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Delirium Risk of Dexmedetomidine and Midazolam in Patients Treated with Postoperative Mechanical Ventilation: a Meta-analysis.

ABSTRACT: To evaluate by meta-analysis the effects of dexmedetomidine versus midazolam on postoperative delirium in patients that received postoperative mechanical ventilation.The electronic databases of PubMed, Web of Science, EMbase, CNKI, CBM, Cochrane library and WanFang were searched by two reviewers. All the clinical studies related to dexmedetomidine versus midazolam on postoperative delirium were screened and collected in this meta-analysis. The combined postoperative delirium risk between dexmedetomidine and midazolam groups was pooled by random effect model. The publication bias was assessed by Begg's funnel plot and Egger's line regression test.A total of six studies including 386 subjects (202 in the dexmedetomidine group and 184 in the midazolam group) were finally included in this meta-analysis. All six studies reported adequate sequence generation. Three studies used blindness methods and 2 publications were free of selective reporting. However, only 1 publication reported allocation concealment. Because of significant heterogeneity across the studies (I2=61.7%, p<0.05), the data were pooled by random effect model. Pooled data showed the postoperative delirium risk in the dexmedetomidine group was significantly lower than that of the midazolam group (RR=0.20 (095%CI:0.09~0.47, p<0.05)).The Begg's funnel plot showed obvious asymmetry at the bottom and Egger's line regression test also indicated significant publication bias (t=-6.51, p<0.05).Compared with midazolam, patients that received dexmedetomidine for postoperative mechanical ventilation sedation had less risk of developing delirium.

SUBMITTER: Peng W

PROVIDER: S-EPMC5553133 | biostudies-other | 2017

REPOSITORIES: biostudies-other

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Project description:BackgroundPostoperative delirium is common among older surgical patients and may be associated with anesthetic management during the perioperative period. The aim of this study is to assess whether intravenous midazolam, a short-acting benzodiazepine used frequently as premedication, increased the incidence of postoperative delirium.MethodsAnalyses of existing data were conducted using a database created from 3 prospective studies in patients aged 65 years or older who underwent elective major noncardiac surgery. Postoperative delirium occurring on the first postoperative day was measured using the confusion assessment method. We assessed the association between the use or nonuse of premedication with midazolam and postoperative delirium using a χ2 test, using propensity scores to match up with 3 midazolam patients for each control patient who did not receive midazolam.ResultsA total of 1266 patients were included in this study. Intravenous midazolam was administered as premedication in 909 patients (72%), and 357 patients did not receive midazolam. Those who did and did not receive midazolam significantly differed in age, Charlson comorbidity scores, preoperative cognitive status, preoperative use of benzodiazepines, type of surgery, and year of surgery. Propensity score matching for these variables and American Society of Anesthesiology physical status scores resulted in propensity score-matched samples with 1-3 patients who used midazolam (N = 749) for each patient who did not receive midazolam (N = 357). After propensity score matching, all standardized differences in preoperative patient characteristics ranged from -0.07 to 0.06, indicating good balance on baseline variables between the 2 exposure groups. No association was found between premedication with midazolam and incident delirium on the morning of the first postoperative day in the matched dataset, with odds ratio (95% confidence interval) of 0.91 (0.65-1.29), P = .67.ConclusionsPremedication using midazolam was not associated with higher incidence of delirium on the first postoperative day in older patients undergoing major noncardiac surgery.

