Dexmedetomidine in Palestinian intensive care units: The first multicenter cross-sector survey of sedation practices,protocol gaps,and withdrawal challenges

Abstract

Objective

Dexmedetomidine has emerged as an important sedative due to its ability to provide cooperative sedation while preserving respiratory drive. However, its clinical use may vary across healthcare systems, particularly in resource-limited settings. This study aimed to assess patterns of dexmedetomidine use, associated protocols, withdrawal experiences, and perceived barriers across different intensive care units in the Palestinian healthcare system.

Methods

A multicenter cross-sectional survey was conducted between October 2025 and January 2026 in governmental, teaching, and private hospitals. Anesthesiologists, intensive care physicians, and nurses with ≥ 6 months of experience were invited to complete a structured questionnaire addressing sedation practices, dosing, monitoring, withdrawal, perceptions, and institutional protocols.

Results

A total of 158 healthcare professionals participated (response rate 71.8%). Propofol (86.7%) and midazolam (70.9%) were the most commonly used sedatives, while dexmedetomidine was reported in 56.3% of intensive care units, predominantly as an adjunct (73.4%). Formal protocols were present in only 29.7% of units, and validated monitoring tools were used by 43.7%. Withdrawal symptoms were reported by 38.0% of respondents, most often after 48-72 hours of infusion. Significant sectoral differences were observed, with dexmedetomidine use reported in 55.1% of teaching hospitals and 43.8% of private hospitals, but only 1.1% of governmental hospitals (p < 0.001). Professional role also influenced practice. Fentanyl use was reported by 86.2% of ICU physicians, 66.7% of anesthesiologists, and 47.3% of nurses (p = 0.001). Cost was identified as a barrier by 46.2% of respondents, and inconsistent availability was reported by 43.7%, with both factors limiting routine use.

Conclusion

Limited protocols, inconsistent monitoring, and cost barriers hindered routine use of dexmedetomidine, while withdrawal was reported after prolonged infusions. These findings provide context-specific evidence to guide national guidelines, hospital protocols, and workforce training, with procurement and monitoring reforms as immediate priorities.

Keywords

dexmedetomidine intensive care sedation practices withdrawal weaning resource-limited healthcare health professional education

Introduction

Sedation is a cornerstone of modern intensive care, shaping patient comfort, ventilator synchrony, neurocognitive outcomes, and overall trajectories of care.^1,2 Both inadequate and excessive sedation have been linked to adverse consequences, including prolonged mechanical ventilation, delirium, cardiovascular instability, and extended intensive care unit stays.^3,4 These risks underscore the need for evidence-based, protocol-driven strategies that balance efficacy with safety.

Internationally, the Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption (PADIS) guidelines provide the most comprehensive framework for sedation management, recommending light, titratable sedation, daily interruption, and preferential use of non-benzodiazepine agents such as propofol and dexmedetomidine, while discouraging routine benzodiazepine use.^5–7 Structured protocols have been associated with improved outcomes, including reduced ventilation duration, shorter ICU stays, and lower costs.⁸ However, adherence to PADIS principles is often challenged in low- and middle-income countries, including Palestine, due to limited drug availability, inconsistent monitoring tools, and the absence of national protocols.

Globally, propofol and benzodiazepines remain the backbone of intensive care unit sedation.^3,4 Dexmedetomidine has emerged as a distinctive agent because of its α₂-adrenergic mechanism, ability to provide lighter, cooperative sedation, and reduced risk of respiratory depression compared with traditional agents.^1,9,10 These pharmacological properties position dexmedetomidine as both a promising alternative and a valuable adjunct to conventional sedatives such as benzodiazepines and propofol.^1,11

Although dexmedetomidine is increasingly embraced in critical care worldwide, its utilization remains highly contingent on institutional context, local resources, and clinician expertise.^1,11–13 Beyond its pharmacological profile, practical considerations, such as cost, inconsistent availability, the absence of standardized protocols, and concerns regarding cardiovascular adverse effects, continue to shape prescribing decisions and limit its widespread adoption.^14,15 Recent studies across diverse healthcare systems have revealed striking heterogeneity in dosing regimens, infusion durations, monitoring practices, and strategies for managing withdrawal, underscoring a persistent gap between evidence-based recommendations and real-world practice.^16–19 This divergence between PADIS guideline recommendations and local practice highlights the urgent need to contextualize sedation strategies within resource-limited environments.

