Safety of dexmedetomidine for the control of agitation in critically ill traumatic brain injury patients: a descriptive study

Abstract

Background Behavioural disturbances such as agitation are common following traumatic brain injury and can interfere with treatments, cause self‐harm and delay rehabilitation. As there is a lack of evidence on the optimal approach to manage agitation in recovering TBI patients, various pharmacological agents are used including antipsychotics, anticonvulsants and sedative agents. Among sedatives, the safety and efficacy of dexmedetomidine to control agitation in traumatic brain injury patients is not well documented. Objective To describe the safety, use and efficacy of dexmedetomidine for the management of agitation following traumatic brain injury in the intensive care unit. Methods Medical records of all patients admitted to the intensive care unit of the Hôpital Sacré‐Coeur de Montréal for a traumatic brain injury who received dexmedetomidine for agitation between 1 January 2017 and 31 December 2017 were reviewed. Patients who received dexmedetomidine for indications other than agitation were excluded. Data on dexmedetomidine prescription practices and safety were extracted. Frequency of agitation and concomitant psychoactive medication use was explored over a period starting two days prior to the initiation of dexmedetomidine to six days after or discontinuation, whichever came first. Results We identified 41 patients in whom dexmedetomidine was initiated. Dexmedetomidine was started on median ICU day 3 (25th‐75th percentiles: 2–7) and had a median treatment duration of 3 days (25th‐75th percentiles: 3–6) and a mean average rate of 0.62 mcg/kg/h (SD 0.25). Although hypotension (76%) and bradycardia (54%) were common, only one patient required intervention. The proportion of patients with at least one episode of agitation decreased from 100% on day 0, to 88%, 69% and 63% on days 1, 2 and 3 of dexmedetomidine, respectively. The decrease was statistically significant difference between days 0 and 2 as well as between days 0 and 3. Concomitant use of propofol and benzodiazepines also decreased over the course of dexmedetomidine treatment. Conclusion Dexmedetomidine use was safe and associated with a reduction in agitation in traumatic brain injury patients in the 96 hours following its initiation.

Dexmedetomidine alleviates early brain injury following traumatic brain injury by inhibiting autophagy and neuroinflammation through the ROS/Nrf2 signaling pathway

“…Recent studies have confirmed that DEX exerts its protective effects on various organ injuries ( 12 , 20 ). Based on accumulating evidence, DEX also improves neurological function and delirium in patients ( 21 ) and alleviates EBI in the TBI model and the effect of DEX is dose-dependent ( 12 , 22 , 23 ). Huang and Hao ( 22 ) report that DEX relieves early brain injury (EBI) by inhibiting inflammation and decreasing neuronal apoptosis, which may depend on the TLR4/NF-κB signaling pathway.…”

Assessment of the effects of dexmedetomidine on outcomes of traumatic brain injury using propensity score analysis

“…In 2016, another study demonstrated that Dex infusion in TBI patients does not worsen neurological functioning [22]. Recently, Dex was found to be associated with a reduction in paroxysmal sympathetic hyperactivity and agitation in TBI patients [23,24]. Although opposite opinions exist considering Dex's side effects of reducing blood pressure and heart rate, researchers agreed that more studies would be necessary to evaluate Dex's effects on TBI patients.…”

Dexmedetomidine Opioid Sparing Effect in Mechanically Ventilated Children (DOSE): Trial of Fentanyl versus Fentanyl + Dexmedetomidine for Maintenance of Sedation

“…To expand the inclusion/exclusion criteria, an IRB amendment to the original protocol was requested on September 30, 2019, with the following alterations: (1) extension of the time for exposure to fentanyl/dexmedetomidine to 48 hours pre-enrollment to allow for enrollment of patients admitted overnight and on the weekends, with a plan to carefully record the prerandomization concomitant medications and account for these in any statistical analyses; (2) removal of the traumatic brain injury and pediatric cerebral performance category > 3 exclusion, while limiting participants with these clinical features to 8 participants per cohort; (3) removal of the exclusion criterion of admission for cardiac surgery; and (4) request for a single-guardian consent. Alterations (2) and (3) were based on these patient populations already receiving dexmedetomidine in clinical practice 20,21 and having rigorous systematic assessments of these agents within the trial would provide much-needed additional evidence. The Data and Safety Monitoring Board agreed with these protocol alterations, and they agreed to provide an extra safety assessment after the first five cardiac surgery participants were enrolled.…”