Abstract 4368413: Selective Sedation: Patient Characteristics Associated with Sedative Choice in Cardiogenic Shock

Abstract

Introduction: Propofol has demonstrated favorable outcomes in mechanically ventilated ICU patients, including shorter ventilation times and ICU stays. However, its use in cardiogenic shock remains controversial due to concerns about hypotension and negative inotropic effects. Despite its frequent use, limited evidence guides sedative selection in this high-risk group. We examined whether baseline characteristics and illness severity differed by sedative type in cardiogenic shock. Research Question: Among cardiogenic shock patients admitted to the CICU, how do baseline characteristics differ by predominant sedative exposure? Methods: We conducted a retrospective cohort study of 3,480 adults admitted to the Northwell Health CICU between 2016–2022 with an ICD-coded diagnosis of cardiogenic shock. Patients were grouped by sedative if >75% of cumulative sedation shifts involved a single agent: Propofol (n=669), Dexmedetomidine (n=745), Fentanyl (n=135), Midazolam (n=72), or categorized as Mixed (n=1859) if no single agent predominated. Ketamine users (n=3) were excluded. Key variables included age, Charlson Comorbidity Index (CCI), mean arterial pressure (MAP), serum lactate, creatinine, and maximum cardiogenic shock stage (SCAI). Kruskal-Wallis and Chi-squared tests were used for continuous and categorical comparisons. Results: Baseline characteristics varied significantly by sedative group (all p<0.001). Propofol patients were younger (mean age 69.6), with higher MAP (71.2 mmHg), lower lactate (4.25 mmol/L), and lower creatinine (2.03 mg/dL). Fentanyl and Midazolam groups had greater illness severity: older age (74.1 and 70.2), lower MAP (58.9 and 64.1 mmHg), higher lactate (6.94 and 5.83 mmol/L), and higher creatinine (2.82 and 2.45 mg/dL). Max SCAI was similar across groups. Conclusions: Propofol recipients were generally younger with more favorable baseline hemodynamic profiles, while fentanyl and midazolam recipients exhibited greater markers of illness severity. Despite these differences, the maximum cardiogenic shock stage (SCAI) was similar across groups. These findings suggest a potential selection bias, with clinicians possibly reserving propofol for patients perceived as lower risk due to safety concerns. However, the similarity in SCAI stage suggests that such avoidance may not reflect actual illness severity. Prospective studies are needed to determine whether propofol is truly contraindicated—or underutilized—in patients with advanced cardiogenic shock.