Dexmedetomidine versus Propofol Sedation Reduces Delirium after Cardiac Surgery

Abstract

Background Postoperative delirium (POD) is a serious complication after cardiac surgery. Use of dexmedetomidine to prevent delirium is controversial. The authors hypothesized that dexmedetomidine sedation after cardiac surgery would reduce the incidence of POD. Methods After institutional ethics review board approval, and informed consent, a single-blinded, prospective, randomized controlled trial was conducted in patients 60 yr or older undergoing cardiac surgery. Patients with a history of serious mental illness, delirium, and severe dementia were excluded. Upon admission to intensive care unit (ICU), patients received either dexmedetomidine (0.4 μg/kg bolus followed by 0.2 to 0.7 μg kg−1 h−1 infusion) or propofol (25 to 50 μg kg−1 min−1 infusion) according to a computer-generated randomization code in blocks of four. Assessment of delirium was performed with confusion assessment method for ICU or confusion assessment method after discharge from ICU at 12-h intervals during the 5 postoperative days. Primary outcome was the incidence of POD. Results POD was present in 16 of 91 (17.5%) and 29 of 92 (31.5%) patients in dexmedetomidine and propofol groups, respectively (odds ratio, 0.46; 95% CI, 0.23 to 0.92; P = 0.028). Median onset of POD was on postoperative day 2 (1 to 4 days) versus 1 (1 to 4 days), P = 0.027, and duration of POD 2 days (1 to 4 days) versus 3 days (1 to 5 days), P = 0.04, in dexmedetomidine and propofol groups, respectively. Conclusions When compared with propofol, dexmedetomidine sedation reduced incidence, delayed onset, and shortened duration of POD in elderly patients after cardiac surgery. The absolute risk reduction for POD was 14%, with a number needed to treat of 7.1.

Dexmedetomidine for prevention of delirium in elderly patients after non-cardiac surgery

“…This is the first study to report on the efficacy of subsedative dose dexmedetomidine to reduce the development of delirium, both in non-intubated patients and in those requiring mechanical ventilation and sedation with γ-aminobutyric acid (GABA) receptor agonists. This study adds to the growing body of evidence that dexmedetomidine can reduce the development of delirium (21)(22)(23). Prior studies, however, compared dexmedetomidine to other sedating agents, either benzodiazepines or propofol.…”

“…When used as the primary sedative for intubated medical and surgical ICU patients, dexmedetomidine reduced the duration of delirium when compared to benzodiazepines (21,22). Additionally, in patients undergoing cardiac surgery, dexmedetomidine has been shown to reduce the incidence of postoperative delirium when compared to propofol, leading to a reduction in ICU time and cost related to delirium (23). A recent trial in patients with hyperactive delirium that prevented weaning from mechanical ventilation found that dexmedetomidine increased ventilator-free hours and resolved delirium symptoms faster than placebo (24).…”

Delirium in the Cardiac Intensive Care Unit

“…The DEXCOM (Dexmedetomidine Compared to Morphine) study randomized such patients to dexmedetomidine or morphine and showed that dexmedetomidine reduced the duration but not incidence of delirium 63. Djaiani et al randomized patients to dexmedetomidine versus propofol and found that dexmedetomidine reduced the incidence of delirium (17.5% versus 31.5%, OR 0.46; P =0.028) and reduced duration (2 days versus 3 days, P =0.04) 64. However, a randomized placebo controlled trial undertaken by Li et al failed to demonstrate any reduction in the incidence of delirium when dexmedetomidine was administered during anaesthesia and during the early postoperative period (4.9% in the dexmedetomidine group versus 7.7% in the control group, P =0.345) 65.…”

Dexmedetomidine for the treatment of hyperactive delirium refractory to haloperidol in non-intubated patients

“…They also found significantly lower total costs with dexmedetomidine, primarily due to decreased ICU stay and reduced mechanical ventilation. Most recently, a randomized controlled trial of dexmedetomidine versus propofol for ICU sedation after cardiac surgery found a decreased incidence and reduced duration of delirium with dexmedetomidine, leading to a reduction in ICU time and cost related to delirium (11). Thus, results from multiple trials examining dexmedetomidine for sedation consistently demonstrate improved delirium outcomes and reduce cost with the use of dexmedetomidine.…”

“…A promising therapy that can not only treat delirium symptoms but may also prevent the development of delirium is the alpha-2 agonist dexmedetomidine. Several studies have shown that dexmedetomidine, when used for sedation of patients on mechanical ventilation, can reduce the incidence and duration of delirium (8)(9)(10)(11) and hasten extubation of patients with hyperactive delirium (12,13). There is little data, however, on its effectiveness in non-intubated patients.…”