 Patients who have survived critical illness are at increased risk for long term morbidity and mortality. Maybe we tend to forget this fact, as we lose sight of these patients when they leave our unit. But this is especially true for ICU patients aged 65 and older! There have been clues that influenza vaccination might reduce morbidity after surviving critical illness and Christiansen et al. have looked exactly into this topic. The investigators examined whether an influenza vaccination (flu shot) affects the 1-year risk of myocardial infarction, stroke, heart failure, pneumonia, and death among ICU survivors aged 65 and older. The investigators Performed a nationwide population-based cohort study They used the Danish Intensive Care Database To evaluate a total 89'818 ICU survivors from 2005 until 2015 It is noteworthy that Influenza vaccinated patients (these were 39% of all) were older, had more chronic diseases and used more prescription medications! Their findings show that 1. Influenza vaccinated patients showed an 8% decreased risk of death and a 16% reduced risk of hospitalisation for stroke within one year 2. Cardiac surgery patients were the subgroup that profited most 3. Unfortunately, no significant association was found for the risk of hospitalisation for myocardial infarction, heart failure or pneumonia.  The flu shot saves lives! This is another strong hint, that the influenza vaccination is clearly of benefit to all adults aged 65 and older. This is especially true for ICU survivors! Christiansen at al. Intensive Care Med 2019 Jul;45(7):957-967. Also worth mentioning: Not only influenza A but also Influenza B infection can pose a risk for severe secondary infection in previously healthy and younger persons. Aebi et al. BMC Infect Dis 2010 Oct 27;10:308.  When the FDA approved dexmedetomidine (DEX) in 1999, intensive care medicine had a novel and highly promising drug at its disposal. Compared to clonidine, dexmedetomidine is an 8 times more selective, central alpha 2 agonist, which binds to all 3 subtypes of the receptor. The properties of this substance were auspicious, among them: sedation, analgesia, neuroprotective effects and a lack of respiratory depression. - Sedation decreases sympathetic activity, aggression and leads to a non-REM-like state, which of all sedatives comes closest to natural sleep. Cognitive functions are maintained, and patients usually remain arousable. - Dexmedetomidine has a particular analgesic effect via modulation in the region of the posterior horn of the spinal cord. This has shown to reduce the use of opiates. - By reducing cerebral catecholamines, dexmedetomidine exerts a neuroprotective effect. - Interestingly, sedation with dexmedetomidine is not associated with significant respiratory depression. These properties pointed to a wide range of applications in the intensive care unit: - Sedation in patients with non-invasive ventilation - Weaning of invasively ventilated patients - Agitated delirium - Treatment of various withdrawal syndromes - Fiberoptic awake intubation in theatre conditions Dexmedetomidine comes with its side effects, though. Most commonly bradycardia and hypotension are observed, making second and third-degree heart block a contraindication. Also, nausea and a dry mouth might be seen. Interestingly, prolonged use might be associated with some extent of discontinuation syndrome similar to clonidine. This involves hypertension, tachycardia, nervousness etc. What Evidence Do We Have So Far? |
The SPICE III Trial |  |
Precisely this question was now addressed by Shehabi et al., published in the NEJM
They performed an
International (8 countries, 74 ICU's), randomised controlled, unblinded trial
In which they evaluated
4000 ICU patients that were expected to need mechanical ventilation for at least 48 hours and required sedation for safety or comfort
They compared
Patients sedated with propofol, midazolam or other agents as prescribed by the treating physician with patients receiving dexmedetomidine as a continuous infusion
(if DEX alone was insufficient, other agents could be added! In fact, 64% of patients also received propofol, 3% midazolam and 7% received both)
They found
1. No difference in 90-day mortality (primary outcome) and
2. No difference in death after 180 days, institutional dependency at 180 days, mean cognitive decline and assessment of the quality of life. Also no difference in median days free from coma to day 28 and median ventilator-free days at day 28 (all secondary outcomes)
3. Dexmedetomidine was though associated with significantly more events of bradycardia, hypotension (no further info on the use of vasopressors) and asystoles (14 vs 2; 7 required mechanical resuscitation measures)
- DEX is an attractive sedative in certain situations (alcohol withdrawal, other forms of delirium, weaning process etc.), BUT
- DEX doesn't seem to provide any advantage in the sedation of mechanically ventilated patients in the ICU and
- Might be problematic due to adverse cardiovascular effects, especially in this group of patients
Shehabe et al. N Engl J Med 2019; 380:2506-2517
Did you Know?
Apparently, intranasal dexmedetomidine seems used successfully for sedation in adults and children. J Clin Neurophysiol. 2019 May 16.
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