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Comparison of Two Sedation Regimens During Targeted Temperature Management After Cardiac Arrest
Comparison of Two Sedation Regimens During Targeted Temperature Management After Cardiac Arrest
Paul M, Bougouin W, Dumas F, et al. Resuscitation. 2018 Mar 16;
Study Question: Do short-acting compared to long-acting sedatives hasten awakening in post-cardiac arrest patients undergoing targeted temperature management (TTM)?
Study Description: This before-after study used prospectively collected registry data to compare sedation with midazolam and fentanyl (Period 1, 2008-2013) to propofol and remifentanil (Period 2, 2014-2016) in comatose post-cardiac arrest patients undergoing TTM with target temperatures between 32-34°C. Patients were excluded for death within 48 hours, brain death, neurologic cause for cardiac arrest, or repeated sedation after rewarming. The primary outcome was delayed awakening, which was defined as failure to achieve three consecutive Richmond Agitation-Sedation Scale (RASS) values ≥-2 within 48 hours of sedative discontinuation. Secondary outcomes included rate of seizure, ventilator-associated pneumonia, ventilator-free days at 28 days, and vasopressor-free days at 28 days.
Results: Period 1 (P1) included 326 patients and Period 2 (P2) had 134 patients. Although Cardiac-Arrest-Hospital Prognosis (CAHP) scores were similar, patients in the P2 group were older (64 vs. 59 years, p = 0.004), received sedation for a longer time (40 vs. 34 hr, p = 0.0003), and received less neuromuscular blockade (72% vs. 99%, p<0.001). The median time to awakening after discontinuation of sedation was shorter in the P2 group [17 (IQR 7-60) vs. 2.5 (IQR 1-9) hours], but 60% of patients in both groups achieved awakening. Delayed awakening occurred in fewer patients in the P2 group (17% vs. 4%, p < 0.001). Patients in the P2 group experienced more ventilator-free days (25 vs. 24, p = 0.007), but fewer vasopressor-free days (25 vs. 26, p = 0.02). There was no difference in rates of seizures or pneumonia between the two groups.
Conclusion(s): Short-acting sedatives led to earlier awakening and shorter duration of mechanical ventilation in post-cardiac arrest patients undergoing TTM.
Perspective: This study demonstrated similar results to a smaller study evaluating the same sedative regimens. Prior literature has demonstrated faster awakening with propofol than midazolam in mixed ICU populations, but it remains unclear what remifentanil’s effects are since this study changed both the sedative and analgesic medications. This study supports the use of propofol over midazolam in post-cardiac arrest TTM patients, but further study is needed to determine the optimal analgesic in this population.