Current sedation guidelines recommend avoiding benzodiazepines but express no preference for propofol versus dexmedetomidine. In addition, there are limited data on how well randomized controlled trials on sedatives generalize to routine practice where conditions tend to be more varied and complex.
We gathered daily sedative exposure data from all patients on mechanical ventilation for ≥3 days over a 7-year period in a large academic medical center. We compared hazard ratios for ventilator-associated events (VAEs), extubation, hospital discharge, and hospital death amongst benzodiazepines, propofol, and dexmedetomidine using proportional subdistribution hazard models with competing risks. We adjusted all analyses for ICU type, demographics, comorbidities, procedures, severity of illness, hypotension, oxygenation, renal function, opioids, neuroleptics, neuromuscular blockers, awakening and breathing trials, and calendar year.
We evaluated 9,603 consecutive episodes of mechanical ventilation. Benzodiazepines and propofol were associated with increased VAE risk whereas dexmedetomidine was not. Propofol was associated with less time to extubation compared to benzodiazepines (HR for extubation 1.4, 95% CI 1.3-1.5). Dexmedetomidine was associated with less time to extubation compared to both benzodiazepines (HR 2.3, 95% CI 2.0-2.7) and propofol (HR 1.7, 95% CI 1.4-2.0) but there were relatively few dexmedetomidine exposures available for analysis. There were no differences between any two agents in hazards for hospital discharge or mortality.
In this large, real-world cohort, propofol and dexmedetomidine were associated with less time to extubation compared to benzodiazepines but dexmedetomidine was also associated with less time to extubation compared to propofol. These possible differences merit further study.