Sedation Practice in Intensive Care: A randomised controlled pilot study

Early goal directed sedation consisting of a dexmedetomidine based sedation protocol: The primary sedative agent in the intervention arm is dexmedetomidine delivered by continuous infusion without a loading dose, supplemented by alternative sedative agents as outlined below, to achieve the level of sedation specified by the treating clinician. Effective pain relief is provided by an infusion or boluses of an opioid (eg morphine or fentanyl) or other agent (eg ketamine) at the discretion of the treating clinician. This is particularly important during painful or noxious procedures (eg. endotracheal suction) Dexmedetomidine arm [known as GpDex]: refer to study algorithm Commence dexmedetomidine infusion at 1.0 mcg/kg/hr without a loading dose. This will take about 45 minutes to produce full sedative effect. Dexmedetomidine infusion will be titrated to sedative effect up to a maximum dose of 1.4 mcg/kg/hr (depending on age: 0-1 yrs 1.0 micrograms/kg/hour, 1-5 years 1.4 mcg/kg/hr, 5-10 years 1.3 mcg/kg/hr, >10 years 1.0 mcg/kg/hr) with dose of infusion specified by the treating clinician to achieve the desired level of sedation specified by the treating clinician. a) Dexmedetomidine infusion will be continued until sedation is no longer required to a maximum of 14 days after enrolment. 2) Boluses or infusion or both of opioids, as chosen by the treating clinician, will be administered, if required, at a dose specified by the treating clinician to provide analgesia 3) Alternative sedative agents may be considered if a combination of dexmedetomidine and opioid infusions do not provide sufficient sedation. Examples include ketamine, chloral hydrate, sedating anti-histamines, phenobarbitone as per physician preference 4) Supplemental propofol can be used (up to a maximum of 24 hours and a maximum dose of 4 mg/kg/hr, in accordance with individual intensive care unit policy), always at the lowest effective dose to: a) Provide sedation during commencement and initial titration of dexmedetomidine infusion b) To optimise sedation to achieve the level of sedation specified by the treating clinician at any time when dexmedetomidine alone and at maximum dose is insufficient to provide patient comfort and safety c) Provide rescue sedation for immediate control of sudden agitation at any time d) Provide additional sedation during procedures 5) Benzodiazepines (such as midazolam, diazepam and clonazepam) may be administered if sufficient level of sedation is not attained with the above measures. 6) Clonidine should not be administered concurrently with dexmedetomidine (although may used to prevent or treat suspected dexmedetomidine withdrawal).