Use of Propofol and Dexmedetomidine in Neuro Critical Care: Impact on Delirium Rate and Length of Intubation

Introduction: Delirium is common in the neuro critical care (NCC) and is associated with increased ventilator dependent length of stay (1). Studies evaluating dexmedetomidine and propofol in NCC and incidence of delirium are limited (2) and show mixed results. Dexmedetomidine reduced postoperative delirium compared to propofol (3). However, a study showed a greater incidence of delirium in intubated medical intensive care unit (MICU) patients receiving dexmedetomidine compared to propofol (4).

Objective: To determine if a combination of propofol and dexmedetomidine in NCC decreased rates of delirium and / or length of intubation when compared to propofol alone.

Methods: Retrospective chart review of Neuro ICU records from 2015-2020. Charts were filtered by ICD codes and intubation. Charts showing all variables of interest (intubation date, extubation date, propofol and dexmedetomidine administration, length of ICU stay, evidence of delirium, and Glasgow Coma Scale (GCS) were included. Chart extraction is ongoing. Statistical analysis included: Preliminary analyses were conducted to examine the characteristics and distributions of all variables of interest. Correlational coefficient to assess relationships among variables of interest, t-test analysis to examine whether length of intubation differed by medication group.

Results: 368 patients identified in this ongoing study. Reason for intubation included:  Neurosurgery, Substance related, Seizures, and brain Hemorrhage. 206 received Propofol, 125 received propofol / dexmedetomidine and 37 received Dexmedetomidine only. Mean incidents of delirium, propofol only 59 (28%), Propofol/Dexmedetomidine 53 (42%), Dexmedetomidine only 13 (35%). Length of intubation/stay results available for 138 patients: Average age for the intubation group 66.58. Propofol only 78, Propofol/Dexmedetomidine 50, Dexmedetomidine only 10. Mean length of Intubation was 1.72 days propofol only, 3.38 days for propofol/ dexmedetomidine, 2.40 for Dexmedetomidine only. Using a t-test analysis, there was a significant difference in days intubated when patients received propofol compared to when patients received combined therapy (p value = 0.0008).  

Conclusions: In this preliminary analysis, the addition of dexmedetomidine did not equate to lower rates of delirium and / or length of intubation in NCC. Prolonged intubation is identified in patients who received both propofol and dexmedetomidine. Analysis of start and stop times of propofol and dexmedetomidine for our patient sample is ongoing. Dexmedetomidine is often added around the time of extubation. Prospective study is needed.

References:

1. Harrington CJ et al. “Delirium: Presentation, Epidemiology, and Diagnostic Evaluation (Part 1).” Rhode Island Medical Journal (2013),

2. Owusu KA et al. DEXmedetomidine compared to Propofol in Neurocritical Care [DEXPRONE]: A multicenter retrospective evaluation of clinical utility and safety, J Crit Care2020 Dec.

 

3. Maldonado JR et al. Dexmedetomidine and the reduction of postoperative delirium after cardiac surgery. Psychosomatics. 2009

4. Briski, M et al. Comparison of dexmedetomidine and propofol in the incidence of delirium, Critical Care Medicine: January 2020