Chest
Volume 103, Issue 2, February 1993, Pages 557-564
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Propofol vs Midazolam in Short-, Medium-, and Long-term Sedation of Critically III Patients: A Cost-Benefit Analysis

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The purpose of this study was to evaluate and compare the clinical effects, safety, and economic cost of propofol and midazolam in the sedation of patients undergoing mechanical ventilation in the ICU. Eighty-eight critically ill patients were studied and randomly allocated to receive short-term (less than 24 h), medium-term (24 h to 7 days), and prolonged (more than 7 days) continuous sedation with propofol (n=46) or midazolam (n = 42). Mean doses required were 2.36 mg/kg/h for propofol and 0.17 mg/kg/h for midazolam. Patients in the group receiving propofol showed a percentage of hours of sedation at the desired level (grade 2, 3, 4, or 5 on the Ramsay scale) of 93 percent, compared with 82 percent (p<0.05) in the group receiving midazolam. Both agents were considered safe with respect to the induction of adverse reactions during their use in prolonged sedation. Recovery after interrupting sedation was significantly faster in patients treated with propofol than in those sedated with midazolam (p<0.05). Recovery of total consciousness was predictable according to sedation time in propofol-treated subgroups (r = 0.98, 0.88, and 0.92, respectively), while this correlation was not observed in the midazolam-treated group. In the subgroup with sedation of less than 24 h, propofol provided a cost savings of approximately 2,000 pesetas (pts) per patient, due to shorter stays in the ICU. We conclude that propofol is a sedative agent with the same safety, higher clinical effectiveness, and a better cost-benefit ratio than midazolam in the continuous sedation of critically ill patients.

Section snippets

Patients

In a prospective study, patients admitted to our general 14-bed ICU were randomized to groups between January and September 1991. Criteria for admission to the study were (1) age above 16 years old, (2) probable need for controlled mechanical ventilation, and (3) severity of illness classified at admission as equal to or higher than 9 points on the simplified acute physiologic score (SAPS).10 Informed consent was obtained either directly from the patient or from his or her relatives. One

Group Comparison

Eighty-eight patients were admitted to the study. Forty-six patients (40 men and 6 women) received propofol, and 42 (36 men and 6 women) were sedated with midazolam.

There were no significant differences between groups and subgroups with respect to age, weight, consciousness level before starting sedation (valued by GCSC scoring), and severity of illness at admission (determined by SAPS scoring) (Table 1).

Reasons for Admission: A wide variety of illnesses motivated admission. In the

DISCUSSION

Elimination of etomidate and the alfaxalone-alfadolone combination (Althesin) has produced difficulties in the search for an ideal sedative agent in intensive care practice. Because of their cumulative side effects, thiopental (thiopentone) and other barbiturates are not advisable for continuous perfusion. Although clomethiazole promised to be useful, its use should be accompanied by a provision of fluids, and recovery delays of up to 48 h have been reported.13 Ketamine offers the advantage of

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  • Cited by (0)

    Supported by the Hospital de Barcelona Research Committee.

    NOTE: The current (1/93) exchange rate is 111 pesetas to $1 US.

    Manuscript received March 1!; revision accepted June 23.

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