Dexmedetomidine for Analgesia in Nonintubated Patients With Traumatic Rib Fractures: A Randomized Clinical Trial.

Importance: Traumatic rib fractures are associated with significant morbidity, including pulmonary complications and prolonged opioid use. Identifying adjunctive treatments that can reduce opioid consumption without compromising safety remains a clinical priority, particularly in nonintubated trauma patients. Objective: To evaluate whether adding dexmedetomidine to standard multimodal analgesia reduces opioid consumption in nonintubated patients in the intensive care unit (ICU) with traumatic rib fractures. It was hypothesized that adjunctive dexmedetomidine would reduce opioid use and improve numerical pain scores. Design, Setting, and Participants: This prospective, randomized, double-blind, placebo-controlled clinical trial was conducted from July 2021 to October 2023. Data were analyzed during January 2024. The study took place at a single academic level I trauma center ICU. Participants included nonintubated adult trauma patients (18 years or older) with 3 or more rib fractures who were admitted to the ICU. Exclusion criteria included a Glasgow Coma Scale score less than 14, bradycardia, hypotension, pregnancy, cirrhosis, chronic opioid use, or inability to consent. Of 41 enrolled patients, 19 received dexmedetomidine (46.3%). Exposure: Continuous intravenous infusion of dexmedetomidine (0.4 to 0.6 µg/kg per hour) or placebo (normal saline) for up to 48 hours, in addition to standard multimodal pain management. Main Outcomes and Measures: The primary outcome was the numerical pain score (NPS) over 48 hours. Secondary outcomes included oral morphine equivalents (OME) at 24 and 48 hours and pulmonary complications. Results: Among 41 patients (median age, 62 years; median injury severity score, 20), no significant differences were found in baseline characteristics between groups. Mean OME at 24 hours was 59.2 mg (dexmedetomidine) vs 54.9 mg (placebo) and 125.5 mg vs 87.1 mg at 48 hours. Median NPS was 4 in both groups. Pulmonary complication rates and ICU length of stay were also similar. Dexmedetomidine was discontinued in 47.4% of patients due to adverse events or patient request. Conclusions and Relevance: Adjunctive dexmedetomidine did not reduce opioid consumption, improve pain scores, or lower pulmonary complication rates in nonintubated patients in the ICU with traumatic rib fractures. These findings do not support routine use of dexmedetomidine for analgesia in this patient population. Trial Registration: ClinicalTrials.gov Identifier: NCT05321121.