Marked differences in intensive care practices are evident when comparing low-income regions with high-income countries. Resource-limited environments often face pronounced disparities in staffing density, infrastructure, and reliable access to essential medications.^19,20 In such settings, sedation practices are frequently shaped by institutional norms and local clinical experience rather than by cohesive national guidelines, resulting in substantial variability in the administration and monitoring of sedatives.^1,11–13 Within Palestine, intensive care services encounter additional systemic challenges, including heterogeneous intensive care unit capacities, sector-specific disparities between governmental, teaching, and private hospitals, and the absence of national sedation guidelines. Moreover, the broader geopolitical and economic context imposes profound constraints on healthcare delivery. Restrictions on movement, recurrent supply chain disruptions, and limited access to advanced pharmaceuticals contribute to inconsistent drug availability and hinder the implementation of standardized protocols. Economic pressures, compounded by resource scarcity and dependence on external aid, further exacerbate inequities in sedation practices across institutions. These intersecting challenges not only limit clinicians’ flexibility in prescribing and administering agents such as dexmedetomidine but also underscore the urgent need for context-specific evidence to inform national guidelines.

Despite the global rise in dexmedetomidine use, no published study has systematically examined sedation practices in Palestinian intensive care units or explored clinicians’ perceptions of its role in daily care. Addressing this gap is essential for aligning international recommendations with local realities and advancing safe, effective sedation strategies in resource-limited and politically constrained settings. The present study therefore aimed not only to describe current practices but also to generate evidence that can inform national sedation guideline development, support hospital-level protocol design, and highlight workforce training needs. By linking descriptive findings to actionable applications, this work provides a foundation for immediate practice improvements and future prospective research. Specifically, we assessed monitoring techniques, dosage regimens, infusion durations, and clinical indications guiding dexmedetomidine administration; compared healthcare providers’ perceptions of its safety, effectiveness, and adverse effect profile with those of other sedatives; and examined the availability and implementation of hospital-level protocols. Differences across hospital sectors and professional groups were also analyzed, thereby offering a comprehensive overview of current practices and contextual challenges.

Methods

Study design and settings

This study employed a cross-sectional descriptive design, which is well-suited for evaluating current clinical practices, professional knowledge, and institutional protocols. The design allowed simultaneous assessment of multiple variables without the need for long-term follow-up or invasive procedures, making it particularly appropriate given the scarcity of published research on sedation practices in Palestinian intensive care units. The study was conducted in strict adherence to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines, with the completed checklist provided as Supplemental Table S1.

Data collection was undertaken between October 2025 and January 2026 across intensive care units in major hospitals representing governmental, teaching, and private hospitals. This study was conducted across intensive care units in 11 institutions: An-Najah National University Hospital, Rafidia Surgical Hospital, Al-Watani Hospital, Al-Arabi Specialized Hospital, Nablus Specialized Hospital, Khalil Suleiman Governmental Hospital, Ibn Sina Specialized Hospital, Martyr Dr. Thabet Thabet Governmental Hospital, Darwish Nazzal Governmental Hospital, Tubas Turkish Governmental Hospital, and Salfit Governmental Hospital. The inclusion of hospitals with diverse capacities and resources enabled a comprehensive evaluation of sedation practices across different clinical environments.

Participants

The study population comprised anesthesiologists, intensive care physicians, and licensed intensive care nurses employed at major hospitals in the West Bank of Palestine Inclusion criteria were: (i) fulltime employment in an intensive care unit within one of the participating hospitals, (ii) direct involvement in patient sedation management, and (iii) at least six months of uninterrupted ICU practice. To ensure that respondents possessed sufficient clinical exposure to routine sedation practices, eligibility was restricted to healthcare professionals with a minimum of six months of continuous intensive care unit experience. Exclusion criteria included visiting consultants not permanently assigned to the unit, individuals with primarily administrative responsibilities, and staff members who did not actively participate in patient sedation decision-making. This approach ensured that the data reflected the perspectives and practices of frontline clinicians directly involved in sedation management.

