Dexmedetomidine vs Midazolam

Dexmedetomidine vs Midazola for sedation of critically ill patients : A randomised control trial. Riker, R. et al. JAMA 301 (5) 489-99.

This prospective, double blind, multicentred RCT compared the alpha agonist dexmedotomdine against midazolam. It was designed to assess safety & efficacy. A total of 375 patients expected to be ventilated for > 24hrs were randomised to either agent targeted to a RASS score of between -2 to +1. Primary outcome measure was period of time within target range, secondary end points included delirium scores & duration of ventilation

Tight Glucose Control – A Meta-analysis

Benefits & Risks of Tight Glucose Control in Critically Ill Adults; A Meta-Analysis. Weiner et al. JAMA. 2008;300(8):933-944.

This meta-analysis of 28 studies of “tight glucose control” on AICU inevitably includes papers studying different protocols on different patients and hence is limited in its applicability. I’m not sure that meta-analysis serves any purpose not bettered by a brief reading of the key studies of this concept, as there is significant heterogenity within the studies and the vast majority of the numbers come from a few well known trials. The failure of any study to replicate Van de Berge’s original 30% mortality reduction now begins to suggest that the benefit of tight glucose control is at best marginal and perhaps non-existent. There is of course a potential harm from the well documented increased risk of hypoglyceamia. The meta-analysis generates an RR of 0.93 (0.85-1.03) for tight glycaemic control. They could identify no stratified group that showed a consistent mortality benefit, including medical ICU patients (as in the original study).

The accompanying editorial is more useful and summarises the problems with investigating glucose control. Namely…