Dexmedetomidine Use in Intensive Care Unit Sedation and Postoperative Recovery in Elderly Patients Post-Cardiac Surgery (DIRECT)

Chitnis, Shruti; Mullane, Darren; Brohan, Janette; Noronha, Andrea; Paje, Howard; Grey, Rebecca; Sidhu, Jesse; Klein, Rael

doi:10.1053/j.jvca.2021.09.024

Cited by 4 publications

(3 citation statements)

References 42 publications

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“…LOWDEXDEL used a similar infusion strategy, beginning at chest closure and run at 0.4 ug/kg/h, in n = 349 patients and also demonstrated no benefit in delirium incidence compared to propofol [22]. The DIRECT trial, which randomized n = 70 adults aged 75 and older, found no benefit for open-label dexmedetomidine in their primary outcome of quality of recovery at postoperative day 3; delirium incidence, which was a secondary outcome, was found to be qualitatively lower in the dexmedetomidine group (24% vs. 42%), but with a nonsignificant p-value due to lack of study power [2 ▪ ]. These small additional trials, among others, have been criticized for lack of blinding, low study power, and poor generalizability, but in total fail to provide strong support for the use of dexmedetomidine in a cardiac surgical population to prevent delirium.…”

Section: What Do the Data Say? It Depends On How You Look At Itmentioning

confidence: 97%

“…Delirium lies at the intersection of traditional and patient-centered outcomes, as it directly leads to personal and family distress, and it is reproducibly associated with delayed neurocognitive recovery, loss of independence and increased likelihood of nonhome discharge, increased hospital length of stay, cost, morbidity and mortality [1,2 ▪ ]. According to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, delirium is defined as a disturbance in attention, representing a change from baseline, which develops over a short period of time, fluctuates over the course of the day, is accompanied by an additional cognitive deficit, is not better explained by a preexisting neurocognitive condition and is a direct consequence of a physiologic insult [3].…”

Section: Introductionmentioning

confidence: 99%

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Cardiac surgery, ICU sedation, and delirium: is dexmedetomidine the silver bullet?

Smith

Whitlock

2022

Current Opinion in Anaesthesiology

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Purpose of reviewDelirium is a marker of acute brain insufficiency and a harbinger of poor outcomes and increased healthcare costs. Despite success preventing delirium by nonpharmacologic measures, the incidence in the postcardiac surgical ICU population remains high. Dexmedetomidine, a selective alpha-2 agonist, is a plausible preventive agent with sedative, anxiolytic, analgesic, sympatholytic and anti-inflammatory properties, and is the subject of very active study in cardiac surgery populations.Recent findingsRecent trials, including DEXACET (2019), DECADE (2020), LOWDEXDEL (2021), and DIRECT (2022) individually, failed to show a benefit for dexmedetomidine and highlighted associated risks. Meta-analyses have offered conflicting results, highlighting the complexity of delirium, and likely interaction of multiple etiological pathways; those that concluded benefit often were driven by trials at high risk of bias. Meta-analyses excluding biased trials currently suggest no benefit for dexmedetomidine over control in unselected cardiac surgical populations.SummaryAlthough using dexmedetomidine to prevent delirium in unselected cardiac surgical patients is not supported by current evidence, there remains hope that it may offer benefits in highly selected populations, and further trials are ongoing.

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Section: What Do the Data Say? It Depends On How You Look At Itmentioning

confidence: 97%

Section: Introductionmentioning

confidence: 99%

Cardiac surgery, ICU sedation, and delirium: is dexmedetomidine the silver bullet?

Smith

Whitlock

2022

Current Opinion in Anaesthesiology

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“…11 Last, a small RCT demonstrated no difference in delirium with the use of DEX versus propofol in elderly patients undergoing cardiac surgery. 13 The lack of benefit in these studies may stem from a reduction in delirium risk as a result of reduced benzodiazepines rather than a dose-dependent protective effect of DEX. 10 Dexmedetomidine has also been evaluated in nonmechanically ventilated adults for delirium prevention.…”

Section: Deliriummentioning

confidence: 99%

Niche Roles for Dexmedetomidine in the Intensive Care Unit

et al. 2023

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Objective: Review dexmedetomidine use in critically ill patients for niche indications including sleep, delirium, alcohol withdrawal, sepsis, and immunomodulation. Data Sources: Literature was sought using PubMed (February 2012-November 2022). Search terms included dexmedetomidine AND (hypnotics OR sedatives OR sleep OR delirium OR immunomodulation OR sepsis OR alcohol withdrawal). Study Selection and Data Extraction: Relevant studies conducted in humans ≥18 years published in English were included. Exclusion criteria included systematic reviews, meta-analyses, and studies evaluating oral dexmedetomidine or other alpha-2 agonists. Data Synthesis: A total of 231 articles were retrieved. After removal of duplicates, title and abstract screening, and application of inclusion criteria, 35 articles were included. Across the clinical conditions included in this review, varying clinical outcomes were seen. Dexmedetomidine may improve morbidity outcomes in delirium, sleep, and alcohol withdrawal syndrome. Due to limited human studies and poor quality of evidence, no conclusions can be drawn regarding the role of dexmedetomidine in immunomodulation or sepsis. Relevance to Patient Care and Clinical Practice: This review presents data for potential niche roles of dexmedetomidine aside from sedation in critically ill patients. This may serve as a guide for sedation selection in critically ill patients who may also benefit from the pleiotropic effects of dexmedetomidine due to a clinical condition discussed in this review. Conclusion: While further studies are needed, dexmedetomidine may provide benefit in other indications in critically ill patients including delirium, sleep, and alcohol withdrawal. Given the poor quality of evidence of dexmedetomidine use in immunomodulation and sepsis, no conclusions can be drawn.

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Postoperative Dexmedetomidine Infusion and Chronic Postsurgical Pain in Thoracoscopic Pulmonary Nodule Surgery: A Retrospective Study with Propensity-Score-Matched Analysis

Sun,

Zhong,

Wang

et al. 2024

Pain Ther

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Dexmedetomidine Use in Intensive Care Unit Sedation and Postoperative Recovery in Elderly Patients Post-Cardiac Surgery (DIRECT)

Cited by 4 publications

References 42 publications

Cardiac surgery, ICU sedation, and delirium: is dexmedetomidine the silver bullet?

Cardiac surgery, ICU sedation, and delirium: is dexmedetomidine the silver bullet?

Niche Roles for Dexmedetomidine in the Intensive Care Unit

Postoperative Dexmedetomidine Infusion and Chronic Postsurgical Pain in Thoracoscopic Pulmonary Nodule Surgery: A Retrospective Study with Propensity-Score-Matched Analysis

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