• ABCDEF bundle
• Analgesia
• Delirium
• Paquete medidas ABCDEF
• Post intensive care syndrome
• Sedación
• Sedation
• Síndrome post-cuidados intensivos

• Humans
• Critical Illness/psychology
• Critical Illness/therapy
• Critical Care
• Patient Safety
• Delirium/prevention & control
• Delirium/therapy
• Patient Care Bundles
• Intensive Care Units
• Treatment Outcome
• Early Ambulation

• ABCDEF bundle
• Analgosedación
• Analgosedation
• COVID-19 pandemic
• Critically ill patient
• Deep sedation
• Delirium
• Oversedation
• Paciente crítico
• Pandemia COVID-19
• Paquete medidas ABCDEF
• Sedación profunda
• Sobresedación

• Humans
• COVID-19
• Intensive Care Units
• Pain Management/methods
• Hypnotics and Sedatives/therapeutic use
• Hypnotics and Sedatives/administration & dosage
• Conscious Sedation/methods
• Critical Care/methods
• SARS-CoV-2
• Practice Guidelines as Topic

• IK2 RX004799 RRD VA
• T32 HL087738 NHLBI NIH HHS

• Cardiac surgery
• Dexmedetomidine
• Propofol
• Sleep quality

• Delirium
• Dexmedetomidine
• Schizophrenia

• Humans
• Dexmedetomidine/adverse effects
• Dexmedetomidine/administration & dosage
• Female
• Aged
• Schizophrenia/drug therapy
• Hypnotics and Sedatives/adverse effects
• Hypnotics and Sedatives/administration & dosage
• Delirium/chemically induced
• Propofol/adverse effects
• Propofol/administration & dosage

• Cardiogenic shock
• Coronary revascularization
• Inotropic therapy
• Mechanical ventilation
• Medical treatment
• Revascularización coronaria
• Shock cardiogénico
• Tratamiento inotrópico
• Tratamiento médico
• Vasopresores
• Vasopressors
• Ventilación mecánica

• Shock, Cardiogenic/therapy
• Shock, Cardiogenic/etiology
• Humans
• Cardiotonic Agents/therapeutic use
• Vasoconstrictor Agents/therapeutic use
• Renal Replacement Therapy/methods
• Respiration, Artificial
• Myocardial Revascularization
• Hemodynamics
• Extracorporeal Membrane Oxygenation

• Benzodiazepines
• Meta-analysis
• Postoperative delirium
• Surgery
• Systematic review

• Humans
• Benzodiazepines/adverse effects
• Benzodiazepines/administration & dosage
• Delirium/etiology
• Postoperative Complications/etiology
• Perioperative Period

• checklist
• implementation
• mortality
• outcomes
• quality improvement
• severe trauma

• Humans
• Pilot Projects
• Critical Illness/therapy
• Prospective Studies
• Retrospective Studies
• Sleep Deprivation/drug therapy
• Pain/diagnosis
• Pain/drug therapy
• Delirium/drug therapy
• Delirium/etiology
• Observational Studies as Topic

• paediatric research
• brain injuries

• Humans
• Child
• Deglutition Disorders/etiology
• Deglutition Disorders/therapy
• Deglutition Disorders/epidemiology
• Airway Extubation/adverse effects
• Length of Stay
• Intubation, Intratracheal/adverse effects
• Craniocerebral Trauma/complications
• Retrospective Studies

• LPVS
• cognitive impairment
• hippocampus
• inflammation
• ventilator-induced lung injury

• Natural Science Foundation of Jiangxi Province
• National Natural Science Foundation of China

• Agitation
• Dexmedetomidine
• ICU
• Non-pharmacological interventions
• Patient-reported outcome measures
• Physical restraints

• Adult
• Humans
• Dexmedetomidine/therapeutic use
• Restraint, Physical/adverse effects
• Quality of Life
• Intensive Care Units
• Anxiety
• Randomized Controlled Trials as Topic
• Multicenter Studies as Topic

• 10140302110007 ZonMw
• ZonMW

• Analgesia
• Comfort
• Confort
• Critical patients
• Delirio
• Delirium
• Dolor
• Individualisation
• Individualización
• Intensive care units
• Pacientes críticos
• Pain
• Recomendaciones
• Recommendations
• Sedación
• Sedation
• Unidades de cuidados intensivos

• Humans
• Delirium/prevention & control
• Analgesia
• Intensive Care Units
• Pain
• Anesthesia

• Anesthetic conserving device
• inhalation sedation
• intensive care unit
• intravenous sedation
• length of stay

• benzodiazepines
• intraoperative awareness
• meta-analysis
• perioperative medicine
• postoperative delirium
• systematic review

