Patricia Kritek, MD, reviewing
NEJM Journal Watch
Key clinical outcomes were similar with either drug.
Current best practice in the intensive care unit (ICU) is to use the least medication necessary to keep patients alert, interactive, and comfortable while they receive mechanical ventilation. Compared with propofol and benzodiazepines, dexmedetomidine has been associated with less delirium and lighter sedation in small studies, although larger trials have been less definitive. Bench research suggests dexmedetomidine might have anti-inflammatory properties and help with bacterial clearance.
Investigators randomized 422 patients with sepsis and respiratory failure requiring invasive mechanical ventilation to receive either dexmedetomidine or propofol for sedation. More than half of patients were on vasopressors at enrollment. Sedation was targeted to a Richmond Agitation Sedation Score (RASS) of 0 to −2 (which corresponds with light sedation); median RASS values were −2 in both groups. Midazolam was used as a rescue medication in about one quarter of patients, and nearly half received antipsychotic medications.
Days free of coma or delirium at 14 days, ventilator-free days, and mortality were similar between groups. Hypotension was common in both groups (55% of patients); more patients in the dexmedetomidine group developed bradycardia (30% vs. 19%), although symptomatic bradycardia did not differ. About 25% of patients showed evidence of cognitive impairment at 6-month follow-up.
This trial confirms what is recommended by the Society of Critical Care Medicine — use either propofol or dexmedetomidine (Crit Care Med 2018; 46:e825). Without clear differences, use what is familiar in your ICU and what is most cost-effective.