December 03, 2013
Benzodiazepines (midazolam and lorazepam) and nonbenzodiazepines (propofol and dexmedetomidine) are common pharmacotherapeutic agents that are required in the ICU for sedation of both mechanically ventilated and non-mechanically ventilated patients. However, mechanically ventilated patients traditionally require a more aggressive dosing strategy for these agents including the use of continuous infusions to maintain patient comfort. Pharmacists have had an active role in the implementing of dosing protocols and guidelines within each of our hospital and health systems to optimize the use of these agents based on best practice in coordination of controlling drug costs. In 2002, the Society of Critical Care Medicine (SCCM), American Society of Health-Systems Pharmacists (ASHP), and American College of Chest Physicians collaborated in publishing clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill. In 2013, the guidelines were updated and provided recommendations based on the best evidence available for the management of pain, agitation, and delirium in adult patients in the ICU. The goal of this document was to provide a roadmap for developing integrated, evidence-based, and patient-centered protocols for preventing and treating pain, agitation, and delirium in the care of the critically ill patient.
One particular issue that has drawn much debate within hospitals and health systems has been the use of benzodiazepines or nonbenzodiazepines for sedation of the mechanically ventilated patient. The 2013 guidelines have documented that light sedation in adult ICU patients is associated with improved clinical outcomes (shorter length of mechanical ventilation and shorter length of ICU stay). The guidelines recommend that propofol or dexmedetomidine may be preferred over benzodiazepines. Although the data has demonstrated these improved outcomes (which is our ultimate goal), some institutions may not have embraced the use of these agents due to regional supply shortages of propofol or the significant cost of dexmedetomidine compared to benzodiazepines.
Although propofol is generic there continues to be shortages due to manufacturing delays. Dexmedetomidine’s price will soon decrease based on the future availability of a generic formulation. Since many pharmacists are actively involved with creating sedation protocols or guidelines within their institutions, this will adversely affect how your protocols are developed or updated.
I would like to generate a discussion of the audience members on a few important points. Do you currently follow the 2013 guidelines and use propofol and or dexmedetomidine for light-sedation? Has your drug budgets on the use of propofol and or dexmedetomidine increased since the guidelines have been published? Do you continue to use midazolam or lorazepam as the primary sedatives of choice either as a continuous infusion or PRN (pro re nata)? Does your nursing staff document level of sedation utilizing a hospital approved sedation scoring system? Will the future addition of generic dexmedetomidine adversely affect your drug selection? I would welcome an interactive discussion on the above questions and any other thoughts you would like to share on this topic.
Michael J. Cawley, PharmD, RRT, CPFT, is a Professor of Clinical Pharmacy at the Philadelphia College of Pharmacy, University of the Sciences. He has greater than 25 years of experience practicing in the areas of medical, surgical, trauma, and burn intensive care as both a critical care clinical pharmacist and registered respiratory therapist.