Evaluating the Use of Adjunctive Dexmedetomidine for Alcohol Withdrawal in Critically Ill Patients

INTRODUCTION: Dexmedetomidine is commonly used in combination with benzodiazepines for the management of alcohol withdrawal syndrome (AWS), but limited data exist regarding its use with phenobarbital (PHB). The purpose of this analysis was to evaluate the utility of dexmedetomidine in addition to PHB for AWS in adult patients admitted to the intensive care unit (ICU).

METHODS : This was a single-center, retrospective cohort analysis of critically ill adult patients who received PHB plus either dexmedetomidine (DEX) or different adjunctive therapies (NO-DEX) for AWS between 2018 and 2021. Patients were excluded if they had underlying altered mental status or seizure disorder unrelated to AWS, received PHB at outside hospitals, or were pregnant. Coarsened exact matching (CEM) was performed to match patients based on APACHE II score and intubation at first hospital contact in a 1:1 ratio to ensure similar cohorts. The primary outcome was ICU length of stay (LOS). A linear regression analysis was performed to assess the effects of dexmedetomidine on ICU LOS when accounting for various confounders, such as mechanical ventilation, antipsychotic use, and RASS > +1 on day one of treatment. Notable secondary outcomes included days with delirium and incidence of mechanical ventilation after PHB administration.

RESULTS: Of the 606 encounters evaluated, 197 met criteria for inclusion. After CEM was performed, 56 encounters remained in each group for analysis and groups were comparable at baseline. The median ICU LOS was 97.2 [50.1:139.5] hours for the DEX group and 47.5 [28.8:88.1] hours for the NO-DEX group (p = 0.002). The linear regression analysis showed the use of dexmedetomidine (p=0.008) and the need for mechanical ventilation (p=0.035), were independently associated with an increased ICU LOS by 49.8 and 41.4 hours, respectively. The DEX group had higher rates of total delirium days (208 vs. 143 days, p < 0.001) and a higher incidence of mechanical ventilation after PHB administration (32% vs. 9%, p < 0.001).

CONCLUSIONS: This analysis suggests the use of dexmedetomidine as an adjunct to PHB for AWS was associated with a prolonged ICU LOS. Additional studies are needed to further understand the role of dexmedetomidine as an adjunct therapy in the treatment of AWS in critically ill patients.