The use of dexmedetomidine in the emergency department: A systematic review

Kevin Baumgartner, Veronica Groff, Lauren H Yaeger, Brian M Fuller, Kevin Baumgartner, Veronica Groff, Lauren H Yaeger, Brian M Fuller

Abstract

Background: Dexmedetomidine (DEX), a centrally acting alpha-2 agonist, is increasingly used for sedation in multiple clinical settings. Evidence from the intensive care unit and operative settings suggests DEX may have significant advantages over traditional GABAergic sedatives such as benzodiazepines. There has been limited research on the use of DEX in the emergency department (ED).

Methods: We performed a systematic review of the medical literature to identify all published evidence regarding the use of DEX in the ED. We included randomized and nonrandomized studies and studies reporting any use of DEX in the ED, even when it was not the primary focus of the study. Two authors reviewed studies for inclusion, and a single author assessed studies for quality and risk of bias and abstracted data.

Results: We identified 35 studies meeting inclusion criteria, including 11 randomized controlled trials, 13 cohort and other nonrandomized studies, and 11 case reports and case series. Significant heterogeneity in interventions, comparators, indications, and outcomes precluded data pooling and meta-analysis. We found modest evidence that DEX was efficacious in facilitating medical imaging and mixed and limited evidence regarding its efficacy for procedural sedation and sedation of nonintubated medical and psychiatric patients. Our results suggested that DEX is associated with bradycardia and hypotension, which are generally transient and infrequently require medical intervention.

Conclusions: A limited body of generally poor- to moderate-quality evidence suggests that the use of DEX may be efficacious in certain clinical scenarios in the ED and that DEX use in the ED is likely safe. Further high-quality research into DEX use in the ED setting is needed, with a particular focus on clear and consistent selection of indications, identification of clear and clinically relevant primary outcomes, and careful assessment of the clinical implications of the hemodynamic effects of DEX therapy.

© 2022 Society for Academic Emergency Medicine.

