Syst Rev. 2015 Nov 6;4:154. doi: 10.1186/s13643-015-0139-7.
BACKGROUND: Management and choice of sedation is important during critical illness in order to reduce patient suffering and to facilitate the delivery of care. Unfortunately, medications traditionally used for sedation in the intensive care unit (ICU) such as benzodiazepines and propofol are associated with significant unwanted effects. Clonidine is an alpha-2 selective adrenergic agonist that may have a role in optimizing current sedation practices in the pediatric and adult critically ill populations by potentially minimizing exposure to other sedative agents.
METHODS/DESIGN: We will search MEDLINE, EMBASE, CINAHL, ACPJC, the Cochrane trial registry, World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), and clinicaltrials.gov for eligible observational studies and randomized controlled trials investigating the use of clonidine as an adjunctive or stand-alone sedative agent in patients requiring invasive mechanical ventilation. Our primary outcome is the duration of mechanical ventilation. Secondary outcomes include the following, listed by priority: duration of sedation infusions, dose of sedation used, level of sedation, incidence of withdrawal from other sedatives, delirium incidence, ICU and hospital length of stay, use and duration of non-invasive ventilation, and all-cause ICU and hospital mortality. We will also capture unwanted effects potentially associated with clonidine administration such as clinically significant hypotension or bradycardia, clonidine withdrawal, self-extubation, and the accidental removal of central intravenous lines and arterial lines. We will not apply any publication date, language, or journal restrictions. Two reviewers will independently screen and identify eligible studies using predefined eligibility criteria and then review full reports of all potentially relevant citations. A third reviewer will resolve disagreements if consensus cannot be achieved. We will use Review Manager (RevMan) to pool effect estimates from included studies across outcomes. We will present the results as relative risk (RR) with 95 % confidence intervals (CI) for dichotomous outcomes and as mean difference (MD) or standardized mean difference (SMD) for continuous outcomes with 95 % CI. We will assess the quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. DISCUSSION: The aim of this systematic review is to summarize the evidence on the efficacy and safety of clonidine as a sedative agent in the critically ill population.
The pronounced prevalence of delirium in geriatric patients admitted to the intensive care unit (ICU) and its increased morbidity and mortality is a well-established phenomenon. The purpose of this review is to explore the potential use of dexmedetomidine in preventing or managing ICUdelirium in older patients. Articles used were identified and selected through multiple search engines, including Google Scholar, PubMed, and MEDLINE. Keywords such as dexmedetomidine, delirium, geriatric, ICU delirium, delirium in elderly, and palliative were used to obtain the specific articles used for this paper and restricted to articles published in 1990 or later. Articles specifically looking at the use of dexmedetomidine as compared to a study drug and its potential for use in ICU patients, as opposed to overall reviews of dexmedetomidine, were compared. When compared to benzodiazepines for the prevention or treatment of ICU delirium in the elderly, dexmedetomidine was associated with a reduction indelirium, as well as decreased morbidity and mortality. Dexmedetomidine has also been shown to be effective in limiting risk factors associated with ICU delirium such as length and depth of sedation. As opposed to benzodiazepines or opiates, dexmedetomidine provides effective analgesia, sympatholysis, and anxiolysis without causing respiratory depression and allows a patient to more effectively interact with practitioners. The review of these nine articles indicates that these favorable attributes and overall decreased duration and incidence of deliriummake dexmedetomidine a viable option in preventing or reducing ICU delirium in high-risk geriatric patients and as a palliative adjunct to help control symptoms and stressors.
KEYWORDS: agitation; delirium; dexmedetomidine; geriatric; intensive care unit; sedation
INTRODUCTION: Randomized controlled trials suggest clinical outcomes may be improved with dexmedetomidine as compared with benzodiazepines; however, further study and validation are needed. The objective of this study was to determine the clinical effectiveness of a sedation protocol minimizing benzodiazepine use in favor of early dexmedetomidine. METHODS: We conducted a before-after study including adult surgical and medical intensive care unit (ICU) patients requiring mechanical ventilation and continuous sedation for at least 24 hours. The before phase included consecutive patients admitted between 1 April 2011 and 31 August 31 2011. Subsequently, the protocol was modified to minimize use of benzodiazepines in favor of early dexmedetomidine through a multidisciplinary approach, and staff education was provided. The after phase included consecutive eligible patients between 1 May 2012 and 31 October 2012. RESULTS: A total of 199 patients were included, with 97 patients in the before phase and 102 in the after phase. Baseline characteristics were well balanced between groups. Use of midazolam as initial sedation (58% versus 27%, P <0.0001) or at any point during the ICU stay (76% versus 48%, P <0.0001) was significantly reduced in the after phase. Dexmedetomidine use as initial sedation (2% versus 39%, P <0.0001) or at any point during the ICU stay (39% versus 82%, P <0.0001) significantly increased. Both the prevalence (81% versus 93%, P =0.013) and median percentage of days with delirium (55% (interquartile range (IQR), 18 to 83) versus 71% (IQR, 45 to 100), P =0.001) were increased in the after phase. The median duration of mechanical ventilation was significantly reduced in the after phase (110 (IQR, 59 to 192) hours versus 74.5 (IQR, 42 to 148) hours, P =0.029), and significantly fewer patients required tracheostomy (20% versus 9%, P =0.040). The median ICU length of stay was 8 (IQR, 4 to 12) days in the before phase and 6 (IQR, 3 to 11) days in the after phase (P =0.252). CONCLUSIONS: Implementing a sedation protocol that targeted light sedation and reduced benzodiazepine use led to significant improvements in the duration of mechanical ventilation and the requirement for tracheostomy, despite increases in the prevalence and duration of ICU delirium.