• Humans
• Aged
• Benzodiazepines/adverse effects
• Emergence Delirium/epidemiology
• Emergence Delirium/prevention & control
• Dexmedetomidine/therapeutic use
• Intraoperative Awareness
• Delirium/chemically induced
• Delirium/prevention & control
• Randomized Controlled Trials as Topic
• Observational Studies as Topic

• aged
• inappropriate prescribing
• intensive care units
• potentially inappropriate medication list
• potentially inappropriate medications
• older adults
• beers criteria
• icu intensive care units

• Humans
• Aged
• Potentially Inappropriate Medication List
• Cohort Studies
• Inappropriate Prescribing
• Retrospective Studies
• Critical Care

• Dose-finding
• Mechanical ventilation
• Remimazolam tosylate
• Sedation

• Humans
• Hypnotics and Sedatives/adverse effects
• Single-Blind Method
• Benzodiazepines
• Intensive Care Units
• Randomized Controlled Trials as Topic
• Multicenter Studies as Topic

• Chemical enhancer
• Dexmedetomidine
• Ion-pair
• Long-acting patch
• Molecular mechanism
• Transdermal

Dexmedetomidine is a centrally acting alpha-2A adrenergic agonist that is commonly used as a sedative and anxiolytic in the intensive care unit (ICU), with prolonged use increasing risk of withdrawal symptoms upon sudden discontinuation. As clonidine is an enterally available alpha-2A adrenergic agonist, it may be a suitable agent to taper off dexmedetomidine and reduce withdrawal syndromes. The appropriate dosing and conversion strategies for using enteral clonidine in this context are not known. The objective of this systematic review is to summarize the evidence of enteral clonidine application during dexmedetomidine weaning for prevention of withdrawal symptoms.

To systematically review the practice, dosing schema, and outcomes of enteral clonidine use during dexmedetomidine weaning in critically ill adults.

This was a systematic review of enteral clonidine used during dexmedetomidine weaning in critically ill adults (≥ 18 years). Randomized controlled trials, prospective cohorts, and retrospective cohorts evaluating the use of clonidine to wean patients from dexmedetomidine in the critically ill were included. The primary outcomes of interest were dosing and titration schema of enteral clonidine and dexmedetomidine and risk factors for dexmedetomidine withdrawal. Other secondary outcomes included prevalence of adverse events associated with enteral clonidine use, re-initiation of dexmedetomidine, duration of mechanical ventilation, and ICU length of stay.

A total of 3427 studies were screened for inclusion with three meeting inclusion criteria with a total of 88 patients. All three studies were observational, two being prospective and one retrospective. In all included studies, the choice to start enteral clonidine to wean off dexmedetomidine was made at the discretion of the physician. Weaning time ranged from 13 to 167 h on average. Enteral clonidine was started in the prospective studies in a similar protocolized method, with 0.3 mg every 6 h. After starting clonidine, patients remained on dexmedetomidine for a median of 1-28 h. Following the termination of dexmedetomidine, two trials tapered enteral clonidine by increasing the interval every 24 h from 6 h to 8h, 12h, and 24 h, followed by clonidine discontinuation. For indicators of enteral clonidine withdrawal, the previously tolerable dosage was reinstated for several days before resuming the taper on the same protocol. The adverse events associated with enteral clonidine use were higher than patients on dexmedetomidine taper alone with increased agitation. The re-initiation of dexmedetomidine was not documented in any study. Only 17 (37%) patients were mechanically ventilated with median duration of 3.5 d for 13 patients in one of the 2 studies. ICU lengths of stay were similar.

Enteral clonidine is a strategy to wean critically ill patients from dexmedetomidine. There is an association of increased withdrawal symptoms and agitation with the use of a clonidine taper.

• Clonidine
• Dexmedetomidine
• Intensive care unit
• Withdrawal
• Weaning

• cardiac intensive care
• mechanical ventilation

• Allostasis
• Critical illness
• Multiple organ failure
• Sedatives

• Agitation
• Antipsychotics
• Delirium
• Dexmedetomidine
• Pharmacologic agents

• Delirium
• Health-related quality of life
• ICU
• MCS12
• Mental health

The purpose of the present study was to investigate the efficacy and safety of remimazolam besylate compared with dexmedetomidine for the relief of agitated delirium in non-intubated older patients after orthopedic surgery.

