Safety and efficacy of dexmedetomidine in acutely ill adults requiring non-invasive ventilation: a systematic review and meta-analysis of randomized trials.

ABSTRACT Background While clinical studies have evaluated dexmedetomidine as a strategy to improve non-invasive ventilation (NIV) comfort and tolerance in patients with acute respiratory failure (ARF), their results have not been summarized. Research Question We sought to determine if dexmedetomidine when compared to another sedative or placebo reduces the risk of delirium, mortality, need for intubation and mechanical ventilation, or intensive care unit (ICU) length of stay (LOS) in adults with ARF initiated on NIV in the ICU? Study Design and Methods We electronically searched MEDLINE, EMBASE, and the Cochrane Library from inception to July 31st, 2020 for randomized clinical trials (RCTs). We calculated pooled relative risks (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes with the corresponding 95% confidence intervals (CIs) using a random-effect model. Results Twelve RCTs were included in our final analysis (n=738 patients). The use of dexmedetomidine, compared to other sedation strategies or placebo, reduced the risk of intubation (RR 0.54, 95% CI 0.41 to 0.71, moderate certainty), delirium (RR 0.34, 95% CI 0.22 to 0.54, moderate certainty), and ICU LOS (MD -2.40 days, 95% CI -3.51 to -1.29, low certainty). Use of dexmedetomidine was associated with an increased risk of bradycardia (RR 2.80, 95% CI 1.92 to 4.07, moderate certainty) and hypotension (RR 1.98, 95% CI 1.32 to 2.98, moderate certainty). Interpretation Compared to any sedation strategy or placebo, dexmedetomidine reduced the risk of delirium and the need for mechanical ventilation, while increasing the risk of bradycardia and hypotension. The results are limited by imprecision and further large RCTs are needed. Registration This protocol was registered on PROSPERO ( https://www.crd.york.ac.uk/prospero/ ). The protocol registration number is 175086