The Use of Dexmedetomidine in the Emergency Department: A Cohort Study

Abstract

Introduction: Management of sedation, analgesia, and anxiolysis are cornerstone therapies in the emergency department (ED). Dexmedetomidine (DEX), a central alpha-2 agonist, is increasingly being used, and intensive care unit (ICU) data demonstrate improved outcomes in patients with respiratory failure. However, there is a lack of ED-based data. We therefore sought to: 1) characterize ED DEX use; 2) describe the incidence of adverse events; and 3) explore factors associated with adverse events among patients receiving DEX in the ED. Methods: This was a single-center, retrospective, cohort study of consecutive ED patients administered DEX (January 1, 2017–July 1, 2019) at an academic, tertiary care ED with an annual census of ~90,000 patient visits. All included patients (n= 103) were analyzed for characterization of DEX use in the ED. The primary outcome was a composite of adverse events, bradycardia and hypotension. Secondary clinical outcomes included ventilator-, ICU-, and hospital-free days, and hospital mortality. To examine for variables associated with adverse events, we used a multivariable logistic regression model. Results: We report on 103 patients. Dexmedetomidine was most commonly given for acute respiratory failure, including sedation for mechanical ventilation (28.9%) and facilitation of non-invasive ventilation (17.4%). Fifty-four (52.4%) patients experienced the composite adverse event, with hypotension occurring in 41 patients (39.8%) and bradycardia occurring in 18 patients (17.5%). Dexmedetomidine was stopped secondary to an adverse event in eight patients (7.8%). Duration of DEX use in the ED was associated with an increase adverse event risk (adjusted odds ratio, 1.004; 95% confidence interval, 1.001, 1.008). Conclusion: Dexmedetomidine is most commonly administered in the ED for patients with acute respiratory failure. Adverse events are relatively common, yet DEX is discontinued comparatively infrequently due to adverse events. Our results suggest that DEX could be a viable option for analgesia, anxiolysis, and sedation in ED patients.

The use of dexmedetomidine in the emergency department: A systematic review

“…A key finding of this review is that some of the most common and important indications for DEX in the ED are clearly underinvestigated. It is particularly noteworthy that there is very little evidence describing the use of DEX to facilitate invasive or noninvasive mechanical ventilation, which was reported in only one cohort study 19 and two case reports 57,59 . As ED boarding times for critically ill patients continue to increase, this will be a critical area to address with future research.…”

“…Other indications, including facilitation of mechanical ventilation or NIPPV and prevention of ketamine-associated emergence delirium or ketamine-associated adverse effects, were uncommonly reported, significantly limiting any high-level conclusions. Notably, use of DEX in intubated ED patients was reported in only one cohort study 19 and one case report. 57 Adverse events associated with DEX Eight RCTs reported information regarding adverse events associated with DEX.…”

“…The most common indication for DEX was procedural sedation, which was reported in three RCTs, 32,36,39 six cohort and nonrandomized studies, 19,20,43,47,48,50 and two case reports or series. 52,53 Pooling of efficacy results was not feasible due to the heterogeneity of DEX dose and route, procedures being reported, and outcome measurements used.…”

“…Five cohort studies and other nonrandomized studies 19,21,23,46,49 and six case reports and case series 12,51,[54][55][56]60 reported the use of DEX for the purposes of sedation of nonintubated agitated or delirious patients with medical or psychiatric emergencies. The 2012 study by Calver and Isbister 23 had poor efficacy results (only five of 13 patients successfully sedated), possibly related to its unique dosing approach and a priori difficult to sedate patient population, but other studies reporting efficacy results were more encouraging (successful sedation in all six case reports or series and sedation with avoidance of intubation in about 70% of patients in the cohort study by Krenz et al 21 ).…”

“…10,11 Limited data from the ED domain also suggest that DEX may be useful in several clinical scenarios, including procedural sedation and anxiolysis, sedation of agitated nonintubated patients, sedation to facilitate radiologic imaging in pediatric patients, and facilitation of NIPPV and invasive positive pressure ventilation. [19][20][21][22] However, other experts have questioned the efficacy of DEX in the ED setting and raised concerns about its safety, 23 and the slow onset of action of intravenous (IV) DEX may limit its utility in ED patients requiring rapid intervention. Given the potential benefits of DEX in the ED population and the overall paucity of ED-based data that exists, we conducted a systematic review of the global biomedical literature regarding the use of DEX in the ED setting.…”