Cardiac surgery, ICU sedation, and delirium: is dexmedetomidine the silver bullet?

Smith, W. S.; Whitlock, Elizabeth L.

doi:10.1097/aco.0000000000001207

Cited by 3 publications

(2 citation statements)

References 30 publications

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“…Although sedation-free protocols could reduce days without mechanical ventilation in critically ill patients, it was associated with higher risk of delirium [ 55 ]. To date, however, sufficient evidence on the optimal sedation strategy for older patients is lacking [ 56 ]. Dosing the serum [ 57 ] or cerebrospinal fluid biomarkers [ 58 ] may provide a new tool to guide decision-making for preventing delirium in the cardiac intensive care unit in the near future, although it has not yet proven to be sufficiently specific for this goal.…”

Section: Optimal Strategy During the Acute Phase Of Coronary Syndrome...mentioning

confidence: 99%

Management of Coronary Artery Disease in Older Adults: Recent Advances and Gaps in Evidence

Cacciatore,

Spadafora,

Bernardi

et al. 2023

JCM

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Coronary artery disease (CAD) is highly prevalent in older adults, yet its management remains challenging. Treatment choices are made complex by the frailty burden of older patients, a high prevalence of comorbidities and body composition abnormalities (e.g., sarcopenia), the complexity of coronary anatomy, and the frequent presence of multivessel disease, as well as the coexistence of major ischemic and bleeding risk factors. Recent randomized clinical trials and epidemiological studies have provided new data on optimal management of complex patients with CAD. However, frail older adults are still underrepresented in the literature. This narrative review aims to highlight the importance of assessing frailty as an aid to guide therapeutic decision-making and tailor CAD management to the specific needs of older adults, taking into account age-related pharmacokinetic and pharmacodynamic changes, polypharmacy, and potential drug interactions. We also discuss gaps in the evidence and offer perspectives on how best in the future to optimize the global strategy of CAD management in older adults.

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Section: Optimal Strategy During the Acute Phase Of Coronary Syndrome...mentioning

confidence: 99%

Management of Coronary Artery Disease in Older Adults: Recent Advances and Gaps in Evidence

Cacciatore,

Spadafora,

Bernardi

et al. 2023

JCM

View full text Add to dashboard Cite

show abstract

“…Sedation choice is another modifiable risk factor needing further examination. Initial positive reports of dexmedetomidine in cardiac surgery have recently been eclipsed by strong RTCs questioning its benefit [ 94 , 98 , 107 , 108 ]. As a result, there continues to be no single sedative agent deemed helpful in delirium treatment or prevention in any realm of critical care.…”

Section: Part 2 – Selected Gaps In Knowledge and Future Direction Of ...mentioning

confidence: 99%

The Future of Cardiothoracic Surgical Critical Care Medicine as a Medical Science: A Call to Action

et al. 2022

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Cardiothoracic surgical critical care medicine (CT-CCM) is a medical discipline centered on the perioperative care of diverse groups of patients. With an aging demographic and an increase in burden of chronic diseases the utilization of cardiothoracic surgical critical care units is likely to escalate in the coming decades. Given these projections, it is important to assess the state of cardiothoracic surgical intensive care, to develop goals and objectives for the future, and to identify knowledge gaps in need of scientific inquiry. This two-part review concentrates on CT-CCM as its own subspeciality of critical care and cardiothoracic surgery and provides aspirational goals for its practitioners and scientists. In part one, a list of guiding principles and a call-to-action agenda geared towards growth and promotion of CT-CCM are offered. In part two, an evaluation of selected scientific data is performed, identifying gaps in CT-CCM knowledge, and recommending direction to future scientific endeavors.

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Remifentanil vs. dexmedetomidine for cardiac surgery patients with noninvasive ventilation intolerance: a multicenter randomized controlled trial

Hao,

Wu,

et al. 2024

j intensive care

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Background The optimal sedative regime for noninvasive ventilation (NIV) intolerance remains uncertain. The present study aimed to assess the efficacy and safety of remifentanil (REM) compared to dexmedetomidine (DEX) in cardiac surgery patients with moderate-to-severe intolerance to NIV. Methods In this multicenter, prospective, single-blind, randomized controlled study, adult cardiac surgery patients with moderate-to-severe intolerance to NIV were enrolled and randomly assigned to be treated with either REM or DEX for sedation. The status of NIV intolerance was evaluated using a four-point NIV intolerance score at different timepoints within a 72-h period. The primary outcome was the mitigation rate of NIV intolerance following sedation. Results A total of 179 patients were enrolled, with 89 assigned to the REM group and 90 to the DEX group. Baseline characteristics were comparable between the two groups, including NIV intolerance score [3, interquartile range (IQR) 3–3 vs. 3, IQR 3–4, p = 0.180]. The chi-squared test showed that mitigation rate, defined as the proportion of patients who were relieved from their initial intolerance status, was not significant at most timepoints, except for the 15-min timepoint (42% vs. 20%, p = 0.002). However, after considering the time factor, generalized estimating equations showed that the difference was statistically significant, and REM outperformed DEX (odds ratio = 3.31, 95% confidence interval: 1.35–8.12, p = 0.009). Adverse effects, which were not reported in the REM group, were encountered by nine patients in the DEX group, with three instances of bradycardia and six cases of severe hypotension. Secondary outcomes, including NIV failure (5.6% vs. 7.8%, p = 0.564), tracheostomy (1.12% vs. 0%, p = 0.313), ICU LOS (7.7 days, IQR 5.8–12 days vs. 7.0 days, IQR 5–10.6 days, p = 0.219), and in-hospital mortality (1.12% vs. 2.22%, p = 0.567), demonstrated comparability between the two groups. Conclusions In summary, our study demonstrated no significant difference between REM and DEX in the percentage of patients who achieved mitigation among cardiac surgery patients with moderate-to-severe NIV intolerance. However, after considering the time factor, REM was significantly superior to DEX. Trial registration ClinicalTrials.gov (NCT04734418), registered on January 22, 2021. URL of the trial registry record: https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S000AM4S&selectaction=Edit&uid=U00038YX&ts=3&cx=eqn1z0.

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Cardiac surgery, ICU sedation, and delirium: is dexmedetomidine the silver bullet?

Cited by 3 publications

References 30 publications

Management of Coronary Artery Disease in Older Adults: Recent Advances and Gaps in Evidence

Management of Coronary Artery Disease in Older Adults: Recent Advances and Gaps in Evidence

The Future of Cardiothoracic Surgical Critical Care Medicine as a Medical Science: A Call to Action

Remifentanil vs. dexmedetomidine for cardiac surgery patients with noninvasive ventilation intolerance: a multicenter randomized controlled trial

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