References

REFERENCES

    1. Vasilevskis EE, Han JH, Hughes CG, Ely EW. Epidemiology and risk factors for delirium across hospital settings. Best Pract Res Clin Anaesthesiol. 2012;26(3):277-287. doi:10.1016/j.bpa.2012.07.003
    1. Fraser GL, Devlin JW, Worby CP, et al. Benzodiazepine versus nonbenzodiazepine-based sedation for mechanically ventilated, critically ill adults: a systematic review and meta-analysis of randomized trials. Crit Care Med. 2013;41(9 Suppl 1):S30-S38. doi:10.1097/CCM.0b013e3182a16898
    1. Hemphill S, McMenamin L, Bellamy MC, Hopkins PM. Propofol infusion syndrome: a structured literature review and analysis of published case reports. Br J Anaesth. 2019;122(4):448-459. doi:10.1016/j.bja.2018.12.025
    1. Tse AHW, Ling L, Lee A, Joynt GM. Altered pharmacokinetics in prolonged infusions of sedatives and analgesics among adult critically ill patients: a systematic review. Clin Ther. 2018;40(9):1598-1615.e2. doi:10.1016/j.clinthera.2018.07.021
    1. Scholz J, Steinfath M, Schulz M. Clinical pharmacokinetics of alfentanil, fentanyl and sufentanil: an update. Clin Pharmacokinet. 1996;31(4):275-292. doi:10.2165/00003088-199631040-00004
    1. Weerink MAS, Struys MMRF, Hannivoort LN, Barends CRM, Absalom AR, Colin P. Clinical pharmacokinetics and pharmacodynamics of Dexmedetomidine. Clin Pharmacokinet. 2017;56(8):893-913. doi:10.1007/s40262-017-0507-7
    1. Wu XH, Cui F, Zhang C, et al. Low-dose dexmedetomidine improves sleep quality pattern in elderly patients after noncardiac surgery in the intensive care unit: a pilot randomized controlled trial. Anesthesiology. 2016;125(5):979-991. doi:10.1097/ALN.0000000000001325
    1. Chrysostomou C, Schmitt CG. Dexmedetomidine: sedation, analgesia and beyond. Expert Opin Drug Metab Toxicol. 2008;4(5):619-627. doi:10.1517/17425255.4.5.619
    1. Hoy SM, Keating GM. Dexmedetomidine: a review of its use for sedation in mechanically ventilated patients in an intensive care setting and for procedural sedation. Drugs. 2011;71(11):1481-1501. doi:10.2165/11207190-000000000-00000
    1. Lewis K, Piticaru J, Chaudhuri D, et al. Safety and efficacy of dexmedetomidine in acutely ill adults requiring noninvasive ventilation: a systematic review and meta-analysis of randomized trials. Chest. 2021;159(6):2274-2288. doi:10.1016/j.chest.2020.12.052
    1. Long B, Gottlieb M. Dexmedetomidine in critically ill adults requiring noninvasive ventilation. Acad Emerg Med. 2022;29:384-386. doi:10.1111/acem.14368
    1. Gottula AL, Gorder KL, Peck AR, Renne BC. Dexmedetomidine for acute management of intrathecal baclofen withdrawal. J Emerg Med. 2019;58(1):e5-e8. doi:10.1016/j.jemermed.2019.09.043
    1. Lam RPK, Yip WL, Wan CK, Tsui MSH. Dexmedetomidine use in the ED for control of methamphetamine-induced agitation. Am J Emerg Med. 2017;35(4):665.e1-665.e4. doi:10.1016/j.ajem.2016.11.004
    1. Wightman RS, Nelson LS, Lee JD, Fox LM, Smith SW. Severe opioid withdrawal precipitated by Vivitrol®. Am J Emerg Med. 2018;36(6):1128.e1-1128.e2. doi:10.1016/j.ajem.2018.03.052
    1. Tobias JD. Dexmedetomidine to control agitation and delirium from toxic ingestions in adolescents. J Pediatr Pharmacol Ther. 2010;15(1):43-48.
    1. Riker RR, Shehabi Y, Bokesch PM, et al. Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial. JAMA. 2009;301(5):489-499. doi:10.1001/jama.2009.56
    1. Pandharipande PP, Pun BT, Herr DL, et al. Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial. JAMA. 2007;298(22):2644-2653. doi:10.1001/jama.298.22.2644
    1. Jakob SM, Ruokonen E, Grounds RM, et al. Dexmedetomidine vs midazolam or propofol for sedation during prolonged mechanical ventilation: two randomized controlled trials. JAMA. 2012;307(11):1151-1160. doi:10.1001/jama.2012.304
    1. Sinnott J, Holthaus CV, Ablordeppey E, Wessman BT, Roberts BW, Fuller BM. The use of dexmedetomidine in the emergency department: a cohort study. West J Emerg Med. 2021;22(5):1202-1209. doi:10.5811/westjem.2021.4.50917
    1. Woods R, Miller P, Prater N, Eggleston M. 205. Ketadex for adult procedural sedation in the emergency department: a pilot study [abstract]. Ann Emerg Med. 2016;68(4S):S80.
    1. Krenz J, Fuh L, Koehl J, Goldsmith A, White B, Hayes B. 809. The use of dexmedetomidine for agitation and procedural sedation in the emergency department [abstract]. Acad Emerg Med. 2021;28(S1):S381.
    1. Neville DNW, Hayes KR, Ivan Y, McDowell ER, Pitetti RD. Double-blind randomized controlled trial of intranasal Dexmedetomidine versus intranasal midazolam as anxiolysis prior to pediatric laceration repair in the emergency department. Acad Emerg Med. 2016;23(8):910-917. doi:10.1111/acem.12998
