From the Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina.
Duke University School of Medicine, Durham, North Carolina.
Anesth Analg. 2024 Aug 1;139(2):366-374. doi: 10.1213/ANE.0000000000006869. Epub 2024 Jul 15.
Traumatic brain injury (TBI) is an expensive and common public health problem. Management of TBI oftentimes includes sedation to facilitate mechanical ventilation (MV) for airway protection. Dexmedetomidine has emerged as a potential candidate for improved patient outcomes when used for early sedation after TBI due to its potential modulation of autonomic dysfunction. We examined early sedation patterns, as well as the association of dexmedetomidine exposure with clinical and functional outcomes among mechanically ventilated patients with moderate-severe TBI (msTBI) in the United States.
We conducted a retrospective cohort study using data from the Premier dataset and identified a cohort of critically ill adult patients with msTBI who required MV from January 2016 to June 2020. msTBI was defined by head-neck abbreviated injury scale (AIS) values of 3 (serious), 4 (severe), and 5 (critical). We described early continuous sedative utilization patterns. Using propensity-matched models, we examined the association of early dexmedetomidine exposure (within 2 days of intensive care unit [ICU] admission) with the primary outcome of hospital mortality and the following secondary outcomes: hospital length of stay (LOS), days on MV, vasopressor use after the first 2 days of admission, hemodialysis (HD) after the first 2 days of admission, hospital costs, and discharge disposition. All medications, treatments, and procedures were identified using date-stamped hospital charge codes.
The study population included 19,751 subjects who required MV within 2 days of ICU admission. The patients were majority male and white. From 2016 to 2020, the annual percent utilization of dexmedetomidine increased from 4.05% to 8.60%. After propensity score matching, early dexmedetomidine exposure was associated with reduced odds of hospital mortality (odds ratio [OR], 0.59; 95% confidence interval [CI], 0.47-0.74; P < .0001), increased risk for liberation from MV (hazard ratio [HR], 1.20; 95% CI, 1.09-1.33; P = .0003), and reduced LOS (HR, 1.11; 95% CI, 1.01-1.22; P = .033). Exposure to early dexmedetomidine was not associated with odds of HD (OR, 1.14; 95% CI, 0.73-1.78; P = .56), vasopressor utilization (OR, 1.10; 95% CI, 0.78-1.55; P = .60), or increased hospital costs (relative cost ratio, 1.98; 95% CI, 0.93-1.03; P = .66).
Dexmedetomidine is being utilized increasingly as a sedative for mechanically ventilated patients with msTBI. Early dexmedetomidine exposure may lead to improved patient outcomes in this population.
创伤性脑损伤（TBI）是一个昂贵且常见的公共卫生问题。TBI 的治疗通常包括镇静以促进机械通气（MV）以保护气道。右美托咪定作为一种潜在的候选药物，由于其对自主神经功能障碍的潜在调节作用，在 TBI 后早期镇静时可改善患者预后。我们研究了美国中重度 TBI（msTBI）机械通气患者的早期镇静模式，以及右美托咪定暴露与临床和功能结局的关系。
我们使用 Premier 数据集进行了回顾性队列研究，确定了 2016 年 1 月至 2020 年 6 月期间需要 MV 的重症成人 msTBI 患者队列。头部颈部简略损伤量表（AIS）值为 3（严重）、4（严重）和 5（危急）定义为 msTBI。我们描述了早期连续镇静的利用模式。使用倾向匹配模型，我们检查了早期右美托咪定暴露（在 ICU 入院后 2 天内）与主要结局医院死亡率以及以下次要结局的关联：医院住院时间（ LOS ）、MV 天数、入院后第 2 天开始使用血管加压药、入院后第 2 天开始血液透析（HD）、医院费用和出院处置。所有药物、治疗和程序均使用带有日期戳的医院收费代码确定。
该研究人群包括 19751 名在 ICU 入院后 2 天内需要 MV 的患者。患者主要为男性和白人。2016 年至 2020 年，右美托咪定的年利用率从 4.05%增加到 8.60%。在进行倾向评分匹配后，早期使用右美托咪定与降低医院死亡率的几率相关（比值比[OR]，0.59；95%置信区间[CI]，0.47-0.74；P<0.0001），增加了从 MV 中解脱的风险（风险比[HR]，1.20；95%CI，1.09-1.33；P=0.0003），并缩短了 LOS（HR，1.11；95%CI，1.01-1.22；P=0.033）。早期使用右美托咪定与 HD（OR，1.14；95%CI，0.73-1.78；P=0.56）、血管加压药使用（OR，1.10；95%CI，0.78-1.55；P=0.60）或增加的医院费用（相对成本比，1.98；95%CI，0.93-1.03；P=0.66）无关。
右美托咪定作为一种镇静剂，在 msTBI 机械通气患者中的使用越来越多。早期使用右美托咪定可能会改善该人群的患者预后。
