Authors: Su X et al., Lancet 2016 Aug 16;
But this practice probably is unnecessary in extubated patients.
In a recent placebo-controlled study, delirium resolved more quickly in delirious patients in the intensive care unit (ICU) who received dexmedetomidine (NEJM JW Gen Med May 15 2016 and JAMA 2016; 315:1455). However, whether this finding was due to a direct effect of dexmedetomidine on delirium or less use of other medications that contribute to delirium is unclear. Investigators in China randomized 700 older patients (age, ≥65) who underwent noncardiac surgery to receive low-dose dexmedetomidine (0.1 µg/kg/hour) or placebo postoperatively. Infusion was initiated shortly after arrival in the ICU in nonintubated patients but was delayed until sedatives were weaned in intubated patients; dexmedetomidine ran overnight on the first postoperative night and was terminated at 8:00 a.m.
During 7 days of follow-up, postoperative delirium was significantly less common in patients who received dexmedetomidine than in those who didn’t (9% vs. 23%). Intubated patients’ median time to extubation was lower with dexmedetomidine than with placebo (4.6 hours vs. 6.9 hours), and scores on a subjective sleep-quality scale were significantly better with dexmedetomidine.
We have a growing appreciation for the importance of sleep and the effect of sleep disruption on hospitalized patients, but starting an infusion of a medication to promote sleep and lower delirium risk seems to be excessive in a cohort of patients who, overall, are unlikely to become delirious. I don’t think this practice makes sense in extubated patients, and I still favor the interpretation that dexmedetomidine works well for intubated patients as a sedative-sparing agent.