Abstract
Background.
A significant category of patients, especially those who have undergone cardiac operations and
neuroangiography interventions, needs prolonged mechanical ventilation as well as sedation to adapt to
ongoing ventilatory support. Approaches to sedation significantly differs according to the protocols approved
in the centers, funding and financial support, subjective assessment instruments, but not the objective scales
or instrumental assessment tools. Aim of this study - to compare clinical and pharmacoeconomic efficien
cy and comfort of medical staff work during sedation in mechanically ventilated patients.
Material and methods.
78 consecutively admitted patients, who were mechanically ventilated after cardiac
surgeries (n = 36) and intracranial interventions (n = 42), were included in the prospective randomized study.
Propofol, sevoflurane dexmedetomidine were used, the dosage was titrated to achieve clinical effect.
Objective evaluation criteria were hemodynamic stability (was assessed by the need to use vasoactive drugs),
the need for neuromuscular blocking agents, the duration of discontinuation of mechanical ventilation, rate
of post-sedation cognitive impairment, sedation level assessed with the RASS scale and the bispectral index.
Subjective evaluation criteria: comfort of medical staff work (was evaluated in scores), the rate of neurolo
gical recovery (stopping sedation) and rate of return to the initial level of sedation, the coefficient of cost effi
ciency.
Results.
All options have reported a moderate level of sedation (from -3.1 to -3.9 scores assessed with the
RASS scale), or moderate hypnotic stage (from 47 to 65 scores by BIS). The need to use antispasmodics and
vasopressors has been significantly higher in cardiac patients, receiving propofol and dexmedetomidine,
compared to those under inhalation sedation
(p
= 0.011). In the group of patients, who have undergone neu
rosurgeries, dexmedetomidine has been more beneficial. Both groups have reported high rate of post-seda
tion cognitive impairment after propofol (37.5-55,6 vs. 20-25%). Dexmedetomidine and sevoflurane have
provided a rapid discontinuation of mechanical ventilation (3.5—6.9 hrs vs. 16.3-19.5 with propofol). For
medical staff it has been more comfortable to use i.v. (the highest scores,
p
= 0.02 compared with sevoflu
rane). Economic evaluation has reported efficient use of propofol for sedation up to 24 hrs, but later all its
benefits are loosing due to the buildup of tolerance, the same has been observed with sevoflurane, which
required the replacement of daily inhalation system.
Conclusion.
The choice of drugs should be differentiated by the goals and duration of sedation as well as con
sidered by efficacy and dosages, evaluated with objective methods. Periodic changes of sedatives appear to be
reasonable and might help to perform more efficient, manageable and cheap sedation.
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