Study protocol to test the efficacy of self-administration of dexmedetomidine sedative therapy on anxiety, delirium, and ventilator days in critically ill mechanically ventilated patients: an open-label randomized clinical trial

Abstract

Background Administration of sedative and opioid medications to patients receiving mechanical ventilatory support in the intensive care unit is a common clinical practice. Methods A two-site randomized open-label clinical trial will test the efficacy of self-management of sedative therapy with dexmedetomidine compared to usual care on anxiety, delirium, and duration of ventilatory support after randomization. Secondary objectives are to compare self-management of sedative therapy to usual care on level of alertness, total aggregate sedative and opioid medication exposure, and ventilator-free days up to day 28 after study enrolment. Exploratory objectives of the study are to compare self-management of sedative therapy to usual care on 3- and 6-month post-discharge physical and functional status, psychological well-being (depression, symptoms of post-traumatic stress disorder), health-related quality of life, and recollections of ICU care. ICU patients (n = 190) who are alert enough to follow commands to self-manage sedative therapy are randomly assigned to self-management of sedative therapy or usual care. Patients remain in the ICU sedative medication study phase for up to 7 days as long as mechanically ventilated. Discussion The care of critically ill mechanically ventilated patients can change significantly over the course of a 5-year clinical trial. Changes in sedation and pain interventions, oxygenation approaches, and standards related to extubation have substantially impacted consistency in the number of eligible patients over time. In addition, the COVID-19 pandemic resulted in mandated extended pauses in trial enrolment as well as alterations in recruitment methods out of concern for study personnel safety and availability of protective equipment. Patient triaging among healthcare institutions due to COVID-19 cases also has resulted in inconsistent access to the eligible study population. This has made it even more imperative for the study team to be flexible and innovative to identify and enrol all eligible participants. Patient-controlled sedation is a novel approach to the management of patient symptoms that may be able to alleviate mechanical ventilation-induced distress without serious side effects. Findings from this study will provide insight into the efficacy of this approach on short- and long-term outcomes in a subset of mechanically ventilated patients. Trial registration ClinicalTrials.gov NCT02819141. Registered on June 29, 2016.

The future of intensive care: delirium should no longer be an issue

“…Timely introduction of specific agents that may promote weaning, reduce agitation and delirium will facilitate early weaning and liberation from mechanical ventilation [ 38 ]. Moreover, new insights in relation of sedation with personalized care may be provided by trials evaluating the efficacy of patient-controlled sedation to manage symptoms associated with the distress induced by mechanical ventilation [ 39 ]. Sedation trials in the future need to incorporate non-pharmacological interventions as part of integrated approach to optimal sedation, anxiolysis and delirium management.…”

21st century critical care medicine: An overview

“…Lastly, the ‘Patient-controlled comfort measures’ have integration of customizable environmental and comfort controls. This allows patients to personalize their immediate surroundings, influencing factors like lighting and noise levels, contributing to a more comfortable and healing-oriented environment including pain and sedation control[ 125 ].…”

The impact of the COVID-19 pandemic on ICU clinical trials: a description of one research team’s experience

“…Patients must follow simple commands, be able to use a medication push-button infusion device, and be willing to self-administer a sedative agent to be eligible for enrollment via own informed consent or from a legally authorized representative (LAR). A detailed description of the parent clinical trial and its protocol can be found elsewhere [ 11 ]. All research was performed in accordance with human subjects in research guidelines put forth by Mayo Clinic’s Institutional Review Board (IRB) and the University of Minnesota IRB for greater than minimal risk clinical trials.…”