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Dexmedetomidine Use in Critically Ill Children With Acute Respiratory Failure
Mary Jo C Grant1, James B Schneider, Lisa A Asaro
11Department of Pediatric Critical Care, Primary Children's Hospital, Salt Lake City, UT.2Division of Pediatric Critical Care Medicine, Cohen Children's Medical Center, Hofstra-Northwell School of Medicine, New York, NY.3Department of Cardiology, Boston Children's Hospital, Boston, MA.4Department of Pharmacy, Boston Children's Hospital, Boston, MA.5Department of Pharmacy, UC Davis Medical Center, Sacramento, CA.6Department of Pediatric Critical Care, University of Maryland Medical Center, Baltimore, MD.7Division of Pediatric Critical Care Medicine, Connecticut Children's Medical Center, Hartford, CT.8Division of Pediatric Critical Care Medicine, Department of Pediatric Critical Care, Phoenix Children's Hospital, University of Arizona College of Medicine, Phoenix, AZ.9Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA.10Department of Pediatrics, Harvard Medical School, Boston, MA.11Department of Family and Community Health, School of Nursing and Department of Anesthesia and Critical Care Medicine, the Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.12Department of Critical Care and Cardiovascular Nursing, Boston Children's Hospital, Boston, MA.
Insights
Dexmedetomidine can be a primary sedative for less critically ill children, improving sedation target achievement. Its use as a secondary agent offers no benefit, but it may shorten ventilator weaning when used for extubation.
Area of Science:
- Pediatric Critical Care Medicine
- Pharmacology
- Respiratory Medicine
Background:
- Current sedation therapies for critically ill children on mechanical ventilation are often suboptimal.
- Dexmedetomidine is an alternative sedative agent with potential benefits in pediatric intensive care.
Purpose of the Study:
- To describe the utilization patterns and clinical outcomes of dexmedetomidine in children requiring mechanical ventilation for acute respiratory failure.
- To evaluate dexmedetomidine's efficacy as a primary sedative, secondary sedative, and periextubation agent.
Main Methods:
- Secondary analysis of data from the Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) trial.
- Categorization of 1,224 "usual care" patients based on dexmedetomidine use: primary, secondary, periextubation, or never prescribed.
- Description of dexmedetomidine exposure, sedation, and clinical profiles.
Main Results:
- 49% of "usual care" patients received dexmedetomidine.
- As a primary sedative (11% of patients), dexmedetomidine was used in less critically ill children and improved time to sedation target.
- As a secondary sedative, it was associated with more inadequate pain and sedation events; as a periextubation agent, it shortened ventilator weaning time.
Conclusions:
- Dexmedetomidine is beneficial as a primary sedative in less critically ill pediatric patients, facilitating rapid achievement of sedation targets.
- Its use as a secondary sedative agent does not appear to provide additional benefits.
- Dexmedetomidine may aid in extubation for children intolerant of an awake, intubated state, potentially shortening mechanical ventilation duration.
Objective:
Care of critically ill children includes sedation but current therapies are suboptimal. To describe dexmedetomidine use in children supported on mechanical ventilation for acute respiratory failure.
Design:
Secondary analysis of data from the Randomized Evaluation of Sedation Titration for Respiratory Failure clinical trial.
Setting:
Thirty-one PICUs.
Patients:
Data from 2,449 children; 2 weeks to 17 years old.
Interventions:
Sedation practices were unrestrained in the usual care arm. Patients were categorized as receiving dexmedetomidine as a primary sedative, secondary sedative, periextubation agent, or never prescribed. Dexmedetomidine exposure and sedation and clinical profiles are described.
Measurements And Main Results:
Of 1,224 usual care patients, 596 (49%) received dexmedetomidine. Dexmedetomidine as a primary sedative patients (n = 138; 11%) were less critically ill (Pediatric Risk of Mortality III-12 score median, 6 [interquartile range, 3-11]) and when compared with all other cohorts, experienced more episodic agitation. In the intervention group, time in sedation target improved from 28% to 50% within 1 day of initiating dexmedetomidine as a primary sedative. Dexmedetomidine as a secondary sedative usual care patients (n = 280; 23%) included more children with severe pediatric acute respiratory distress syndrome or organ failure. Dexmedetomidine as a secondary sedative patients experienced more inadequate pain (22% vs 11%) and sedation (31% vs 16%) events. Dexmedetomidine as a periextubation agent patients (n = 178; 15%) were those known to not tolerate an awake, intubated state and experienced a shorter ventilator weaning process (2.1 vs 2.3 d).
Conclusions:
Our data support the use of dexmedetomidine as a primary agent in low criticality patients offering the benefit of rapid achievement of targeted sedation levels. Dexmedetomidine as a secondary agent does not appear to add benefit. The use of dexmedetomidine to facilitate extubation in children intolerant of an awake, intubated state may abbreviate ventilator weaning. These data support a broader armamentarium of pediatric critical care sedation.
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