Safety, Efficacy, and Clinical Outcomes of Dexmedetomidine for Sedation in Traumatic Brain Injury: A Scoping Review

Abstract

Dexmedetomidine is a promising alternative sedative agent for moderate-severe Traumatic brain injury (TBI) patients. Although the data are limited, the posited benefits of dexmedetomidine in this population are a reduction in secondary brain injury compared with current standard sedative regimens. In this scoping review, we critically appraised the literature to examine the effects of dexmedetomidine in patients with moderate-severe TBI to examine the safety, efficacy, and cerebral and systemic physiological outcomes within this population. We sought to identify gaps in the literature and generate directions for future research. Two researchers and a librarian queried PubMed, Embase, Scopus, and APA Psy-cINFO databases. Of 920 studies imported for screening, 11 were identified for inclusion in the review. The primary outcomes in the included studied were cerebral physiology, systemic hemodynamics, sedation levels and delirium, and the presence of paroxysmal sympathetic hyperactivity. Dexmedetomidine dosing ranged from 0.2 to 1 ug/kg/h, with 3 studies using initial boluses of 0.8 to 1.0 ug/kg over 10 minutes. Dexmedetomidine used independently or as an adjunct seems to exhibit a similar hemodynamic safety profile compared with standard sedation regimens, albeit with transient episodes of bradycardia and hypotension, decrease episodes of agitation and may serve to alleviate symptoms of sympathetic hyperactivity. This scoping review suggests that dexmedetomidine is a safe and efficacious sedation strategy in patients with TBI.Given its rapid onset of action and anxiolytic properties, dexmedetomidine may serve as a feasible sedative for TBI patients.

Comment on “Dexmedetomidine Sedation in Traumatic Brain Injury: A Transforming Clinical Research and Knowledge in Traumatic Brain Injury Study”

“…W e thank Suresh and Magoon (1) for their thoughtful comments regarding our article recently published in the issue of Critical Care Medicine (2), which demonstrated that early dexmedetomidine exposure was not associated with improved 6-month functional outcomes in the entire population of mechanically ventilated patients with moderate-severe traumatic brain injury (TBI), but may have clinical benefit in patients with indications for ICP monitoring. We agree with the authors that sedation choice following TBI is important and may impact clinical outcomes in this population, as well as that large cohort studies such as the Transforming Clinical Research and Knowledge in Traumatic Brain Injury (TRACK-TBI) are helpful in examining clinical and functional outcomes in this population (3). Through the conduct of comparative effectiveness research using rigorous observational study designs, the most promising findings can lead to definitive prospective randomized controlled trials.…”

“…Although the limited access to patient records in any retrospective research is understandable, it is likely that the severe TBI cohort of cases on ICP monitoring in the index study was on stringent hemodynamic and cerebral perfusion pressure surveillance during their stay in the ICU that could have had contributed to favorable long-term GOS. Furthermore, episodes of bradycardia and significant hypotension, although transient, have been reported to occur with dexmedetomidine sedation (whether used independently or as an adjunct) among TBI patients, as highlighted in recent research reviews by Hatfield et al and Jeffcote et al (3,4).…”

“…Vijay Krishnamoorthy, MD, MPH, PhD [1][2][3] Nancy Temkin, PhD 4,5 Jason Barber, MS 5 Sunny Yang Liu, BA 6…”

Not So Fast—Pressing the Brakes on Sympathetic Hyperactivity After Traumatic Brain Injury*

“…First, the small sample size with suboptimal timing and duration of dexmedetomidine exposure limits the anticipated treatment effect. Dexmedetomidine is a newer sedative with a limited, although reassuring, evidence base for TBI compared with traditional sedation (4). Generic formulations became available shortly before the TRACK-TBI study began enrolling in 2014, which should have minimized cost-related concerns of using the drug.…”

Association of Early Dexmedetomidine Utilization With Clinical Outcomes After Moderate-Severe Traumatic Brain Injury: A Retrospective Cohort Study

“…12 These pharmacologic properties lead to several favorable effects including modulation of autonomic dysfunction, reduced delirium incidence, and a more favorable sedation profile. 6,13 A recent review found that dexmedetomidine, when used independently or as an adjunct, had a similar hemodynamic safety profile as other sedatives, and may decrease delirium and sympathetic hyperactivity in patients with TBI. 13 However, evidence for dexmedetomidine's efficacy in the treatment of MV patients with msTBI has been mixed.…”