To the Editor Dr Reade and colleagues1 assessed the effect of dexmedetomidine on ventilator-free time in patients with agitated delirium. We have concerns about their definition of outcomes, potential clinician subconscious cognitive biases, and randomization imbalances.
The authors equated the use of tracheostomy and no sedation for 4 hours to an extubation. Because tracheostomies change the clinical course of weaning and delirium, they cannot be analyzed as a success or as a censoring event.2 Clinicians may be inclined to reduce sedatives in patients with tracheostomies because the risk of self-extubation is lower and a tracheostomy contributes less to agitation than an endotracheal tube. A sensitivity analysis considering a tracheostomy as the worst-case scenario or the longest intubation time possible3 would be useful to report.
Hamilton M, Amaral A. Dexmedetomidine to Reduce Intubation Time in Patients With Agitated Delirium. JAMA. 2016;316(7):772-773. doi:10.1001/jama.2016.8599