Variables

Demographic and professional variables included participants’ age, gender, professional roles, including anesthesiologist, intensive care unit physician, or intensive care nurse, and years of intensive care unit experience. These measures provided a profile of the workforce and allowed comparisons across professional categories and levels of experience. Institutional variables captured the characteristics of the respondents’ workplace, including hospital sector, including governmental, teaching, or private, geographic location, intensive care unit bed capacity, and estimated annual intensive care unit admissions. These variables contextualized clinical practices within the structural and resource capacities of different hospitals.

Clinical practice variables focused on sedation management and specifically on the use of dexmedetomidine. Respondents were asked to report the sedatives routinely used in their intensive care units, the clinical indications for dexmedetomidine, typical dosing regimens, infusion durations, and methods of administration. Monitoring practices were assessed by inquiring about the use of standardized sedation assessment tools and the frequency of patient evaluation. Participants also reported observed adverse effects and experiences with dexmedetomidine withdrawal, including incidence, timing, and common manifestations such as agitation, delirium, or cardiovascular instability, as well as strategies employed for withdrawal management.

Perception variables explored healthcare providers’ views on dexmedetomidine relative to other sedatives. These included perceived effectiveness, safety, and tolerability, as well as opinions on cost, availability, and the presence or absence of institutional sedation protocols. Respondents were also asked to identify barriers and facilitators influencing the clinical adoption of dexmedetomidine in their intensive care units.

Sample size

The required sample size was calculated using Cochran’s formula for a single proportion, a standard approach in cross-sectional studies. Based on administrative records, the total number of eligible intensive care unit staff in the Palestinian hospitals in the West Bank was estimated at approximately 400 professionals. Assuming a 95% confidence level, a 5% margin of error, and a conservative prevalence estimate of 50%. The finite population correction was applied to account for the limited target population. Ultimately, 158 clinicians completed the survey, providing a robust dataset that closely approached the calculated requirement.

Study tools and data collection

Data were collected using a structured, self-administered questionnaire that was informed by previously published surveys of sedation practices and adapted to the Palestinian intensive care unit context.^21–24 Beyond describing current practices, the questionnaire was deliberately structured to capture information that could inform national sedation guideline development, support hospital-level protocol design, and highlight workforce training priorities. To ensure clarity, relevance, face, and content validity, the instrument was reviewed by experts in critical care (n = 3) and pharmacology (n = 3). The questionnaire was then pilot tested among 25 intensive care unit professionals for readability and comprehensibility. Based on pilot feedback, items were revised to improve clarity and comprehensibility. The final questionnaire was specifically designed to capture both objective practices and subjective perceptions regarding the use of dexmedetomidine and other sedative agents.

Participants were recruited by field researchers, who were final-year medical students. These researchers approached eligible clinicians directly in their places of work and invited them to participate in the study. The questionnaire collected demographic and professional information (age, gender, role, years of intensive care unit experience, and intensive care unit type), institutional characteristics (hospital sector, bed capacity, and annual admissions), and routine sedation practices (commonly used agents, clinical indications, and role of dexmedetomidine as first-line, adjunctive, or rescue therapy). Additional domains focused on dexmedetomidine-specific practices, including dosing regimens, infusion durations, monitoring techniques, and the presence of institutional or weaning protocols. Clinicians were also asked to report experiences with withdrawal, including incidence, timing, and manifestations, as well as strategies employed for withdrawal management. Perception-related items assessed views on safety, effectiveness, cost, availability, and the need for institutional or national guidelines. Finally, an open-ended section invited participants to describe challenges, propose alternatives, and recommend improvements to sedation protocols. The questionnaire is provided in Supplemental Table S2.

Statistical analysis

All analyses were performed using the Statistical Package for the Social Sciences (SPSS), version 26 (IBM Corp., Armonk, NY, USA). Continuous variables such as age, years of intensive care unit experience, and intensive care unit bed capacity were assessed for distributional properties and summarized as medians with interquartile ranges [Q1-Q3]. Categorical variables, including gender, profession, hospital sector, intensive care unit type, and sedation practices, were described using frequencies (n and percentages).

