Melbourne, Australia—Approved by the FDA since 1999, dexmedetomidine is commonly used in the ICU because it produces sedation while maintaining a degree of arousability, according to a new study.

A report in the New England Journal of Medicine also points out the alpha2-adrenoceptor agonist might reduce the duration of mechanical ventilation and delirium among patients in the ICU, but has not been extensively studied as the primary sedative agent in patients using that type of breathing support.

Monash University–led researchers conducted an open-label, randomized trial that enrolled critically ill adults who had been undergoing ventilation for less than 12 hours in the ICU and were expected to continue to receive ventilatory support for longer than the next calendar day. They compared patients receiving dexmedetomidine as the sole or primary sedative versus those on usual care, i.e., receiving propofol, midazolam, or other sedatives.

With the primary outcome defined as the rate of death from any cause at 90 days, the target range of sedation scores on the Richmond Agitation and Sedation Scale—scored from -5 (unresponsive) to +4 (combative)— was -2 to +1, (lightly sedated to restless). The primary outcome was the rate of death from any cause at 90 days.

Results indicate that in a modified intention-to-treat analysis involving 3,904 patients, the primary outcome event occurred in 566 of 1,948 (29.1%) in the dexmedetomidine group and in 569 of 1,956 (29.1%) in the usual-care group (adjusted risk difference, 0.0 percentage points; 95% CI, -2.9-2.8).

An ancillary finding, however, was that to achieve the prescribed level of sedation, patients in the dexmedetomidine group received supplemental propofol (64% of patients), midazolam (3%), or both (7%) during the first two days after randomization. In the usual-care group, on the other hand, propofol, midazolam or both were administered as primary sedatives in 60%, 12%, and 20% of the patients, respectively.

The study determined that bradycardia and hypotension were more common in the dexmedetomidine group.

“Among patients undergoing mechanical ventilation in the ICU, those who received early dexmedetomidine for sedation had a rate of death at 90 days similar to that in the usual-care group and required supplemental sedatives to achieve the prescribed level of sedation,” the study authors report, adding that more adverse events were reported in the dexmedetomidine group than in the usual-care group.

Researchers note that in previous randomized trials comparing dexmedetomidine with several commonly used sedatives, the drug was associated with a shorter time to extubation, a higher number of days free from coma or delirium, and a shorter duration of unresponsive sedation

In this study, however, “among critically ill adults undergoing mechanical ventilation in the ICU, the early administration of dexmedetomidine as the sole or primary sedative did not result in lower 90-day mortality than usual care.”

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