{"id":28474,"date":"2025-09-24T04:52:00","date_gmt":"2025-09-23T20:52:00","guid":{"rendered":"https:\/\/csccm.org.cn\/?p=28474"},"modified":"2025-09-24T05:43:45","modified_gmt":"2025-09-23T21:43:45","slug":"icu-management-practice-%e5%af%bb%e6%89%be%e5%8d%95%e4%b8%80%e6%9c%80%e4%bd%b3%e9%95%87%e9%9d%99%e8%8d%af%e7%89%a9","status":"publish","type":"post","link":"https:\/\/csccm.org.cn\/?p=28474","title":{"rendered":"[ICU Management &#038; Practice]: \u5bfb\u627e\u5355\u4e00\u6700\u4f73\u9547\u9759\u836f\u7269"},"content":{"rendered":"\n<h1 class=\"wp-block-heading\">Searching for the Single Best Sedative<\/h1>\n\n\n\n<ul>\n<li>In&nbsp;<a href=\"https:\/\/healthmanagement.org\/c\/icu\">ICU<\/a><\/li>\n\n\n\n<li>Thu, 22 May 2025<\/li>\n<\/ul>\n\n\n\n<figure class=\"wp-block-image size-large\"><img decoding=\"async\" src=\"https:\/\/res.cloudinary.com\/healthmanagement-org\/image\/upload\/c_thumb,f_auto,fl_lossy,q_90\/v1747917031\/cw\/00130141_cw_image_wi_9eacae526c78812bf08170c6cc5dc4d4.webp\" alt=\"\"\/><\/figure>\n\n\n\n<p>Critically ill patients on invasive mechanical ventilation often need continuous sedation to manage pain and anxiety. For decades, researchers have sought the ideal sedative for these patients.&nbsp;<\/p>\n\n\n\n<p>Propofol, a lipid-based drug that enhances \u03b3-aminobutyric acid (GABA) receptor activity, is widely used in intensive care for varying levels of sedation. Dexmedetomidine is another sedative commonly used in critically ill patients. As an \u03b12-adrenergic receptor agonist, it produces lighter sedation and is often combined with other agents for deeper sedation. Both dexmedetomidine and propofol can cause significant side effects, including hypotension\u2014more frequently with propofol.&nbsp;<\/p>\n\n\n\n<p>Dexmedetomidine is also associated with dose-limiting bradycardia. Prolonged or high-dose use of propofol can lead to propofol-related infusion syndrome, a potentially fatal condition marked by metabolic acidosis, cardiac dysfunction, hyperlipidaemia, and rhabdomyolysis, with an estimated mortality rate of up to 37%.<\/p>\n\n\n\n<p>Continuous infusions of sedatives like dexmedetomidine and propofol are commonly used for critically ill patients, with best practices emphasising minimising and regularly interrupting sedation to use the lowest effective dose. Clinical trials comparing dexmedetomidine and propofol found that while dexmedetomidine patients were more alert and able to communicate, key outcomes such as mortality, ventilator-free days, and delirium-free days were similar between the two.&nbsp;<\/p>\n\n\n\n<p>Clonidine, another \u03b12-adrenergic agonist with similar effects to dexmedetomidine, can be given orally or enterally and is suggested for intermittent sedation to reduce sedation levels while maintaining comfort.<\/p>\n\n\n\n<p>Walsh and colleagues report the A2B trial, a multicentre, open-label, 3-group randomised clinical trial comparing dexmedetomidine- or clonidine-based sedation versus propofol-based sedation in critically ill adults on invasive mechanical ventilation expected to last at least 48 hours. Adjunctive propofol was permitted for patients on \u03b12-adrenergic agonists if additional sedation was needed or if dose-limiting side effects occurred.<\/p>\n\n\n\n<p>Although sedation targets for dexmedetomidine and clonidine were guided, clinical teams had final control over sedation dosing, ventilation weaning, and extubation timing. This flexible approach, aiming to minimise sedation, likely enhances the study\u2019s generalisability.&nbsp;<\/p>\n\n\n\n<p>The researchers hypothesised that \u03b12-adrenergic agonist sedation would shorten the time to successful extubation (extubation followed by 48 hours without ventilation). Secondary outcomes included 180-day mortality, delirium, and bradycardia.<\/p>\n\n\n\n<p>The investigators enrolled over 1,400 patients from 41 UK intensive care units. The three groups were well balanced at baseline, with a median non-neurological SOFA score of 8 and nearly two-thirds of patients presenting with sepsis. Although prior use of propofol and an opiate was required for inclusion, only 1% had received dexmedetomidine and 2% clonidine before enrolment.