Critically Ill Patients with Severe Cirrhosis Receiving Dexmedetomidine at a Higher Risk of Cardiovascular Instability: Application of an Objective Novel Cirrhosis Scoring System

BackgroundDexmedetomidine is a first-line sedative in intensive care unit (ICU) patients. Dexmedetomidine has a high hepatic extraction ratio, where clearance is primarily determined by hepatic blood flow. In cirrhosis, hepatic blood flow is reduced, and reduced dexmedetomidine clearance may confer increased susceptibility to cardiovascular adverse effects. Drug-induced hypotension can complicate diagnosis and treatment for the ICU-based clinician. This study's objective was to evaluate clinically significant cardiovascular adverse drug reactions (CS CV-ADRs) according to liver disease severity, stratified by the Albumin-Bilirubin (ALBI) grade, in patients with cirrhosis.MethodsThis retrospective, observational, case-control study using inverse probability of treatment weighting with the propensity score assessed adults at an academic medical center in Detroit, Michigan, from July 2018 through June 2023. Critically ill patients with cirrhosis receiving intravenous dexmedetomidine in an ICU were included. Patients experiencing a CS CV-ADR within 24 h of dexmedetomidine initiation were cases and those without a CS CV-ADR were controls. The primary outcome was incidence of CS CV-ADRs stratified by liver disease severity. A CS CV-ADR included a hemodynamic event and clinically relevant intervention each within 60 minutes. A multivariable regression was used to identify predictors of CS CV-ADRs.ResultsA total of 95 cases and 95 controls were included. The median (IQR) time to CS CV-ADR was 2.4 h (1.3-9.8). Liver disease severity was stratified using the ALBI Grade, ranging from ALBI Grade 1 (least severe) to Grade 3 (most severe) disease. ALBI Grade 3 was significantly associated with increased odds of CS CV-ADRs (Adjusted OR 2.25; 95% CI [1.47-3.46]).ConclusionsIncreasing liver disease severity according to ALBI Grade was associated with greater odds of CS CV-ADRs in critically ill patients with cirrhosis receiving dexmedetomidine. ALBI Grade may be an objective tool for predicting adverse effects of dexmedetomidine or development of dose adjustments for liver dysfunction.