Comparison Of The Effects Of Dexmedetomidine And Propofol Sedation On Outcomes In Patients After Cardiac Surgery

Part 1 Dexmedetomidine versus propofol sedation for patients after cardiac surgery:a meta-analysis with trial sequential analysis of randomized controlled trialsObjective:It is uncertain whether dexmedetomidine is better than propofol for sedation in post-cardiac surgery patients.We conducted a meta-analysis with trial sequential analysis to compare the effects of dexmedetomidine and propofol sedation on outcomes in adult patients after cardiac surgery.Methods:Randomized controlled trials comparing outcomes in patients who underwent cardiac surgery with dexmedetomidine or propofol were retrieved from PubMed,Embase,Web of Science,the Cochrane Library,clinicaltrials.gov until May 23,2016.Results:A total of 969 patients in 8 studies met the selection criteria.The results revealed that dexmedetomidine was associated with a lower risk of delirium(risk ratio[RR]0.40,95%confidence interval[Ci][0.24,0.64],P=0.0002),a shorter length of intubation(hours;mean difference-0.95,95%CI[-1.26,-0.64],P<0.00001),but a higher incidence of bradycardia(RR 3.17,95%CI[1.41,7.10],P = 0.005)as compared to propofol.There were no statistical differences in the incidence of hypotension or atrial fibrillation,or the length of ICU stay between dexmedetomidine and propofol sedation regimens.Conclusions:Dexmedetomidine sedation could reduce postoperative delirium and was associated with shorter length of intubation,but might increase bradycardia in patients after cardiac surgery compared with propofol.Part 2 Dexmedetomidine versus propofol sedation reduces atrial fibrillation in patients after cardiac surgeryObjective:Atrial fibrillation occurs frequently in patients following cardiac surgery and can be a cause of increased morbidity and mortality.The use of dexmedetomidine to prevent atrial fibrillation is unclear.The present study was designed to evaluate the effect of dexmedetomidine sedation on the incidence of atrial fibrillation after cardiac surgery.Methods:Upon arrival to the intensive care unit(ICU),cardiac surgery patients without prior atrial fibrillation or flutter were randomized to receive either dexmedetomidine(0.2-1.5?g/kg/h)or propofol(0.3-3 mg/kg/h)open-label titrated to a target Richmond agitation-sedation scale of 0 to-3.Our primary endpoint was the incidence of postoperative atrial fibrillation,and the secondary end points were the length of ICU stay,length of hospital stay and hospital costs.Results:Atrial fibrillation occurred in 6 of 44 patients(13.6%)in the dexmedetomidine group compared to 16 of 44 patients(36.4%)in the propofol group(odds ratio = 0.28;95%confidence interval,0.10-0.80;P = 0.025).The median(interquartile range)length of ICU stay in the dexmedetomidine group was significantly lower than in the propofol group(2.9[2.4-3.5]vs 3.5[2.7-4.5]days,P = 0.008),with a trend toward a decrease in median hospital costs(86367 vs 77874 Chinese yuan,P = 0.068).The incidence of hypotension was higher in the dexmedetomidine group than in the propofol group(25/44[56.8%]vs 13/44[29.5%],P = 0.017).Conclusions:Dexmedetomidine sedation reduced the incidence of new onset postoperative atrial fibrillation and shortened the length of ICU stay in patients after cardiac surgery compared to propofol sedation.Dexmedetomidine treatment was associated with more episodes of hypotension.Part 3 Dexmedetomidine versus propofol sedation improves sublingual microcirculation after cardiac surgeryObjective:Microcirculatory dysfunction plays an important role in the occurrence of postoperative complications.The complication rates of cardiac surgery are high and most patients require sedation in the early postoperative period.However,the effects of sedatives on microcirculation remain uncertain in those patients.The present study was designed to investigate and compare the effects of dexmedetomidine and propofol on sublingual microcirculation in patients after cardiac surgery with cardiopulmonary bypass.Methods:On arrival in the intensive care unit,the patients were randomized to receive either dexmedetomidine(0.2-1.5 ?g/kg/h)or propofol(5-50 ?g/kg/min)with open-label titrated to a target richmond agitation-sedation scale of 0-(-3).Sedation for at least 4 hours but less than 24 hours.Sublingual microcirculation were monitored and recorded by sidestream dark field imaging at ICU admission(baseline;T1),4(T2)and 24 hours after ICU admission(T3).Results:Patient characteristics were similar in two groups(32 patients in propofol group,29 patients in dexmedetomidine group).At T2,median changes in perfused small vessel density(PSVD)and the De Backer Score from baseline were significantly greater in the dexmedetomidine group than in the propofol group(1.3 vs 0 mm/mm2,P = 0.025;0.9 vs-0.1/mm,P = 0.005,respectively);median changes in small vessel density(SVD)and the proportion of perfused small vessels(PPV)from baseline also tended to be higher in the dexmedetomidine group compared to the propofol group(1.0 vs-0.1 mm/mm2,P = 0.050;2.1%vs 0.5%,P = 0.062;respectively).At T3,there was still a trend toward greater improvements in the SVD,PPV,PSVD and De Backer Score from baseline in the dexmedetomidine group than in the propofol group.Conclusions:This randomized controlled trial demonstrates that dexmedetomidine sedation may be better for microcirculation improvement in cardiac surgery patients during the early postoperative period compared with propofol.