Daniela Pasero1, Fabio Sangalli2, Massimo Baiocchi3, Ilaria Blangetti4, Sergio Cattaneo5, Gianluca Paternoster6, Marco Moltrasio7, Elisabetta Auci8, Patrizia Murrino9, Francesco Forfori10, Ester Forastiere11, Maria Giovanna De Cristofaro12, Giorgio Deste13, Paolo Feltracco14, Flavia Petrini15, Luigi Tritapepe16, Massimo Girardis17. 1. Department of Anaesthesia and Intensive Care, AOU Città della Salute e della Scienza, Turin, Italy. 2. Department of Perioperative Medicine and Intensive Care, Cardiothoracic And Vascular Anaesthesia and Intensive Care, San Gerardo Hospital, Monza, Italy. 3. Department of Cardiovascular and Thoracic Surgery, University Hospital of Bologna "s. Orsola-malpighi", Bologna, Italy. 4. Department of Cardiovascular and Thoracic Surgery, Azienda Ospedaliera Santa Croce E Carle, Cuneo, Italy. 5. Department of Anaesthesia and Intensive Care Medicine, Aziende Socio Sanitarie Territoriali Papa Giovanni Xxiii, Bergamo, Italy. 6. Department of Anaesthesia and Intensive Care, Azienda Ospedaliera Regionale San Carlo, Potenza, Italy. 7. Cardiac Intensive Care Unit, Centro Cardiologico Monzino, Milan, Italy. 8. Department of Anesthesiology and Intensive Care, S. Maria Della Misericordia Hospital, Udine, Italy. 9. Department of Anaesthesia and Critical Care Medicine, Aorn Ospedali Dei Colli, Naples, Italy. 10. Department of Anaesthesia and Critical Care Medicine, Azienda Ospedaliera Pisana, Pisa, Italy. 11. Department of Anaesthesiology, Regina Elena National Cancer Institute, Rome, Italy. 12. Department of Emergency Medicine, Cardarelli Hospital, Naples, Italy. 13. Uoc Anestesia E Rianimazione, Policlinico Casilino, Roma. 14. Department of Medicine, Anaesthesia and Intensive Care, University Hospital of Padova, Italy. 15. Department of Anaesthesia and Intensive Care, University Hospital of Chieti, Chieti, Italy. 16. Department of Anaesthesiology and Intensive Care Medicine, Umberto I Hospital, "sapienza" University, Rome, Italy. 17. Department of Anaesthesia and Intensive Care, University Hospital of Modena, Modena, Italy.
Abstract
OBJECTIVE: Management of pain, agitation and delirium (PAD) remains to be a true challenge in critically ill patients. The pharmacological proprieties of dexmedetomidine (DEX) make it an ideal candidate drug for light and cooperative sedation, but many practical questions remain unanswered. This structured consensus from 17 intensivists well experienced on PAD management and DEX use provides indications for the appropriate use of DEX in clinical practice. METHODS: A modified RAND/UCLA appropriateness method was used. In four predefined patient populations, the clinical scenarios do not properly cope by the current recommended pharmacological strategies (except DEX), and the possible advantages of DEX use were identified and voted for agreement, after reviewing literature data. RESULTS: Three scenarios in medical patients, five scenarios in patients with acute respiratory failure undergoing non-invasive ventilation, three scenarios in patients with cardiac surgery in the early postoperative period and three scenarios in patients with overt delirium were identified as challenging with the current PAD strategies. In these scenarios, the use of DEX was voted as potentially useful by most of the panellists owing to its specific pharmacological characteristics, such as conservation of cognitive function, lack of effects on the respiratory drive, low induction of delirium and analgesia effects. CONCLUSION: DEX might be considered as a first-line sedative in different scenarios even though conclusive data on its benefits are still lacking.
OBJECTIVE: Management of pain, agitation and delirium (PAD) remains to be a true challenge in critically ill patients. The pharmacological proprieties of dexmedetomidine (DEX) make it an ideal candidate drug for light and cooperative sedation, but many practical questions remain unanswered. This structured consensus from 17 intensivists well experienced on PAD management and DEX use provides indications for the appropriate use of DEX in clinical practice. METHODS: A modified RAND/UCLA appropriateness method was used. In four predefined patient populations, the clinical scenarios do not properly cope by the current recommended pharmacological strategies (except DEX), and the possible advantages of DEX use were identified and voted for agreement, after reviewing literature data. RESULTS: Three scenarios in medical patients, five scenarios in patients with acute respiratory failure undergoing non-invasive ventilation, three scenarios in patients with cardiac surgery in the early postoperative period and three scenarios in patients with overt delirium were identified as challenging with the current PAD strategies. In these scenarios, the use of DEX was voted as potentially useful by most of the panellists owing to its specific pharmacological characteristics, such as conservation of cognitive function, lack of effects on the respiratory drive, low induction of delirium and analgesia effects. CONCLUSION: DEX might be considered as a first-line sedative in different scenarios even though conclusive data on its benefits are still lacking.
Entities:
Keywords:
Sedation; analgesia; critically ill patients; delirium; intensive care
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