A randomized, double-blind pilot study of dexmedetomidine versus midazolam for intensive care unit sedation: patient recall of their experiences and short-term psychological outcomes.
BACKGROUND
Sedation with dexmedetomidine may facilitate ventilator liberation and limit the occurrence of delirium. No trial has assessed patient recall or the development of psychological outcomes after dexmedetomidine sedation. This pilot study evaluated whether transitioning benzodiazepine sedation to dexmedetomidine alters patient recall and the incidence of anxiety, depression, or acute stress disorder (ASD).


METHODS
This investigation was a randomized, double-blind, single-center study. Existing continuous benzodiazepine sedation was converted to dexmedetomidine or midazolam when patients qualified for daily awakenings. Sedation was titrated to achieve Riker sedation agitation scores of 3 to 4. The intensive care unit (ICU) Stressful Experiences Questionnaire, hospital anxiety and depression scale, and the impact of event scale-revised were administered before hospital discharge to assess recall, anxiety, depression, and manifestations of ASD.


RESULTS
A total of 11 patients received dexmedetomidine, and 12 patients received midazolam. Median dosing was 0.61 µg/kg/h for 3.5 days for dexmedetomidine and 3.7 mg/h for 3 days for midazolam. Attainment of goal sedation and analgesia was similar; however, more dexmedetomidine patients experienced agitation and pain. The median duration of mechanical ventilation from study drug initiation to extubation was 3.4 days in dexmedetomidine patients and 2.9 days in midazolam patients. Dexmedetomidine patients remembered 18.5 experiences compared with 8.5 in midazolam patients (P = .015). Rates of anxiety and depression were similar. In all, 5 (62.5%) dexmedetomidine patients and 1 (12.5%) midazolam patient manifested ASD (P = .063), and 1 dexmedetomidine patient and 5 midazolam patients developed new-onset delirium (P = .07). Hypotension occurred in 10 (90.9%) dexmedotomidine patients and 6 (50%) midazolam patients (P = .069).


CONCLUSIONS
Transitioning benzodiazepine sedation to dexmedetomidine when patients qualify for daily awakenings may reduce the development of delirium and facilitate remembrance of ICU experiences but may lead to manifestations of ASD. Monitoring hypotension is required for both the sedatives. Additional comparative studies focusing on the long-term impact of ICU recall and psychological outcomes are needed.
Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA rob.maclaren@ucdenver.edu.
Robert
R
MacLaren
Department of Pharmacy, Denver Health Medical Center, Denver, CO, USA.
Candice R
CR
Preslaski
Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA.
Scott W
SW
Mueller
Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA.
Tyree H
TH
Kiser
Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA.
Douglas N
DN
Fish
Division of Pulmonary and Critical Care Medicine, University of Colorado School of Medicine Aurora, CO, USA.
James C
JC
Lavelle
Division of Pulmonary and Critical Care Medicine, University of Colorado School of Medicine Aurora, CO, USA.
Stephen P
SP
Malkoski
D000328:Adult; D000368:Aged; D001007:Anxiety / Q000139:chemically induced; D016292:Procedural Sedation / Q000379:methods* / Q000523:psychology*; D003422:Critical Care / Q000379:methods*; D003863:Depression / Q000139:chemically induced; D020927:Dexmedetomidine / Q000008:administration & dosage / Q000009:adverse effects; D004311:Double-Blind Method; D005260:Female; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage / Q000009:adverse effects; D007362:Intensive Care Units; D008297:Male; D011939:Mental Recall / Q000187:drug effects*; D008874:Midazolam / Q000008:administration & dosage / Q000009:adverse effects; D008875:Middle Aged; D010865:Pilot Projects; D040701:Stress Disorders, Traumatic, Acute / Q000139:chemically induced; D011795:Surveys and Questionnaires
D006993:Hypnotics and Sedatives; D020927:Dexmedetomidine; D008874:Midazolam
acute stress disorder; anxiety; benzodiazepine; depression; dexmedetomidine; intensive care; posttraumatic stress disorder; recall; sedation