Department of Pharmacy, The Johns Hopkins Hospital, United States of America.
Department of Pharmacy, Atlantic Health System, United States of America.
J Crit Care. 2021 Apr;62:19-24. doi: 10.1016/j.jcrc.2020.10.024. Epub 2020 Nov 2.
Dexmedetomidine (DEX) withdrawal syndrome has been reported in the pediatric population, but literature describing DEX withdrawal in critically ill adults is limited. The purpose of this study was to determine the incidence of DEX withdrawal in adult patients and to identify factors associated with DEX withdrawal syndrome.
A retrospective chart review was performed in the adult intensive care units of two tertiary medical centers. Eligible patients were at least 18 years of age and received DEX for 24 h or more. Patients were excluded if they presented with a primary neurologic diagnosis, had a history of substance abuse, or received any other α2-agonists 24 h before discontinuation of DEX. The primary outcome was the percentage of patients who developed withdrawal as defined by the presence of two or more symptoms (tachycardia, hypertension, vomiting, agitation) within the 24 h following DEX discontinuation.
Of the 165 patients included, 50 patients experienced withdrawal (30.3%), lasting a median of two days. The incidence of withdrawal was higher in surgical (40%) compared to medical (28%) or cardiac (32%) patients (p = 0.004). Median duration of infusion was 52.5 h (interquartile range [IQR], 37.8 to 102.8) in the withdrawal group and 52 h (IQR, 41 to 87) in the non-withdrawal group (p = 0.887). Median DEX dose was 0.56 μg/kg/h (IQR, 0.39 to 0.83) in the withdrawal group and 0.48 μg/kg/h (0.36 to 0.65) in the non-withdrawal group (p = 0.12). Weaning did not reduce the incidence of withdrawal as compared to abrupt discontinuation (p = 0.68). The withdrawal group was more likely to have concomitantly discontinued opioids (54% vs 12.2%) and benzodiazepines (36% vs 0%) at the time of DEX discontinuation compared to the non-withdrawal group (p = 0.004).
Development of DEX-associated withdrawal occurred in approximately 30% of adult patients, comparable to rates reported in pediatric literature. There appeared to be no correlation between dose, exposure, and weaning in the occurrence of withdrawal, but concomitant discontinuation of opioids or benzodiazepines as well as ICU admission type could highlight cases requiring closer monitoring.
地塞米松（DEX）戒断综合征已在儿科人群中报道，但关于危重症成人 DEX 戒断的文献有限。本研究的目的是确定成人患者中 DEX 戒断的发生率，并确定与 DEX 戒断综合征相关的因素。
对两家三级医疗中心的成人重症监护病房进行回顾性图表审查。符合条件的患者年龄至少为 18 岁，接受 DEX 治疗 24 小时或更长时间。如果患者有原发性神经诊断、药物滥用史或在 DEX 停药前 24 小时内接受任何其他 α2-激动剂，则将患者排除在外。主要结局是在 DEX 停药后 24 小时内出现两个或多个症状（心动过速、高血压、呕吐、躁动）的患者比例，以此定义为戒断。
在纳入的 165 名患者中，50 名患者出现戒断（30.3%），持续中位数为两天。外科（40%）患者的戒断发生率高于内科（28%）或心脏（32%）患者（p=0.004）。戒断组的中位输注时间为 52.5 小时（IQR，37.8 至 102.8），非戒断组为 52 小时（IQR，41 至 87）（p=0.887）。戒断组的中位 DEX 剂量为 0.56μg/kg/h（IQR，0.39 至 0.83），非戒断组为 0.48μg/kg/h（0.36 至 0.65）（p=0.12）。与突然停药相比，逐渐停药并未降低戒断的发生率（p=0.68）。与非戒断组相比，戒断组在 DEX 停药时更可能同时停用阿片类药物（54% vs. 12.2%）和苯二氮䓬类药物（36% vs. 0%）（p=0.004）。
大约 30%的成年患者出现了 DEX 相关戒断，与儿科文献报道的发生率相当。在戒断的发生中，剂量、暴露和逐渐停药之间似乎没有相关性，但同时停用阿片类药物或苯二氮䓬类药物以及 ICU 入院类型可能会突出需要更密切监测的病例。
