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The place of dexmedetomidine light sedation in patients with acute brain injury

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To the Editor,

An individualized titration of sedative and analgesic drugs is pivotal in the late phase management of acute brain injury (ABI) patients, when weaning from mechanical ventilation (MV) needs to be implemented [1]. Due to its pharmacologic profile, dexmedetomidine (Dex) represents a drug of choice in such setting. Nevertheless, its use in ABI patients has been recently debated mainly as a consequence of its hemodynamic effects [2, 3]. The present study aimed to evaluate clinical outcomes and safety profile of Dex administration in this patients’ category.

We retrospectively analysed prospectively collected data on the main clinical features and adverse events observed during light sedation with dexmedetomidine (Dex-LS) in ICU patients with ABI. Light sedation was defined by the maintenance of a Richmond Agitation and Sedation Scale (RASS) score between 1 and − 2. The rate of potential side effects during Dex-LS was compared with the 6-h period before Dex initiation (see Additional file 1 for further details).

The main clinical and analgosedation characteristics of the 101 included patients are listed in Table 1. Traumatic ABI (77.2%) was the main admission diagnosis, and haemorrhage (59.4% of the cohort) was the most common admission feature (see Additional file 1: Table S1). Out of 101 patients, 80 were mechanically ventilated during Dex-LS. In most cases, dexmedetomidine was administered in association with other sedatives, opioids or antipsycotic drugs, for a median duration and dosage of 64 h and 0.6 μg/kg/h, respectively.

Table 1 Features of 101 patients undergoing Dex-LS

Dexmedetomidine has been administered safely in our population of ABI patients. Dex infusion rate and duration were comparable with those previously described [2, 3]. The rate of systemic arterial hypotension was consistent with available findings [2, 3] and lower compared with the pre-infusion period. The 23% rate of bradycardia takes place in the wide range of occurrence reported in ABI patients [2]. Nevertheless, bradycardia never imposed dexmedetomidine interruption. These findings should be interpreted in the light of the relatively young age and low severity scores of our population, where Dex was frequently co-infused with other sedatives or opioids. Neither seizure rate nor intracranial pressure increased during Dex-LS, supporting the clinical absence of Dex impact on cerebral physiology [4].

During Dex-LS, the majority of patients were weaned from MV, including more than half who previously failed a weaning attempt. These observations are in line with the available evidence comparing Dex sedation with midazolam and propofol use, even though in ICU patients without ABI [5].

In conclusion, despite the intrinsic limitations of our retrospective design lacking a control group, this study suggests that when used to target light sedation in our cohort of ABI patients, dexmedetomidine was safe and enabled the weaning from MV and the maintenance of spontaneous breathing.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

References

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    Tsaousi GG, Lamperti M, Bilotta F. Role of dexmedetomidine for sedation in neurocritical care patients: a qualitative systematic review and meta-analysis of current evidence. Clin Neuropharmacol. 2016;39:144–51.

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    Humble SS, Wilson LD, Leath TC, Marshall MD, Sun DZ, Pandharipande PP, et al. ICU sedation with dexmedetomidine after severe traumatic brain injury. Brain Inj. 2016;30:1266–70.

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    James ML, Olson DM, Graffagnino C. A pilot study of cerebral and haemodynamic physiological changes during sedation with dexmedetomidine or propofol in patients with acute brain injury. Anaesth Intensive Care 2012;40:949–957.

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    Jakob SM, Ruokonen E, Grounds RM, Sarapohja T, Garratt C, Pocock SJ, et al. Dexmedetomidine vs midazolam or propofol for sedation during prolonged mechanical ventilation: two randomized controlled trials. JAMA. 2012;307:1151–60.

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Acknowledgements

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Author information

MA, GDP and SC conceived and designed the study. All the authors significantly contributed to acquire, analyse and interpret the data and cooperated to draft the manuscript. They all read and approved the present final version.

Correspondence to Simone Carelli.

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The study was approved by the ethics committee of the Catholic University of the Sacred Heart (Prot. UCSC34998/18). Due to its observational, non-interventional design, informed consent was waived.

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The authors declare that they have no competing interests.

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Carelli, S., De Pascale, G., Filetici, N. et al. The place of dexmedetomidine light sedation in patients with acute brain injury. Crit Care 23, 340 (2019) doi:10.1186/s13054-019-2637-9

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