Article of the Month – January 2021

Critical Review and Meta-Analysis of Postoperative Sedation after Adult Cardiac Surgery: Dexmedetomidine Versus Propofol

URL: https://www.jcvaonline.com/article/S1053-0770(20)31136-8/fulltext

DOI: https://doi.org/10.1053/j.jvca.2020.10.022

Published: J Cardiothorac Vasc Anesth. 2020 October 17, in press.

Authors: Hesham A. Abowali, Matteo Paganini, Garrett Enten, Ayman Elbadawiy, Enrico M. Camporesi.

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Article Description:

Prolonged stays in post-anaesthesia care units or intensive care unit (ICU) might have consequences on the clinical outcomes and cost of healthcare services.
Using high doses of sedatives in the ICU settings after cardiac surgery can result in longer ICU stays.
Propofol has been frequently used after cardiac surgery because of its ease of administration and short awakening time, however, its use is limited with the associated hypotension and depressant effect on respiration.
Dexmedetomidine, a highly selective alpha-2 adrenergic agonist, has been widely used nowadays because of its favourable sympatholytic, sedative, anxiolytic, and analgesic effects without causing respiratory depression despite hypotension and bradycardias are reported as associated adverse effects.
The objective of this meta-analysis was to compare the effects of dexmedetomidine and propofol on the quality of sedation and outcomes after cardiac surgery.

Summary:

This meta-analysis analysed 1,184 adult patients undergoing valve or CABG surgery from 11 RCTs, published between 2003 and 2019, comparing the use of dexmedetomidine and propofol for sedation after any type of cardiac surgery.
The overall quality of the studies was moderate.
None of 10 over 11 RCTs fully met the “blinding of participants and personnel” bias criterion.
Interestingly, compared with propofol, patients receiving dexmedetomidine for sedation after cardiac surgery had shorter time to extubation (standardized mean difference [SMD] = -0.70, 95% conﬁdence interval [CI] -0.98 to -0.42, p < 0.001) and ICU stay (SMD = 0.23, 95%CI -1.06 to -0.16, p = 0.008).
The dexmedetomidine and propofol groups had comparative duration of postoperative mechanical ventilation (SMD = -0.72, 95% CI -1.60 to 0.15, N.S.), hospital stay (SMD = -1.13, 95% CI -2.43 to 0.16, N.S0), and incidence of delirium (odds ratio [OR]: 0.68, 95% CI 0.43-1.06, N.S).
Patients received propofol sedation had higher rates of bradycardia (OR: 3.39, 95% CI: 1.20-9.55, p = 0.020) and hypotension (OR: 1.68, 95% CI 1.09-2.58, p = 0.017).
There are several limitations noted during this meta-analysis including:

The sedation scoring systems used in the included studies (RASS and Ramsey scores) can be affected by incorrect evaluation by healthcare professionals.
There was high variability in dosage and duration of postoperative analgesic regimen and also not always stated, that might inﬂuence the clinical outcomes.
The present meta-analysis did not include any paper addressing cardiac transplants in the adult patients in whom the sympatholytic effects of dexmedetomidine on a denervated transplanted heart needs to be studied.

Conclusion:

This meta-analysis did not ﬁnd particular advantages in the use of dexmedetomidine over propofol for the sedation of patients after cardiac surgery.
Time-dependent parameters (time to extubation, durations of postoperative ventilation and ICU and hospital stay) are inaccurate and not reliable for a proper evaluation of the beneﬁts of dexmedetomidine versus propofol.
Further studies are needed to ﬁnd new, reliable outcomes, standardized sedation protocols in patients after cardiac surgery.