Critical Care: Critical Care in the ICU |

Dexmedetomidine: Sedative of Choice in Substance Abuse FREE TO VIEW

Aasim Mohammed; Ana Maheshwari, MD; Stephenie Manns, MD
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Mercy Catholic Medical Center, Yeadon, PA

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):225A. doi:10.1016/j.chest.2016.08.238
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SESSION TITLE: Critical Care in the ICU

SESSION TYPE: Original Investigation Poster Discussion

PRESENTED ON: Monday, October 24, 2016 at 12:00 PM - 01:30 PM

PURPOSE: Dexmedetomidine (DEX) is an alpha-2 adenoreceptor agonist which is increasingly being recognized as an alternative sedative in the critically ill. DEX provides sedation, anxiolysis, analgesia and attenuation of the stress response. We hypothesize that patients with a history of substance abuse would benefit from use of DEX. We studied patient characteristics and outcomes of all patients on DEX infusions and compared them based on their history of substance abuse.

METHODS: A retrospective observational study in Intensive Care Units (ICU) at two academic community hospitals was conducted between January 2014 and September 2015. All medical and surgical ICU patients greater than 18 years old were included. Patients were excluded if DEX was used only for procedural purposes. All patients on a DEX infusion (197) were studied during hospitalization; 47 patients were excluded due to incomplete documentation. Baseline patient demographics, co-morbidities, and clinical characteristics were collected. Patients were divided into two cohorts based on substance abuse (SUBS group) vs no substance abuse (NONSUBS group). Inclusion criteria of the SUBS group included history of substance abuse as per documentation or a positive toxicology screen.

RESULTS: 150 patients on DEX infusion in the ICU were studied. The severity of illness, assessed by APACHE II scores, was similar amongst the SUBS group (25.6, n=90) and NONSUBS group (25.1, n=60). The SUBS group had statistically significant shorter ICU length of stay (LOS) (8.5 days vs 15 days, p< 0.0001), ventilator days (5.6 days vs 10.8 days, p< 0.0001) and hospital LOS (13 days vs 20 days, p = 0.0020). The difference in the mean hours of infusions for SUBS group (38 hours) and NONSUB (47 hours) did not reach statistical significance (p = 0.16). The incidence of bradycardia (SUBS 31% vs NONSUBS 36%, p = 0.48) and hypotension (SUBS 32% vs NONSUBS 45%, p = 0.12) were similar among the two groups. Mortality in the SUBS group was 4% compared to 18% in the NONSUBS group.

CONCLUSIONS: In our study, the SUBS group had similar severity of illness compared to the NONSUBS group, as evidenced by their APACHE II scores. Interestingly, the SUBS group had significantly shorter ICU LOS, ventilator days and hospital LOS as compared to NONSUBS group. Mortality in the SUBS group was significantly less than those in the NONSUBS group. The SUBS group had a trend towards a lower duration time on DEX infusion, possibly contributing to the better outcomes seen compared to the NONSUBS group. In addition to its effects on sedation, DEX effects as an anxioytic and analgesic without causing respiratory depression. These effects may have contributed to the beneficial outcomes of shorter ICU LOS, ventilator days and hospital LOS. In addition, DEX has significant sympathicolytic activity and suppression of the increased sympathetic effects. This additive characteristic of DEX may benefit the pharmacology of patients with substance abuse and may improve clinical outcomes.

CLINICAL IMPLICATIONS: Based on our findings, DEX should be considered as the sedative of choice in patients with a history of substance abuse or a positive toxicology screen. Future larger prospective studies are needed to compare the efficacy and safety of DEX in this setting.

DISCLOSURE: The following authors have nothing to disclose: Aasim Mohammed, Ana Maheshwari, Stephenie Manns

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