SedationComparison between dexmedetomidine and midazolam for sedation of eclampsia patients in the intensive care unit
Introduction
Preeclampsia is characterized by hypertension diagnosed after 20 weeks gestation plus proteinuria. In severe cases, the diastolic blood pressure is 110 mm Hg or more, there is a persistent proteinuria of 2 or more, and any of the following can be present: headaches, visual disturbances, upper abdominal pain, oliguria, increased serum creatinine, thrombocytopenia, increased liver enzymes, fetal growth retardation, and pulmonary edema. Eclampsia is the new onset of seizures before, during, or after labor, which is not attributable to other causes, in a woman with preeclampsia. Eclampsia, a complication of pregnancy characterized by seizures and accompanied by severe hypertension, brain and lung edema, aspiration pneumonia, and acute renal failure, remains a major cause of maternal morbidity and mortality in both developed and developing countries. Proteinuria and acute respiratory distress syndrome can also follow [1].
The main goals of treatment are to stabilize the patient; control derangements of the cardiovascular, hematological, renal, pulmonary, and central nervous systems; and prevent potential future problems [2]. It is critical for both mother and baby that new seizures be effectively controlled; they are usually treated with magnesium sulfate, intramuscularly or intravenously, but may still occur, exacerbating maternal morbidity and mortality [1].
Several anticonvulsant drugs have been tried. Midazolam is a fast-acting benzodiazepine with a short elimination half-life; has powerful anxiolytic, amnesic, hypnotic, anticonvulsant, skeletal muscle relaxant, and sedative properties; and has been used for sedation in the intensive care unit (ICU) for many years. Its use has been proposed for the treatment of eclampsia. Midazolam undergoes extensive oxidation in the liver via the cytochrome P450 enzyme system to form water-soluble hydroxylated metabolites, which are excreted in urine. However, the primary metabolite, namely, 1-hydroxymethylmidazolam, has mild central nervous system depressant activity and may accumulate in the critically ill patient, especially in the case of kidney failure [3], [4], [5].
Dexmedetomidine is a centrally acting α2-agonist with sedative and analgesic properties; it is similar to clonidine but has much greater α2 to α1 binding affinity. The sedative properties are facilitated through the locus coeruleus site in the central nervous system, and the analgesic effects may occur via activation of the α2-receptors by accentuating the action of opioids. After extensive metabolism in the liver, dexmedetomidine is eliminated as methyl and glucuronide conjugates, mainly (95%) via renal excretion [6].
Dexmedetomidine used in intensive care as a sedative without respiratory depressive effects has analgesic properties and controls stress, anxiety, and pain [7].
In this clinical study, we compare dexmedetomidine and midazolam for sedation in eclampsia patients with regard to their effectiveness, hemodynamic characteristics, and ICU discharge time.
Section snippets
Patients and methods
This is a prospective, randomized, and controlled study. After obtaining ethic committee approval from Erciyes University Hospital, patients' first-degree relatives were informed about the study, and their written consent was taken. Forty patients whose pregnancies were terminated via caesarean delivery because of eclampsia and who needed ventilatory support were included in the present study. All patients who had chronic hypertension; cardiac, neurological, hepatic, renal, or endocrinal
Results
There were no statistically significant differences between the GrM and GrD with respect to operation time, age, weight, or height of the patients (P > .05; Table 2).
Dexmedetomidine reduced heart rates at 1, 2, 3, 4, 5, 6, 12, and 24 hours much more than midazolam did (P < .05; Fig. 1). The difference in heart rates disappeared at 48 and 72 hours.
Mean arterial pressure was similar in the 2 groups initially but was lower in the GrD at 5, 6, 12, and 24 hours (P < .05; Fig. 2).
The need for
Discussion
An ideal ICU sedation agent should rapidly act and have analgesic and sedative properties to prevent anxiety and unpleasant recall. It should generate only mild cognitive impairment, allowing easy communication between physician and patient. Moreover, it should not accumulate in the body. It should not demonstrate tachyphylaxis or cause withdrawal symptoms when its use is terminated [8]. In our study, dexmedetomidine allowed a shorter ICU stay and reduced antihypertensive use compared with
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Dexmedetomidine for Acute Management of Intrathecal Baclofen Withdrawal
2020, Journal of Emergency MedicineIntensive care and pregnancy: Epidemiology and general principles of management of obstetrics ICU patients during pregnancy
2016, Anaesthesia Critical Care and Pain MedicineCitation Excerpt :After eclampsia, the use of dexmedetomidine was compared with midazolam in a controlled study and associated with a reduced need of antihypertensive drugs. The duration of ICU stay was decreased in the group of parturients treated with dexmedetomidine [61]. Non-depolarizing neuromuscular blockers cross the placenta barrier.
Efficacy and safety of sedation with dexmedetomidine in critical care patients: A meta-analysis of randomized controlled trials
2016, Anaesthesia Critical Care and Pain MedicineCitation Excerpt :The 16 RCTs included 1994 patients from 19 countries. Seven studies compared dexmedetomidine with propofol alone [10,12,13,19,20,22,24], five with midazolam alone [10,15,17,21,23], two with either propofol or midazolam [8,18], one with lorazepam [14] and one with haloperidol [16]. Six studies evaluated patients admitted to ICUs postoperatively [12,13,15,20,22,24], with one evaluating women admitted after caesarean section [15].
Critical care in pregnancy-Is it different?
2014, Seminars in PerinatologyEfficacy of dexmedetomidine compared with midazolam for sedation in adult intensive care patients: A systematic review
2013, British Journal of AnaesthesiaCitation Excerpt :Jakob and colleagues,15 Riker and colleagues,16 Riker and colleagues,17 and Ruokonen and colleagues18 described effectiveness as the proportion of time spent within a target sedation range (or, as explained by Jakob; ‘maintaining sedation’). Senoglu and colleagues19 defined it as achieving a target level of sedation with respect to certain measurement scales (e.g. RSS, RSAS, and BIS), and in the study by Esmaoglu and colleagues,20 we believed it to be the duration of sedation; however, this was unclear. The pilot study by Riker and colleagues17 was presented at a conference and is only available as an abstract with limited results.
Dexmedetomidine and clonidine: A review of their pharmacodynamy to define their role for sedation in intensive care patients
2012, Annales Francaises d'Anesthesie et de Reanimation