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Sedation After Cardiac Surgery With Propofol or Dexmedetomidine: Between Scylla and Charybdis?

Champion, Sébastien MD

doi: 10.1213/ANE.0000000000002461
Letters to the Editor: Letter to the Editor
Free

Published ahead of print September 12, 2017.

Réanimation, clinique de Parly 2, Ramsay Générale de Santé, Le Chesnay, France, Champion.seb@wanadoo.fr

Published ahead of print September 12, 2017.

Dr Liu et al1 compared outcomes of propofol and dexmedetomidine for postoperative sedation after cardiac surgery. They developed a rational approach that favored dexmedetomidine over propofol. Their article is very well referenced and relevant as dexmedetomidine and propofol are very commonly administered after cardiac surgery. However, they only briefly compare other drugs available for analgesia and sedation. My concern is that their focus on sedation may be too narrow when hemodynamic and analgesic concerns are equally or more important.

I suggest a multimodal patient-centered approach is necessary. For example, some sedatives and analgesics have improved hemodynamic properties when compared with dexmedetomidine. If an opioid-sparing strategy is used, 1 may prefer preventive analgesia with gabapentin or pregabalin over nonsteroidal anti-inflammatory drugs. Ketamine has analgesic and sedative properties with maintained hemodynamics. Dexmedetomidine may limit some detrimental effects (eg, tachycardia) of life-saving drugs. For example, it may limit tachycardia induced by levosimendan. Thus, ideal sedation after cardiac surgery is still to be defined on case by case basis, as stated by the authors. Indeed, sedation with volatile anesthetic agents in the intensive care unit may develop as a preferred approach when moderate- to-deep sedation is needed after cardiac surgery as they may decrease the duration of mechanical ventilation and morbidity in the intensive care unit compared with propofol.2

Additionally, whereas pharmacokinetic and pharmacodynamics properties may lead to prefer dexmedetomidine over clonidine, no definite study showed improved outcomes, to my knowledge. Thus, this older and cheaper drug may have a role in light-to-moderate sedation after cardiac surgery until proof of superiority of dexmedetomidine when patients are not at risk for bradycardia and do not coreceive drugs that may lower heart rate.

Mortality benefit was hypothesized by retrospective studies when dexmedetomidine was administered after cardiac surgery, as cited by the authors (NCT01683448). However, prospective or randomized evidence comparing dexmedetomidine to control after cardiac surgery reported an odds ratio for mortality of 1.0.3

Finally, few patients who undergo fast-track cardiac anesthesia experience complications including delirium. Thus, the majority of these patients do not need sedation but analgesia. Then choosing between propofol and dexmedetomidine may equate to navigating between Scylla and Charybdis.

Sébastien Champion, MDRéanimation, clinique de Parly 2Ramsay Générale de SantéLe Chesnay, FranceChampion.seb@wanadoo.fr

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REFERENCES

1. Liu H, Ji F, Peng K, Applegate RL 2nd, Fleming N. Sedation after cardiac surgery: is one drug better than another? Anesth Analg. 2017;124:1061–1070.
2. Soukup J, Selle A, Wienke A, Steighardt J, Wagner NM, Kellner P. Efficiency and safety of inhalative sedation with sevoflurane in comparison to an intravenous sedation concept with propofol in intensive care patients: study protocol for a randomized controlled trial. Trials. 2012;13:135.
3. Lin YY, He B, Chen J, Wang ZN. Can dexmedetomidine be a safe and efficacious sedative agent in post-cardiac surgery patients? A meta-analysis. Crit Care. 2012;16:R169.
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