Introduction
The optimal ICU sedation strategy to improve patient-reported experience is unknown. In a planned secondary analysis of the A2B randomised trial, we evaluated the effect of sedation strategy (dexmedetomidine, clonidine or propofol) on recalled patient experience at 90 days post-randomisation. Using mediation analyses, we explored plausible mediators of the relationship between sedation strategy and patient experience.
Methods
We analysed data for all patients from A2B who completed the Intensive Care Experience Questionnaire (ICE-Q) at 90 days. The primary outcome was patient-recalled experience, measured by the four ICE-Q domain scores (awareness, frightening memories, recall, satisfaction). Sedation strategy effect was evaluated using linear regression, adjusting for potential confounders. Mediation analyses were conducted for duration of mechanical ventilation; ICU stay; and days with pain behaviour, agitation and coma/delirium.
Results
Of 1404 patients included in the primary trial analysis, 1009 (71.9%) were alive at 90 days post-randomisation with ICE-Qs completed by 289/1009 (28.6%). Compared with propofol, dexmedetomidine sedation was associated with higher awareness of surroundings (median score 32 vs. 28, adjusted mean difference 3.6, 95%CI 1.0–6.2, p = 0.01), but clonidine sedation had no association (difference 2.4, 95%CI -0.2–5.0, p = 0.07). No associations were found with other ICE-Q domains. The contribution of the five potential mediators on the dexmedetomidine–awareness relationship was small.
Discussion
Dexmedetomidine compared with propofol sedation strategy may be associated with increased recalled awareness of surroundings, which is considered a favourable indicator of ICU experience. Together with the primary A2B trial results, which showed no effect on ventilation duration, these hypothesis-generating findings in a subgroup of the A2B cohort do not support the use of dexmedetomidine over propofol based on patient-reported experience. Based on our findings, we advocate that a personalised approach to sedation strategies should continue to be used.
Plain Language Summary
What we did
We looked at patients from the A2B trial who had received intensive care treatment. They had been given one of three sedative medicines: dexmedetomidine, clonidine or propofol. After 90 days, we asked patients who were still alive to remember their time in intensive care. We looked at how aware they were, whether they remembered frightening things, what they could remember and how satisfied they were with their care.
Why we did it
We do not know which sedative medicine gives patients the best experience in intensive care. We wanted to find out whether different sedatives changed what patients remembered about their time in intensive care.
What we found
Patients who received dexmedetomidine were more likely to remember being aware of what was happening around them than patients who received propofol. This may be a good sign because being aware of your surroundings can be part of a better intensive care experience. However, there were no important differences between the medicines in frightening memories, what patients remembered overall or how satisfied they were. The results do not show that dexmedetomidine is better than propofol. Instead, the choice of sedative should continue to be based on what is best for each individual patient.