<\/p>\n\n\n\n<p>The study found no significant difference in time to successful extubation between dexmedetomidine and propofol or between clonidine and propofol. There were also no differences in 180-day mortality or delirium rates. However, patients receiving \u03b12-adrenergic agonists (dexmedetomidine or clonidine) had a higher incidence of severe bradycardia (33%) compared to those on propofol (20%), a rate higher than previously reported. Additionally, agitation was more common in the \u03b12-agonist groups, though this may reflect increased wakefulness, as rescue medication use for agitation was similar across groups.<\/p>\n\n\n\n<p>For clinicians managing sedation in invasively ventilated patients, this study by Walsh and colleagues suggests that dexmedetomidine, enteral clonidine, and propofol produce similar clinical outcomes, with no clear differences across common patient subgroups. Unlike the&nbsp;<a href=\"https:\/\/healthmanagement.org\/c\/icu\/News\/sesar-trial-inhaled-sedation-in-acute-respiratory-distress-syndrome\" target=\"_blank\" rel=\"noreferrer noopener\">SESAR trial<\/a>, which found worse outcomes with inhaled sevoflurane versus propofol, these findings reinforce that no single sedative is ideal for all critically ill patients.<\/p>\n\n\n\n<p>In-depth patient phenotyping may identify subgroups who benefit more from GABA potentiators versus \u03b12-adrenergic agonists. Until then, current evidence supports clinicians using their judgment when choosing sedatives: propofol for deeper sedation, \u03b12-agonists for lighter sedation, and avoiding \u03b12-agonists if bradycardia is a concern. For enteral sedation, clonidine is a reasonable choice, especially to avoid benzodiazepines and antipsychotics. While Walsh and colleagues\u2019 study reassures that common sedation strategies yield similar short-term outcomes, more research is needed on their long-term effects.<\/p>\n\n\n\n<p>The trial suggests there is no single best sedative agent currently. How \u03b12-adrenergic agonists or propofol compare with other options like ketamine or propranolol remains unclear. Ultimately, finding one ideal sedative may be futile, as critically ill patients likely benefit from a dynamic sedation approach that uses different agents at various stages of their illness.<\/p>\n\n\n\n<p>Source: JAMA<\/p>\n\n\n\n<p>Image Credit: iStock&nbsp;<\/p>\n\n\n\n<h4 class=\"wp-block-heading\">References:<\/h4>\n\n\n\n<p>Qian ET,&nbsp;Rice TW (2025)&nbsp;<a href=\"https:\/\/jamanetwork.com\/journals\/jama\/fullarticle\/2834277\" target=\"_blank\" rel=\"noreferrer noopener\">The Search for the Single Best Sedative<\/a>.&nbsp;JAMA<em>.<\/em><\/p>\n\n\n\n<p>Walsh TS,&nbsp;Parker RA,&nbsp;Aitken LM et al. (2025)&nbsp;<a href=\"https:\/\/jamanetwork.com\/journals\/jama\/fullarticle\/2834276\" target=\"_blank\" rel=\"noreferrer noopener\">Dexmedetomidine- or Clonidine-Based Sedation Compared With Propofol in Critically Ill Patients:&nbsp;The A2B Randomized Clinical Trial.<\/a>&nbsp;JAMA<em>.<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Searching for the Single Best Sedative Critically ill p [&hellip;]<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":[],"categories":[24,23],"tags":[],"_links":{"self":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/28474"}],"collection":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=28474"}],"version-history":[{"count":1,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/28474\/revisions"}],"predecessor-version":[{"id":28475,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/28474\/revisions\/28475"}],"wp:attachment":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=28474"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=28474"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=28474"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}