being discharged home.Results: We performed 60 calibrated analyses among all groups and outcomes with 17,410 eligible patients. Sedation with dexmedetomidine was associated with a lower in-hospital mortality rate than sedation with midazolam and propofol or sedation without dexmedetomidine (p < 0.001). When compared with no sedation, the use of midazolam, propofol or dexmedetomidine was associated with a longer ICU stay and longer hospitalization duration (p < 0.01). Patients treated with midazolam were relatively less likely to be discharged home (p < 0.05).Conclusion: Patients treated with dexmedetomidine had a reduced risk of mortality. These data suggest that dexmedetomidine may be the preferred sedative in patients with or at risk for ARDS.

Impact of Sedation Practices on Mortality in COVID-19-Associated Adult Respiratory Distress Syndrome Patients: A Multicenter Retrospective Descriptive Study

“…Similar to the current study, Hu et al 22 showed that after adjusting for nearly identical clinical factors (age; sex; ethnicity; weight; height; APACHE III score; oxygenation index; alveolar-arterial oxygen difference; patient characteristics at discharge; hospital characteristics like number of beds, teaching, and geographic location), a significant mortality benefit was associated with dexmedetomidine when compared to both propofol (aOR 0.58 [0.42-0.79]; P < 0.001) and midazolam (aOR 0.52 [0.40-0.68]; P < 0.001), while midazolam compared to propofol was not significant (aOR 1.23 [0.96-1.57]; P = 0.10). We are uncertain whether the observed mortality benefit associated with dexmedetomidine, as reported in our study and by Hu et al 22 is due to milder disease severity in the treated patients. This ambiguity arises from the fact that dexmedetomidine, being a relatively light sedative, may not suffice in situations where higher post-end-expiratory pressure (PEEP) is needed, primarily due to the patient's comfort requirements.…”

Farmacocinética de las Benzodiacepinas en Pacientes con Falla Hepática en UCI

“…Estos agentes se metabolizan y eliminan a través de vías que dependen menos de la función hepática (33). Para los pacientes de la UCI que requieren ventilación mecánica a largo plazo , la dexmedetomidina puede reducir significativamente la incidencia de delirio y la aparición de AGI, especialmente para los pacientes obesos , el uso de la sedación con dexmedetomidina tiene poco impacto en su función hepática y el metabolismo de los lípidos en sangre , y puede mejorar significativamente el pronóstico (34) Incluso, la sedación con dexmedetomidina se asoció con una tasa de mortalidad hospitalaria más baja que la sedación con midazolam y propofol o la sedación sin dexmedetomidina ( p < 0,001) (35).…”

Dexmedetomidine alleviates acute lung injury by promoting Tregs differentiation via activation of AMPK/SIRT1 pathway

“…It could reduce the oxygen consumption of ARDS. A cohort study systematically showed that the risk of death was reduced in patients with ARDS treated with DEX, and it may be the preferred sedative (Hu et al 2021 ). Furthermore, the progression of hypoxemia is associated with pulmonary as well as systemic inflammatory responses.…”