Evaluating the Safety of Concomitant Propofol and Dexmedetomidine for Sedation in the ICU

Introduction: The 2025 PADIS guideline update recommends dexmedetomidine over propofol for light sedation and/or delirium reduction in critically ill, mechanically ventilated (MV) adult patients; however, concomitant use of dexmedetomidine and propofol is often seen in practice. Recent literature has demonstrated negative outcomes and an increase in adverse effects in certain patients who receive this combination. The purpose of this analysis was to evaluate the safety of concomitant propofol and dexmedetomidine for sedation in a real-world setting.


Methods: This was a single-center, prospective, observational analysis of adult patients receiving MV and concomitant propofol and dexmedetomidine between November 1, 2024 and Febrary 28, 2025. The major outcome was the incidence of hemodynamic instability, defined as either clinically relevant hypotension (administration of fluid bolus ≥500 mL, vasopressor initiation or ≥25% increase in vasopressor rate, or two consecutive mean arterial pressure readings ≤65 mmHg) or bradycardia (heart rate < 60 bpm or ≥20% decrease from baseline). A multivariable regression analysis was performed to identify independent predictors of hemodynamic instability. A subgroup analysis was conducted in patients ≤65 years of age and >65 years of age.


Results: During the study period, 88 patients were included in the analysis. Hemodynamic instability was observed in 49 (55.7%) patients, of these patients 36 (73.5%) experienced hypotension and 33 (67.3%) experienced bradycardia. Time to development of hypotension was 2 hours [1-5.1] and bradycardia was 3.3 hours [1.5-6.5]. When controlling for confounders, the presence of malignancy and vasopressor use were associated with hemodynamic instability. In the subgroup analysis, bradycardia occurred more frequently and had a quicker onset in patients ≤65 years of age, whereas mortality was more prevalent in patients >65 years of age.


Conclusions: This analysis suggests that hemodynamic instability is common with the utilization of concomitant propofol and dexmedetomidine in real-world scenarios. Further studies are warranted to elucidate the impact of concomitant propofol and dexmedetomidine on hemodynamics and patient outcomes.