    1. Calver L, Isbister GK. Dexmedetomidine in the emergency department: assessing safety and effectiveness in difficult-to-sedate acute behavioural disturbance. Emerg Med J. 2012;29(11):915-918. doi:10.1136/emermed-2011-200849
    1. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. doi:10.1136/bmj.n71
    1. Stroup DF, Berlin JA, Morton SC, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis of Observational Studies in Epidemiology (MOOSE) group. JAMA. 2000;283(15):2008-2012. doi:10.1001/jama.283.15.2008
    1. Baumgartner K, Groff V, Yaeger LH, Fuller BM. Dexmedetomidine in the ED systematic review. Center for Open Science. Accessed August 23, 2022.
    1. Reeves B, Deeks J, Higgins J, Shea B, Tugwell P, Wells G. Chapter 24: including non-randomized studies on intervention effects. In: Higgins JPT, Thomas J, Chandler J, et al., eds. Cochrane Handbook for Systematic Reviews of Interventions. Version 6.3. Cochrane; 2022 Accessed August 16, 2022
    1. Sterne JAC, Savović J, Page MJ, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366:l4898. doi:10.1136/bmj.l4898
    1. Wells G, Shea B, O'Connell D, et al. The Newcastle-Ottawa scale (NOS) for assessing the quality of nonrandomized studies in meta-analyses. Ottowa Hospital Research Institute. 2021. Accessed June 16, 2022.
    1. Case series studies quality appraisal checklist. Institute of Health Economics. March 2, 2016. Accessed June 16, 2022.
    1. Bramer WM, Giustini D, de Jonge GB, Holland L, Bekhuis T. De-duplication of database search results for systematic reviews in EndNote. J Med Libr Assoc. 2016;104(3):240-243. doi:10.3163/1536-5050.104.3.014
    1. Masoumi K, Maleki SJ, Forouzan A, Delirrooyfard A, Hesam S. Dexmedetomidine versus midazolam-fentanyl in procedural analgesia sedation for reduction of anterior shoulder dislocation: a randomized clinical trial. Rev Recent Clin Trials. 2019;14(4):269-274. doi:10.2174/1574887114666190809160419
    1. Azizkhani R, Kouhestani S, Heydari F, et al. Comparison of the effects of dexmedetomidine and propofol in reducing recovery agitation in pediatric patients after ketamine procedural sedation in emergency department. J Res Med Sci. 2021;26:61. doi:10.4103/jrms.JRMS_661_20
    1. Azizkhani R, Kouhestani S, Heydari F, Majidinejad S. A comparative study of dexmedetomidine and propofol to prevent recovery agitation in adults undergoing procedural sedation with ketamine: a randomized double-blind clinical trial. Am J Emerg Med. 2021;50:167-172. doi:10.1016/j.ajem.2021.07.059
    1. Derakhshanfar H, Bozorgi F, Hosseini A, et al. Comparing the effects of Dexmedetomidine and midazolam on sedation in children with head trauma to perform CT in emergency department/Upoređivanje efekata deksmedetomidina i midazolama na sedaciju dece sa povredom glave radi snimanja CT-om na Odeljenju urgentne medicine. Acta Fac Med Naiss. 2015;32(1):59-65. doi:10.1515/afmnai-2015-0006
    1. Arhami Dolatabadi A, Memary E, Shojaee M, Kamalifard H. Dexmedetomidine-fentanyl versus midazolam-fentanyl in pain management of distal radius fractures reduction; a randomized clinical trial. Emergency (Tehran, Iran). 2018;6(1):e10.
    1. Kamali A, Taghizadeh M, Esfandiar M, Akhtari AS. A comparison of the effects of dexmedetomidine and propofol in controlling the hemodynamic responses after intubation: a double-blind, randomized, clinical trial study. Open Access Maced J Med Sci. 2018;6(11):2045-2050. doi:10.3889/oamjms.2018.385
    1. Motamed H, Forouzan A, Moezzi M, Alizadeh H. Dexmedetomidine as an adjunctive treatment for acute asthma. Clin Exp Emerg Med. 2021;8(2):89-93. doi:10.15441/ceem.20.038
    1. Motamed H, Masoumi K, Moezzi M, Ghoraian P. Clinical efficacy of dexmedetomidine versus ketamine in shoulder dislocation reduction: a randomized clinical trial study. Med J Islam Repub Iran. 2021;35:152. doi:10.47176/mjiri.35.152
    1. Newcomer J, Kennedy R, Yingling M, Schweiger J, Farber N, Nicol G. T162. Psychotomimetic effects of single-dose ketamine in children: exploring effects of age and alpha-2 agonist pretreatment [abstract]. Neuropsychopharmacology. 2017;42:S398-S399. doi:10.1038/npp.2017.265
    1. Azizkhani R, Heydari F, Ghazavi M, et al. Comparing sedative effect of Dexmedetomidine versus midazolam for sedation of children while undergoing computerized tomography imaging. J Pediatr Neurosci. 2020;15(3):245-251. doi:10.4103/jpn.JPN_107_19
    1. Mekitarian Filho E, Robinson F, de Carvalho WB, Gilio AE, Mason KP. Intranasal dexmedetomidine for sedation for pediatric computed tomography imaging. J Pediatr. 2015;166(5):1313-1315.e1. doi:10.1016/j.jpeds.2015.01.036
    1. Sulton C, McCracken C, Simon HK, et al. Pediatric procedural sedation using dexmedetomidine: a report from the pediatric sedation research consortium. Hosp Pediatr. 2016;6(9):536-544. doi:10.1542/hpeds.2015-0280
