In this episode, I’ll discuss whether there is a benefit from switching to dexmedetomidine when sedation is started with midazolam.
Sedation guidelines recommend light sedation with a non-benzodiazepine agent such as dexmedetomidine or propofol. However, many ICU patients are started on midazolam-based sedation regimens either due to a compelling reason or a clinician’s habit of starting sedation with midazolam.
Anecdotally, in my practice I have found it is far more challenging to convince providers to change from therapy that doesn’t appear broken such as a midazolam infusion, simply to bring treatment in line with guideline recommendations. For whatever reason, the therapy that is started becomes “sticky” until there is an active reason to switch. The easiest way to get the best therapy started is to make the recommendation at the time of the initial decision.
But a recent randomized controlled trial published in the journal Critical Care looked specifically at outcomes in critically ill patients started on midazolam who were then switched to dexmedetomidine.
In this study 252 patients who were critically ill and started on midazolam for sedation with anticipated mechanical ventilation for at least 72 hours were enrolled. Patients were split between 3 groups – those that stayed on midazolam, those that switched to propofol, and those that switched to dexmedetomidine.
All sedatives were titrated to achieve the targeted sedation range (RASS − 2 to 0).
Patients who were switched to dexmedetomidine had an earlier recovery, faster extubation, and more percentage of time at the target sedation level than those in the other 2 groups.
When compared to the midazolam only group, those that were switched to dexmedetomidine had 50% shorter weaning times, and a more than 50% decrease in the incidence of delirium.
The authors concluded:
The sequential use of midazolam and dexmedetomidine was an effective and safe sedation strategy for long-term sedation and could provide clinically relevant benefits for selected critically ill, mechanically ventilated patients.
This study suggests a positive benefit to switching sedation regimens to guideline-recommended therapy even if midazolam is initially chosen, which may help persuade providers to make this switch.
Members of my Hospital Pharmacy Academy have access to several practical training videos that I have created on the use of sedation for critically ill patients. You can get immediate access to these and hundreds of other trainings and resources to help in your practice at pharmacyjoe.com/academy.
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