Dexmedetomidine vs Midazolam for Sedation of Critically Ill Patients&lt;subtitle&gt;A Randomized Trial&lt;/subtitle&gt;

Riker, Richard R.; Shehabi, Yahya; Bokesch, Paula M.; Ceraso, Daniel; Wisemandle, Wayne; Koura, Firas; Whitten, Patrick; Margolis, Benjamin D.; Byrne, Daniel W.; Ely, E. Wesley; Rocha, Marcelo G.

doi:10.1001/jama.2009.56

Cited by 1,419 publications

(985 citation statements)

References 44 publications

(38 reference statements)

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“…The current PRE-DELIRIC model may require on-going validation as new therapies and interventions emerge. For example, the use of new sedatives or analgesics may affect the development of delirium [33][34][35] and consequently could affect the performance of the model. Different risk factors may emerge in the future that may need to be investigated and included in the current PRE-DELIRIC model.…”

Section: Discussionmentioning

confidence: 99%

Recalibration of the delirium prediction model for ICU patients (PRE-DELIRIC): a multinational observational study

et al. 2014

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This is the accepted version of the paper.This version of the publication may differ from the final published version. Methods: A prospective multicenter cohort study was performed in eight intensive care units (ICUs) in six countries. The 10 predictors (age, APACHE-II, urgent and admission category, infection, coma, sedation, morphine use, urea level, metabolic acidosis) were collected within 24 hours after ICU admission. The confusion assessment method for the Intensive Care Unit (CAM-ICU) was used to identify ICU delirium. CAM-ICU screening compliance and inter-rater reliability measurements were used to secure the quality of the data. Permanent repository linkResults: 2,852 adult ICU patients were screened of which 1,824 (64%) were eligible for the study. Main reasons for exclusion were length of stay <1day (19.1%) and sustained coma (4.1%). CAM-ICU compliance was mean (SD) 82±16% and inter-rater reliability 0.87±0.17. The median delirium incidence was 22.5% (IQR 12.8%-36.6%). Although the incidence of all ten predictors differed significantly between centers, the area under the receiver operating characteristic (AUROC) curve of the 8 participating centers remained good: 0.77 (95%CI:0.74-0.79). The linear predictor and intercept of the prediction rule were adjusted and resulted in improved recalibration of the PRE-DELIRIC model. Conclusions:In this multinational study we recalibrated the PRE-DELIRIC-model. Despite differences in the incidence of predictors between the centers in the different countries the performance of the PRE-DELIRICmodel remained good. Following validation of the PRE-DELIRIC model it may facilitate implementation of strategies to prevent delirium and aid improvements in delirium management of ICU patients.4

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Section: Discussionmentioning

confidence: 99%

Recalibration of the delirium prediction model for ICU patients (PRE-DELIRIC): a multinational observational study

et al. 2014

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“…Whereas there was no diff erence in the primary outcome, patients in the dexmedetomidine group had a lower prevalence of delirium and a larger number of delirium-free days. In addition, patients sedated with dexmede tomi dine had a shorter time to extubation [36].…”

Section: Comparative Trialsmentioning

confidence: 94%

“…Had lighter or 'cooperative' sedation goals been achieved (closer to 0 to -1), the incidence of drug-induced coma would likely have been less (particularly with lorazepam), and results may have diff ered. Another recent randomized, double-blind trial, the Safety and Effi cacy of Dexmedetomidine Compared with Midazolam (SEDCOM) trial, compared midazolam to dexmedetomidine [36], requiring daily awakening trials and a targeted RASS score of -2 to +1. Th e primary outcome was percent time within RASS goal and secondary outcomes included assessment of delirium, duration of mechanical ventilation and ICU LOS.…”

Section: Comparative Trialsmentioning

confidence: 99%

‘Cooperative Sedation’: Optimizing Comfort while Maximizing Systemic and Neurological Function

Goodwin¹,

Lewin²,

Mirski³

2012

Annual Update in Intensive Care and Emergency Medicine

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“…The ideal sedative agent should be fast acting, have a rapid onset, not be organ dependent in terms of degradation, not have metabolically active or toxic by-products, have little cardiovascular effects, and be cheap. Over the last 30 years, midazolam, propofol [9], and dexmedetomidine [10,11] have been rolled out with the promise of being better than the previous generation of drugs.Sedation management in the ICU is a complex process involving sedation level assessment, medication administration, and an overall strategy. These three components are essential for correct ICU sedation.…”

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confidence: 99%

Volatile agents for ICU sedation?

Bracco

Donatelli

2011

Intensive Care Med

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Sedation is a standard part of critical care and was unchallenged from 1960 to 2000. Classical sedation approaches are associated with significant post-traumatic stress traits [1]. Because of poor pharmacokinetics/pharmacodynamics and planning problems, patients in the intensive care unit (ICU) spend one-third of their duration of stay being ventilated after the resolution of the problem mandating intubation [2, 3]. The aim of sedation in the ICU is to make the patient calm and tolerant to the critical care therapies, in particular mechanical ventilation. Recently several approaches have proven beneficial for patient care and the healthcare system: prospective trials have shown that daily interruptions of sedation are associated with a decrease in length of ventilation and decrease in ICU stay [4]. If a spontaneous breathing trial is used in addition to daily sedation interruption, the 1-year survival is improved [5] without an increase in psychological consequences [6]. Recent data suggest that no sedation at all may be better [7]. This move has been made possible by the improvement in ventilator algorithms, which are increasingly flexible in dealing with variable patient efforts. Over the last 10 years, the pendulum has moved toward a decrease in sedation with proactive strategies [8]. In this frame, the quest for the ideal sedation agent is continuing. The ideal sedative agent should be fast acting, have a rapid onset, not be organ dependent in terms of degradation, not have metabolically active or toxic by-products, have little cardiovascular effects, and be cheap. Over the last 30 years, midazolam, propofol [9], and dexmedetomidine [10,11] have been rolled out with the promise of being better than the previous generation of drugs.Sedation management in the ICU is a complex process involving sedation level assessment, medication administration, and an overall strategy. These three components are essential for correct ICU sedation. No one will give norepinephrine in the ICU without measuring blood pressure and having a strategy and objectives for vasopressor use, i.e., norepinephrine up to 20 lg/min for a mean arterial pressure (MAP) of 65 mmHg. Why are we tolerating this ''art'' of sedation and analgesia in the ICU? There is confusion in the literature between sedation/ hypnosis, analgesia, delirium management, and relaxation. This is shown by a recent meta-analysis regarding dexmedetomidine [12] pooling studies on dexmedetomidine used with sedation end points, morphine-sparing end points, and delirium end points. A hypnotic is a hypnotic, an analgesic is an analgesic, an antipsychotic is a drug used to treat delirium episodes [13], and a neuromuscular blocker is a relaxant medication. Although these classes of drugs have synergistic effects they cannot be used interchangeably.Volatile anesthesia agents have been in use for 50 years in anesthesia but only marginally in the ICU [14,15]. The first volatile agents were hepatotoxic and induced significant arrhythmias, which make then unsuitable for longterm ICU...

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Dexmedetomidine vs Midazolam for Sedation of Critically Ill Patients<subtitle>A Randomized Trial</subtitle>

Cited by 1,419 publications

References 44 publications

Recalibration of the delirium prediction model for ICU patients (PRE-DELIRIC): a multinational observational study

Recalibration of the delirium prediction model for ICU patients (PRE-DELIRIC): a multinational observational study

‘Cooperative Sedation’: Optimizing Comfort while Maximizing Systemic and Neurological Function

Volatile agents for ICU sedation?

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