Dexmedetomidine for Facilitating Mechanical Ventilation Extubation in Difficult-to-Wean ICU Patients: Systematic Review and Meta-Analysis of Clinical Trials

Mitchell S. Buckley, Department of Pharmacy, 22386Banner-University Medical Center Phoenix, Phoenix, AZ, USA.
Pamela L. Smithburger, Department of Pharmacy and Therapeutics, 15523University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA.
Adrian Wong, Department of Pharmacy Practice, 1825MCPHS University, Boston, MA, USA.
Gilles L. Fraser, Department of Medicine, 12261Tufts University School of Medicine, Boston, MA, USA.
Michael C. Reade, University of Queensland, 3883Royal Brisbane and Women's Hospital, Queensland, Australia.
Michele Klein-Fedyshin, Health Sciences Library System, 6614University of Pittsburgh, Pittsburgh, PA, USA.
Thomas Ardiles, 42283University of Arizona Phoenix School of Medicine, Phoenix, AZ, USA.
Sandra L. Kane-Gill, Department of Pharmacy and Critical Care Medicine, Clinical Translational Science Institute, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA.


BACKGROUND: Agitation and delirium are common in mechanically ventilated adult intensive care unit (ICU) patients and may contribute to delayed extubation times. Difficult-to-wean ICU patients have been associated with an increased risk of longer ICU length of stays and mortality. The purpose of this systematic review and meta-analysis is to evaluate the evidence of dexmedetomidine facilitating successful mechanical ventilation extubation in difficult-to-wean ICU patients and clinical outcomes. METHODS: A literature search was conducted using MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Global Health, Cochrane Central Register of Controlled Trials, Clinical Trial Registries, and the Health Technology Assessment Database from inception to December 5, 2019. Randomized controlled trials evaluating dexmedetomidine with the intended purpose to facilitate mechanical ventilation liberation in adult ICU patients (≥18 years) experiencing extubation failure were included. The primary outcome of time to extubation was evaluated using the weighted mean difference (WMD), with a random effects model. Secondary analyses included hospital and ICU length of stay, in-hospital mortality, hypotension, and bradycardia. RESULTS: A total of 6 trials (n = 306 patients) were included. Dexmedetomidine significantly reduced the time to extubation (WMD: -11.61 hours, 95% CI: -16.5 to -6.7, = .005) and ICU length of stay (WMD: -3.04 days; 95% CI: -4.66 to -1.43). Hypotension risk was increased with dexmedetomidine (risk ratio [RR]: 1.62, 95% CI: 1.05-2.51), but there was no difference in bradycardia risk (RR: 3.98, 95% CI: 0.70-22.78). No differences were observed in mortality rates (RR: 1.30, 95% CI: 0.45-3.75) or hospital length of stay (WMD: -2.67 days; 95% CI: -7.73 to 2.39). CONCLUSIONS: Dexmedetomidine was associated with a significant reduction in the time to extubation and shorter ICU stay in difficult-to-wean ICU patients. Although hypotension risk was increased with dexmedetomidine, no differences in other clinical outcomes were observed.