Seventy-five patients were randomly divided into two groups. Patients assigned to the remimazolam group received a loading dose of 0.075 mg/kg remimazolam besylate over 1 minute, followed by a continuous infusion of 0.1 to 0.3 mg/kg/h. Subjects randomized to the dexmedetomidine group received a loading infusion of 0.5 μg/kg dexmedetomidine over 10 minutes, followed by a maintenance dose of 0.2 to 0.7 μg/kg/h. Meanwhile, RASS score-guided dose titration was followed. To assess the efficacy of the study drugs in terms of time to resolution of agitation, time to first achievement of target sedation, percentage of time within the target sedation range, and time to delirium resolution. Safety of the sedatives was evaluated by adverse events during hospitalization.

Time to resolution of agitation did not differ between the two groups. The time to first achievement of target sedation was 19.0 (9.5 to 31.0) minutes for remimazolam besylate vs 43.5 (15.0 to 142.5) minutes for dexmedetomidine (P < 0.001). Percentage of time within the target sedation range was 77.8% for remimazolam besylate-treated patients and 67.4% for dexmedetomidine-treated patients (P = 0.001). Patients in the remimazolam group had longer time to delirium resolution (29.5 [21.3 to 32.5] hours) than those in the dexmedetomidine group (22.8 [18.9 to 28.5] hours) (P = 0.042). Patients sedated with remimazolam besylate had more oversedation (P = 0.036) but less hypotension (P = 0.007).

Compared with dexmedetomidine, remimazolam besylate was equally effective in relieving agitation, and resulted in earlier achievement of sedation goal and more controllable sedation. Remimazolam may be an ideal agent for obtaining rapid tranquillisation.

• Benzodiazepines
• Delirium/drug therapy
• Dexmedetomidine/adverse effects
• Humans
• Hypnotics and Sedatives/adverse effects
• Orthopedic Procedures

• the Special Scientific Research Project for Anesthesiology
• Sichuan International Medical Exchange & Promotion Association

The clinical approach to sedation in critically ill patients has changed dramatically over the last two decades, moving to a regimen of light or non-sedation associated with adequate analgesia to guarantee the patient’s comfort, active interaction with the environment and family, and early mobilization and assessment of delirium. Although deep sedation (DS) may still be necessary for certain clinical scenarios, it should be limited to strict indications, such as mechanically ventilated patients with Acute Respiratory Distress Syndrome (ARDS), status epilepticus, intracranial hypertension, or those requiring target temperature management. DS, if not indicated, is associated with prolonged duration of mechanical ventilation and ICU stay, and increased mortality. Therefore, continuous monitoring of the level of sedation, especially when associated with the raw EEG data, is important to avoid unnecessary oversedation and to convert a DS strategy to light sedation as soon as possible. The approach to the management of critically ill patients is multidimensional, so targeted sedation should be considered in the context of the ABCDEF bundle, a holistic patient approach. Sedation may interfere with early mobilization and family engagement and may have an impact on delirium assessment and risk. If adequately applied, the ABCDEF bundle allows for a patient-centered, multidimensional, and multi-professional ICU care model to be achieved, with a positive impact on appropriate sedation and patient comfort, along with other important determinants of long-term patient outcomes.

• Università degli Studi di Brescia

• Adult
• Child
• Cross Infection/prevention & control
• Healthcare-Associated Pneumonia/epidemiology
• Healthcare-Associated Pneumonia/prevention & control
• Hospitals
• Humans
• Infant, Newborn
• Infection Control
• Pneumonia
• Pneumonia, Ventilator-Associated/prevention & control
• Ventilators, Mechanical/adverse effects

• CC999999 Intramural CDC HHS

• Anesthesia
• Benzodiazepines
• Delirium
• Perioperative care
• Premedication

Current sedatives have different side effects in long-term sedation. The sequential use of midazolam and dexmedetomidine for prolonged sedation may have distinct advantages. We aimed to evaluate the efficacy and safety of the sequential use of midazolam and either dexmedetomidine or propofol, and the use of midazolam alone in selected critically ill, mechanically ventilated patients.

This single-center, randomized controlled study was conducted in medical and surgical ICUs in a tertiary, academic medical center. Patients enrolled in this study were critically ill, mechanically ventilated adult patients receiving midazolam, with anticipated mechanical ventilation for ≥ 72 h. They passed the spontaneous breathing trial (SBT) safety screen, underwent a 30-min-SBT without indication for extubation and continued to require sedation. Patients were randomized into group M-D (midazolam was switched to dexmedetomidine), group M-P (midazolam was switched to propofol), and group M (sedation with midazolam alone), and sedatives were titrated to achieve the targeted sedation range (RASS − 2 to 0).

