title: Impact of a protocol advocating dexmedetomidine over propofol sedation after robotic-assisted direct coronary artery bypass surgery on duration of mechanical ventilation and patient safety.
abstract: BACKGROUND
  Controversy remains whether propofol or dexmedetomidine is the preferred sedative following cardiac surgery. Dexmedetomidine may offer advantages over propofol among patients undergoing robotic-assisted, minimally invasive, direct coronary artery bypass (MIDCAB) surgery given the rapidity with which this population is usually extubated after surgery.
  
  
  OBJECTIVE
  To measure the impact of a surgery protocol advocating use of dexmedetomidine rather than propofol after MIDCAB surgery on discontinuation of mechanical ventilation and patient safety.
  
  
  METHODS
  The records on consecutive adults undergoing MIDCAB surgery who received postoperative sedation with propofol or dexmedetomidine at a 508-bed academic medical center were analyzed before and after implementation of a post-MIDCAB surgery protocol advocating dexmedetomidine use.
  
  
  RESULTS
  Seventy-three propofol patients were compared with 53 dexmedetomidine patients. The groups were similar, except propofol patients were older (p = 0.002) and more likely to have underlying heart failure that was either moderate or severe (New York Heart Association class III or IV) (p = 0.0001). Time (median [interquartile range]) to extubation (hours) was shorter in the dexmedetomidine group (5.0 [3.6-7.0] vs 9.8 [5.0-16.3]; p = 0.0001). A Cox proportional hazards model revealed that patient age (p = 0.001) and duration of surgery (p = 0.003) influenced time to extubation between the dexmedetomidine and propofol groups but the presence of moderate or severe heart failure (p = 0.438), the number of coronary vessels operated on (p = 0.130), use of an opioid (p = 0.791), or the total dose of morphine administered (p = 0.215) did not. During sedation administration, more propofol-treated patients experienced 1 or more episodes of hypotension (systolic blood pressure ≤80 mm Hg, 11.6% vs 0%; p = 0.02), tachycardia (heart rate ≥120 beats/min, 8.6% vs 0%; p = 0.04), and unarousability (Sedation Agitation Scale score ≤2, 30.0% vs 9.4%; p = 0.03).
  
  
  CONCLUSIONS
  Use of a protocol promoting dexmedetomidine, rather than propofol sedation, after MIDCAB surgery facilitates faster discontinuation of mechanical ventilation and is associated with greater hemodynamic stability and arousability.
authors.affiliation: Brigham and Women's Hospital, Boston, MA, USA. htorbic@partners.org
authors.forename: Heather
authors.initials: H
authors.lastname: Torbic
authors.forename: Stella
authors.initials: S
authors.lastname: Papadopoulos
authors.forename: Justin
authors.initials: J
authors.lastname: Manjourides
authors.forename: John W
authors.initials: JW
authors.lastname: Devlin
mesh_terms: D000368:Aged; D000701:Analgesics, Opioid / Q000008:administration & dosage; D001026:Coronary Artery Bypass / Q000379:methods*; D020927:Dexmedetomidine / Q000627:therapeutic use*; D005260:Female; D006801:Humans; D006993:Hypnotics and Sedatives / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D009020:Morphine / Q000008:administration & dosage; D061214:Patient Safety; D011182:Postoperative Care; D015742:Propofol / Q000627:therapeutic use*; D012121:Respiration, Artificial / Q000379:methods*; D012189:Retrospective Studies; D012371:Robotics
chemical_list: D000701:Analgesics, Opioid; D006993:Hypnotics and Sedatives; D020927:Dexmedetomidine; D009020:Morphine; D015742:Propofol