Sedation and Analgesia Guideline Update: Dex vs Propofol

What's the best first-line sedative for mechanically ventilated patients?

Virtually all critically ill patients experience pain, anxiety, sleep disturbance, agitation, or a combination of these bothersome symptoms. Relieving these burdens should be considered a fundamental aspect of caring for the most seriously ill.

Sedatives and analgesics can also be overused, slowing patients’ recovery or increasing their likelihood of disability.

Sedation for mechanical ventilation is exceptionally difficult to study productively, because most patients needing these potent drugs can’t communicate clearly (to power subjective outcomes) and when given within reasonable ranges, sedation and analgesia have no measurable effect on objective outcomes like mortality.

The major U.S. critical care society periodically issues guidance on the appropriate use of sedation and analgesia in the critically ill. We’ll examine the evidence base for the most recent recommendations.

Sedation: Dexmedetomidine vs. Propofol

Dexmedetomidine (hereafter “dex”) has been compared to propofol in at least 29 randomized trials.

Dex purportedly resulted in less delirium than propofol when both were targeted to light sedation. Dex seems to preserve sensorium better than propofol, so this may be true.

The guideline authors therefore weakly recommended that dexmedetomidine be used over propofol “where light sedation and/or a reduction in delirium are of highest priorities.”

Let’s look more closely at the evidence supporting this recommendation.