When i started training in Critical Care (2003-sorry for dating myself😅) Precedex (Dexmedetomidine) was being launched - the new smart kid on the block, was supposed to be the cure all for sedation needs without the side effect's, could take care of pain, alcohol induced Delirium Tremens.We started using it were amazed at it's results & kept pushing the dose & duration( remember having to take special permission to use > 24 hours).





Later came a slew of studies - Dexmedetomidine - leads to lower delirium, early extubation when used in Intubated patients and even decreases mortality. Proposed mechanism being decreased inflammatory mediator's in Post CABG patients with less myocardial, renal & neuronal injury.





As i became a fighting proponent for it's use in all intubated-ventilated patients, trying to get it into the preferred medication list with Pharmacy Department to drive it's cost down, out comes the SPICE III Trial.





SPICE III Trial (Sedation Practice in Intensive Care Evaluation), was published in NEJM, June 27th 2019 issue, was a Multicenter Multinational Trial across UK, Australia, NZ,Italy, Saudi Arabia, Malaysia Ireland & Switzerland ( 2013-2018).





Mechanically ventilated patients expected to receive ventilation beyond next calendar day were included.1948 patients were in Precedex arm while 1956 in usual care ( propofol, midazolam or combination) , goal was RASS of -2 to +1.Mortality at 90 days was the primary outcome.





At the end of the trial there was no difference in the 2 arms in terms of Mortality at 90 days (29.1% in both arms).Days free of Mechanical Ventilation & Delirium was 1 day more in Precedex arm.Side effects ( Hypotension, Bradycardia & Asystole) were more in Precedex arm 0.7% vs 0.1%.

Despite Fentanyl being used in both arms (80%),additional medications were needed to achieve the goal sedation ( ie - propofol, midazolam or combination had to be added to precedex).





So where does this leave me - 1 day less (maybe) of delirium, mechanical ventilation to be balanced against more side effects including asystole + 70% chance of needing to add a second/ additional sedative medication.





😅Maybe i will go back to Propofol and use precedex early during daily SBT (when RN - says trial aborted due to agitation off sedation). Will need lower dose of precedex and hopefully have lesser side effect's.







