Dexmedetomidine is a more cost-effective option than propofol for sedating mechanically ventilated patients after cardiovascular surgery, according to a single-institution, retrospective study.
“Patients got off the ventilator quicker with dexmedetomidine,” said Matthew Wanat, PharmD, a clinical assistant professor at the University of Houston College of Pharmacy, and a clinical specialist at The Methodist Hospital in Houston.
Although dexmedetomidine (Precedex, Hospira) is increasingly popular with physicians, some administrators have pushed back against its use because of the higher up-front costs. The acquisition cost (average wholesale price) of one day of sedation for a 70-kg patient is $369.94 for dexmedetomidine (0.5 mcg/kg per hour) and $101.61 for propofol (35 mcg/kg per minute), according to Dr. Wanat, who led the study, which was presented at the American College of Clinical Pharmacy’s virtual poster session.
The retrospective study included patients aged 18 years or older who underwent either coronary artery bypass graft surgery and/or valve surgery at Methodist between January and June 2011. Of the 352 patients, 319 received propofol and 33 received dexmedetomidine as the primary sedation drug. The investigators analyzed factors including acquisition costs of the drugs, acquisition costs associated with the addition of a second agent for sedation, costs associated with mechanical ventilation and costs associated with delirium.
The average cost of sedation per patient was $1,647 for dexmedetomidine and $1,831 for propofol. Dexmedetomidine reduced mechanical ventilation time and the need for a second sedative agent. There was no difference in delirium costs.
“We are already using a lot of dexmedetomidine in ICUs. This study adds to our comfort level that dexmedetomidine is cost-effective,” said Marcia Buck, PharmD, a clinical pharmacy coordinator at the University of Virginia Children’s Hospital, in Charlottesville. “With the downsides of using propofol in terms of its toxicity profile, it is good to have this kind of data available.”
Study’s Shortcomings Hamper Concrete Conclusions
John Devlin, PharmD, an associate professor in the Department of Pharmacy Practice at Northeastern University, and a scientist in the Division of Pulmonary, Critical Care and Sleep Medicine at Tufts Medical Center, in Boston, said it was hard to draw conclusions from this cost-analysis, given that clinical outcomes (e.g., duration of mechanical ventilation and delirium) were not based on data from a randomized controlled trial.
“It is likely that underlying patient characteristics, with the potential to influence the clinical outcome—duration of mechanical ventilation—influenced the decision by clinicians to choose dexmedetomidine over propofol as the postsurgical sedative regimen,” commented Dr. Devlin. For example, he said, physicians at his institution generally avoid dexmedetomidine in cardiac surgery patients with underlying severe congestive heart failure and those who remain vasopressor-dependent after surgery.
“Furthermore,” Dr. Devlin said, “there may be a bias to use dexmedetomidine in those patients who are expected to be extubated soon after surgery, given that dexmedetomidine does not influence respiratory drive and maintains greater patient arousability.”
Drs. Wanat and Buck reported no
relevant financial conflicts of interest.
Dr. Devlin has received research grants
and honoraria from Hospira.