    1. Barnes BC, Kamat PP, McCracken CM, et al. Radiologic imaging in trauma patients with cervical spine immobilization at a pediatric trauma center. J Emerg Med. 2019;57(4):429-436. doi:10.1016/j.jemermed.2019.06.048
    1. Burger RK, Figueroa J, McCracken C, Mallory MD, Kamat PP. Sedatives used in children to obtain head CT in the emergency department. Am J Emerg Med. 2021;44:198-202. doi:10.1016/j.ajem.2020.02.035
    1. Calver L, Page CB, Downes MA, et al. The safety and effectiveness of droperidol for sedation of acute behavioral disturbance in the emergency department. Ann Emerg Med. 2015;66(3):230-238.e1. doi:10.1016/j.annemergmed.2015.03.016
    1. Chumpitazi C, Liechti S, Moffett B. 549. Impact of intranasal medications on laceration repairs in the pediatric emergency department [abstract]. Acad Emerg Med. 2017;24(S1):S195. doi:10.1111/acem.13203
    1. Norii T, Homma Y, Shimizu H, et al. Procedural sedation and analgesia in the emergency department in Japan: interim analysis of multicenter prospective observational study. J Anesth. 2019;33(2):238-249. doi:10.1007/s00540-018-02606-0
    1. Pal S, Sharma N, Singh SM, Kumar S, Pannu AK. A prospective cohort study on predictors of mortality of delirium in an emergency observational unit. QJM Mon J Assoc Physicians. 2021;114(4):246-251. doi:10.1093/qjmed/hcaa183
    1. Brahmbhatt S, Stevens H, Chapman A, et al. Optimal dose of intranasal dexmedetomidine for laceration repair in children: a phase II dose-ranging study [abstract 75]. Acad Emerg Med. 2022;29(S1):S43-S44.
    1. Cozzi G, Lega S, Giorgi R, Barbi E. Intranasal Dexmedetomidine sedation as adjuvant therapy in acute asthma exacerbation with marked anxiety and agitation. Ann Emerg Med. 2017;69(1):125-127. doi:10.1016/j.annemergmed.2016.08.005
    1. Carlone G, Trombetta A, Amoroso S, Poropat F, Barbi E, Cozzi G. Intramuscular Dexmedetomidine, a feasible option for children with autism Spectrum disorders needing urgent procedural sedation. Pediatr Emerg Care. 2019;35(6):e116-e117. doi:10.1097/PEC.0000000000001776
    1. Jewett J, Phillips WJ. Dexmedetomidine for procedural sedation in the emergency department. Eur J Emerg Med. 2010;17(1):60. doi:10.1097/MEJ.0b013e3283325ec2
    1. Leikin JB, Amusina O. Use of dexmedetomidine to treat delirium primarily caused by cannabis. Am J Emerg Med. 2017;35(3):524.e1-524.e2. doi:10.1016/j.ajem.2016.10.027
    1. MacCamy K, Hu D. Dexmedetomidine for treatment of delayed peak symptoms of cannabis withdrawal syndrome: a case report. Hosp Pharm. 2021;56(5):462-465. doi:10.1177/0018578720919025
    1. Nauka P, Durst M. Septicemia from urinary tract infection with negative urinary culture: Aeroccocus urinae in an older adult [abstract]. Chest. 2019;156(4):A2137.
    1. Singh D, Dyer A, Gu S, et al. An unusual cause of frequent, sudden, transient, unexplained falls and new-onset status epilepticus: case report and mini-review. Clin Pediatr (Phila). 2018;57(2):173-179. doi:10.1177/0009922817698805
    1. Spalink CL, Barnes E, Palma JA, Norcliffe-Kaufmann L, Kaufmann H. Intranasal dexmedetomidine for adrenergic crisis in familial dysautonomia. Clin Auton Res. 2017;27(4):279-282. doi:10.1007/s10286-017-0442-6
    1. Stockton J, Kyle-Sidell C. Dexmedetomidine and worsening hypoxemia in the setting of COVID-19: a case report. Am J Emerg Med. 2020;38(10):2247.e1-2247.e2. doi:10.1016/j.ajem.2020.05.066
    1. Watt KM, Walgos J, Cheifetz IM, Turner DA. Dexmedetomidine for transport of a spontaneously breathing combative child. Pediatrics. 2012;130(3):e690-e694. doi:10.1542/peds.2011-3397
    1. Preskorn SH, Zeller S, Citrome L, et al. Effect of sublingual dexmedetomidine versus placebo on acute agitation associated with bipolar disorder: a randomized clinical trial. JAMA. 2022;327(8):727-736. doi:10.1001/jama.2022.0799
    1. Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41(1):263-306. doi:10.1097/CCM.0b013e3182783b72
    1. Yu Q, Liu Y, Sun M, et al. Median effective dose of intranasal dexmedetomidine sedation for transthoracic echocardiography in pediatric patients with noncyanotic congenital heart disease: an up-and-down sequential allocation trial. Paediatr Anaesth. 2017;27(11):1108-1114. doi:10.1111/pan.13235
    1. Yuen VM, Irwin MG, Hui TW, Yuen MK, Lee LHY. A double-blind, crossover assessment of the sedative and analgesic effects of intranasal dexmedetomidine. Anesth Analg. 2007;105(2):374-380.
    1. Bailey AM, Baum RA, Horn K, et al. Review of intranasally administered medications for use in the emergency department. J Emerg Med. 2017;53(1):38-48. doi:10.1016/j.jemermed.2017.01.020

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