IMPORTANCE: Whether a2-adrenergic receptor agonist-based sedation, compared with propofol-based sedation, reduces time to extubation in patients receiving mechanical ventilation in the intensive care unit (ICU) is uncertain.
OBJECTIVE: To evaluate whether dexmedetomidine- or clonidine-based sedation reduces duration of mechanical ventilation compared with propofol-based sedation (usual care).
DESIGN, SETTING, AND PARTICIPANTS: Pragmatic, open-label randomized clinical trial conducted at 41 ICUs in the UK including adults who were within 48 hours of starting mechanical ventilation, were receiving propofol plus an opioid for sedation and analgesia, and were expected to require mechanical ventilation for 48 hours or longer. The median time from intubation to randomization was 21.0 (IQR, 13.2-31.3) hours. Recruitment occurred from December 2018 to October 2023; the last follow-up occurred on December 10, 2023.
INTERVENTIONS: The bedside algorithms used targeted a Richmond Agitation-Sedation Scale score of -2 to 1 (unless clinicians requested deeper sedation). The algorithms supported uptitration in the dexmedetomidine- and clonidine-based sedation intervention groups and supported downtitration for propofol-based sedation followed by sedation primarily with the allocated sedation (dexmedetomidine or clonidine). If required, supplemental use of propofol was permitted.
MAIN OUTCOMES AND MEASURES: The primary outcome was time from randomization to successful extubation. The secondary outcomes included mortality, sedation quality, rates of delirium, and cardiovascular adverse events.
RESULTS: Among the 1404 patients in the analysis population (mean age, 59.2 [SD, 14.9] years; 901 [64%] were male; and the mean APACHE II score was 20.3 [SD, 8.2]), the subdistribution hazard ratio (HR) for time to successful extubation was 1.09 (95% CI, 0.96-1.25; P = .20) for dexmedetomidine (n = 457) vs propofol (n = 471) and was 1.05 (95% CI, 0.95-1.17; P = .34) for clonidine (n = 476) vs propofol (n = 471). The median time from randomization to successful extubation was 136 (95% CI, 117-150) hours for dexmedetomidine, 146 (95% CI, 124-168) hours for clonidine, and 162 (95% CI, 136-170) hours for propofol. In the predefined subgroup analyses, there were no interactions with age, sepsis status, median Sequential Organ Failure Assessment score, or median delirium risk score. Among the secondary outcomes, agitation occurred at a higher rate with dexmedetomidine vs propofol (risk ratio [RR], 1.54 [95% CI, 1.21-1.97]) and with clonidine vs propofol (RR, 1.55 [95% CI, 1.22-1.97]). Compared with propofol, the rates of severe bradycardia (heart rate <50/min) were higher with dexmedetomidine (RR, 1.62 [95% CI, 1.36-1.93]) and clonidine (RR, 1.58 [95% CI, 1.33-1.88]). Compared with propofol, mortality was similar over 180 days for dexmedetomidine (HR, 0.98 [95% CI, 0.77-1.24]) and clonidine (HR, 1.04 [95% CI, 0.82-1.31]).
CONCLUSIONS AND RELEVANCE: In critically ill patients, neither dexmedetomidine nor clonidine was superior to propofol in reducing time to successful extubation.
TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03653832.
| Discipline Area | Score |
|---|---|
| Anesthesiology |  |
| Intensivist/Critical Care |  |
This is worth investigating but using 48 hours of ventilation. Design: 1. Not including patients with higher risk delirium is a major mistake. Also, more elderly patients with renal failure should have been included; 2. Whether patients with pre-existing delirium or mental health issues are included or not is not clear; 3. Starting dexmed and clonidine (so-called lighter sedatives) from the beginning rather than at 24-48 hours before weaning is probably not correct; 4. No mention of inotrope requirement; and 5. When study drugs caused higher agitation and needed more rescue propofol, not mentioning incidences of ventilator asynchrony and accidental extubation is another limitation.// This is a good study to determine why using dexmed and clonidine from the beginning is not beneficial, but whether they are helpful during weaning is still undetermined.
The before randomization drugs are a major confounder, particularly in the dexmedetomidine group, but the bigger issue is around other adverse events that are not elucidated. Not using a 4th agent - ketamine - that is growing in popularity and not including many trauma cases (especially TBI) makes the results somewhat irrelevant for me as a Trauma Intensivist.