Total 252 patients were enrolled. Patients in group M-D had an earlier recovery, faster extubation, and more percentage of time at the target sedation level than those in group M-P and group M (all P < 0.001). They also experienced less weaning time (25.0 h vs. 49.0 h; HR1.47, 95% CI 1.05 to 2.06; P = 0.025), and a lower incidence of delirium (19.5% vs. 43.8%, P = 0.002) than patients in group M. Recovery (P < 0.001), extubation (P < 0.001), and weaning time (P = 0.048) in group M-P were shorter than in group M, while the acquisition cost of sedative drug was more expensive than other groups (both P < 0.001). There was no significant difference in adverse events among these groups (all P > 0.05).

The sequential use of midazolam and dexmedetomidine was an effective and safe sedation strategy for long-term sedation and could provide clinically relevant benefits for selected critically ill, mechanically ventilated patients.

NCT02528513. Registered August 19, 2015.

The online version contains supplementary material available at 10.1186/s13054-022-03967-5.

• Critically ill
• Dexmedetomidine
• Mechanical ventilation
• Midazolam
• Propofol
• Sequential sedation

• Anesthesia
• Child
• Emergency Service, Hospital
• Humans
• Hypnotics and Sedatives/therapeutic use
• Intubation, Intratracheal

• anesthesiology
• dexmedetomidine
• mechanical ventilation
• meta–analysis
• sedation
• sepsis

• Adult
• Benzodiazepines/adverse effects
• Cohort Studies
• Humans
• Republic of Korea/epidemiology
• Retrospective Studies
• Sepsis/drug therapy

• Anesthesia
• Ciprofol
• Mechanical ventilation
• Propofol
• Sedation

• Critical care
• Delirium
• Non-pharmacological interventions
• Pharmacological
• Prevention

• Adult
• Bayes Theorem
• Critical Illness
• Delirium/prevention & control
• Humans
• Network Meta-Analysis
• Randomized Controlled Trials as Topic
• Respiration, Artificial/adverse effects

• CIHRFRN144048 CIHR

• Benzodiazepine
• Dexmedetomidine
• Mortality
• Propofol
• Sedative

• Aged
• Aged, 80 and over
• Benzodiazepines/administration & dosage
• Benzodiazepines/adverse effects
• Critical Care
• Critical Illness/mortality
• Critical Illness/therapy
• Dexmedetomidine/administration & dosage
• Dexmedetomidine/adverse effects
• Female
• Hospital Mortality
• Humans
• Hypnotics and Sedatives/administration & dosage
• Hypnotics and Sedatives/adverse effects
• Intensive Care Units
• Length of Stay
• Male
• Middle Aged
• Propofol/administration & dosage
• Propofol/adverse effects
• Republic of Korea
• Respiration, Artificial/statistics & numerical data
• Retrospective Studies
• Time Factors

• 0620181290, 2018 Pfizer

• ABCDEF bundle
• ICU
• analgesia
• critical care
• delirium
• sedation

• Anesthesia and analgesia
• critical care
• emergency medicine

• CRRT
• acute kidney injury
• analgesic
• anticonvulsant
• dosing optimization
• psychotropic

Sedation and analgesia are essential in the intensive care unit in order to promote control of pain, anxiety, prevent loss of materials, accidental extubation and improve the synchrony of patients with ventilator. However, excess of these medications leads to an increased morbidity and mortality, and thus demands protocol.

Preferred Reporting Items for Systematic Reviews and the Meta-Analysis Protocol have been used to undertake this review. Pub Med, Cochrane Library, and Google Scholar search engines were used to find up-to-date evidence that helps to draw recommendations and conclusions.

In this Guideline and Systematic Review, we have used 16 Systemic Review and Meta-Analysis, 3 Evidence-Based Guidelines and 10 RCT Meta-Analysis, 6 Systemic Reviews of Non-randomized Studies, 8 Randomized Clinical Trials, 11 Cohort Studies, 5 Cross-Sectional Studies and 1 Case Report with their respective study descriptions.

Analgesia, which as a sedation basement can reduce sedative use, is key aspect of treatment in ICU patients, and we can also conclude that an analgesic sedation regimen can reduce the occurrence of delirium by reducing sedatives. The aim of this guideline and the systematic review is to write up and formulate analgesia-based sedation for limited resource settings.

Analgesia and sedation are effective in critically ill patients; however, too much sedation is associated with longer periods of mechanical ventilation and longer duration of ICU stay. Poorly managed ICU patients have a delirium rate of up to 80%, increased mortality, longer hospital stays, higher hospital costs and bad long-term outcomes.

•

Critically ill patients shall be awake, alert without pain, anxiety and delirium.

• ICU Analgesia
• ICU Patients
• ICU Sedation
• Sedation and analgesia in the ICU

• Critical care
• Insomnia
• Medications
• Pharmacology
• Sleep