Project description:BackgroundSleep disturbances are prevalent in patients requiring invasive mechanical ventilation in the intensive care unit (ICU) and are associated with worse outcomes. Sedative-dose dexmedetomidine may improve sleep quality in this patient population but is associated with adverse events. Herein, we tested the effect of low-dose dexmedetomidine infusion on nighttime sleep quality in postoperative ICU patients with invasive ventilation.MethodsIn this pilot randomized trial, 80 adult patients who were admitted to the ICU after non-cardiac surgery and required invasive mechanical ventilation were randomized to receive either low-dose dexmedetomidine (0.1 to 0.2 μg/kg/h, n = 40) or placebo (n = 40) for up to 72 h. The primary endpoint was overall subjective sleep quality measured using the Richards-Campbell Sleep Questionnaire (score ranges from 0 to 100, with a higher score indicating better quality) in the night of surgery. Secondary outcomes included sleep structure parameters monitored with polysomnography from 9:00 PM on the day of surgery to the next 6:00 AM.ResultsAll 80 patients were included in the intention-to-treat analysis. The overall subjective sleep quality was median 52 (interquartile 20, 66) with placebo vs. 61 (27, 79) with dexmedetomidine, and the difference was not statistically significant (median difference 8; 95% CI: -2, 22; P = 0.120). Among 68 patients included in sleep structure analysis, those in the dexmedetomidine group tended to have longer total sleep time [median difference 54 min (95% CI: -4, 120); P = 0.061], higher sleep efficiency [median difference 10.0% (95% CI: -0.8%, 22.3%); P = 0.060], lower percentage of stage N1 sleep [median difference -3.9% (95% CI: -11.8%, 0.5%); P = 0.090], higher percentage of stage N3 sleep [median difference 0.0% (95% CI: 0.0%, 0.4%); P = 0.057], and lower arousal index [median difference -0.9 (95% CI -2.2, 0.1); P = 0.091] but not statistically significant. There were no differences between the two groups regarding the incidence of adverse events.ConclusionAmong patients admitted to the ICU after surgery with intubation and mechanical ventilation, low-dose dexmedetomidine infusion did not significantly improve the sleep quality pattern, although there were trends of improvement. Our findings support the conduct of a large randomized trial to investigate the effect of low-dose dexmedetomidine in this patient population.Clinical trial registrationClinicalTrial.gov, identifier: NCT03335527.

Project description:BACKGROUND:To determine the preventive and therapeutic effect of dexmedetomidine on intensive care unit (ICU) delirium. METHODS:The literature search using PubMed and the Cochrane Central Register of Controlled Trials was performed (August 1, 2018) to detect all randomized controlled trials (RCTs) of adult ICU patients receiving dexmedetomidine. Articles were included if they assessed the influence of dexmedetomidine compared to a sedative agent on incidence of ICU delirium or treatment of this syndrome. Accordingly, relevant articles were allocated to the following two groups: (1) articles that assessed the delirium incidence (incidence comparison) or articles that assessed the treatment of delirium (treatment comparison). Incidence of delirium and delirium resolution were the primary outcomes. We combined treatment effects comparing dexmedetomidine versus (1) placebo, (2) standard sedatives, and (3) opioids in random-effects meta-analyses. Risk of bias for each included RCT was assessed following Cochrane standards. RESULTS:The literature search resulted in 28 articles (25 articles/4975 patients for the incidence comparison and three articles/166 patients for the treatment comparison). In the incidence comparison, heterogeneity was present in different subgroups. Administration of dexmedetomidine was associated with significantly lower overall incidence of delirium when compared to placebo (RR 0.52; 95% CI 0.39-0.70; I2?=?37%), standard sedatives (RR 0.63; 95% CI 0.46-0.86; I2?=?69%), as well as to opioids (RR 0.61; 95% CI 0.44-0.83; I2?=?0%). Use of dexmedetomidine significantly increased the risks of bradycardia and hypotension. Limited data were available on circulatory insufficiency and mortality. In the treatment comparison, the comparison drugs in the three RCTs were placebo, midazolam, and haloperidol. The resolution of delirium was measured differently in each study. Two out of the three studies indicated clear favorable effects for dexmedetomidine (i.e., compared to placebo and midazolam). The study comparing dexmedetomidine with haloperidol was a pilot study (n?=?20) with high variability in the results. CONCLUSION:Findings suggest that dexmedetomidine reduces incidence and duration of ICU delirium. Furthermore, our systematic searches show that there is limited evidence if a delirium shall be treated with dexmedetomidine.

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Delirium Risk of Dexmedetomidine and Midazolam in Patients Treated with Postoperative Mechanical Ventilation: a Meta-analysis.

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