In this study, there were no missing data, as participants were required to complete all questionnaire items. Field researchers checked each questionnaire for completeness, and in cases of missing responses, participants were re-approached to provide the information.

Comparisons between groups were conducted to explore differences in sedation practices and perceptions across professional roles (physicians versus nurses) and hospital sectors (governmental, teaching, private). Associations between categorical variables were examined using Chi-square (χ²) tests, with Fisher’s exact test applied when expected cell counts were fewer than five. For continuous variables, non-parametric tests such as the Mann-Whitney U test and Kruskal-Wallis test were used to compare distributions across groups.

Subgroup analyses were conducted to compare sedation and withdrawal practices across professional specialties, presence of formal dexmedetomidine protocols, hospital type and safety perceptions. These analyses were performed to explore institutional and role-based differences in sedation management. A two-sided p-value of less than 0.05 was considered statistically significant.

Ethical considerations

This study was conducted in strict accordance with international and local ethical principles, including those outlined in the Declaration of Helsinki and subsequent updates. Ethical approval was obtained from the Institutional Review Board (IRB) of An-Najah National University (Approval reference number: Med. Dec.2024/56). In addition, the study was approved by all participating institutions.

All participants were fully informed about the objectives, procedures, and voluntary nature of the study, and written informed consent was obtained prior to participation. Confidentiality and anonymity of respondents were safeguarded throughout data collection and analysis, with no identifying information disclosed in any reports or publications. The study design and conduct ensured respect for participants’ autonomy, beneficence, and justice, aligning with both international standards and local regulatory requirements.

Results

Demographic and practice variables of the respondents

In this study, 220 professionals were approached. Of those, 27 declined to participate, 11 did not complete the questionnaire, 21 were recently employed in the intensive care unit and did not meet the inclusion criterion of more than 6 months of experience there, leaving 158 professional participants, giving a response rate of 71.8% (Supplemental Figure 1). The median age of respondents was 29.0 years [26.0, 34.0], reflecting a relatively young workforce engaged in intensive care practices (Table 1). The majority of participants were male (n = 116; 73.4%). In terms of professional background, intensive care nurses accounted for the largest share (93; 58.9%), followed by anesthesiologists (36; 22.8%) and intensive care unit physicians/internists (29; 18.4%). With respect to practice setting, the medical intensive care unit was the most common site of employment (91; 57.6%), while a substantial proportion also reported working in surgical intensive care units (73; 46.2%). Other subspecialty intensive care units, including coronary, pediatric, post-cardiac, and neonatal units, were represented to a lesser extent (Table 1). Professional experience in intensive care was modest overall, with a median of 4.0 years [2.0, 7.0].

Table 1.

Demographic, practice, hospital, and practice setting variables of the respondents (n = 158).

Variable	Median [Q1, Q3] or n (%)
Age (years), median [Q1, Q3]	29.0 [26.0, 34.0]
Gender
Male, n (%)	116 (73.4)
Female, n (%)	42 (26.6)
Specialty
ICU nurse, n (%)	93 (58.9)
Anesthesiologist, n (%)	36 (22.8)
ICU physician/internist, n (%)	29 (18.4)
Type of ICU practice
Medical ICU, n (%)	91 (57.6)
Surgical ICU, n (%)	73 (46.2)
Coronary Care Unit, n (%)	26 (16.5)
Pediatric ICU, n (%)	16 (10.1)
Post-Cardiac Care Unit, n (%)	8 (5.1)
Neonatal ICU, n (%)	6 (3.8)
Professional experience in ICU practice (years), median [Q1, Q3]	4.0 [2.0, 7.0]
Hospital sector
Private, n (%)	67 (42.4)
Teaching, n (%)	61 (38.6)
Governmental, n (%)	30 (19.0)
Number of beds in your ICU, median [Q1, Q3]	7.0 [6.0, 10.0]
Approximate number of annual ICU admissions
< 300, n (%)	41 (25.9)
301-600, n (%)	62 (39.2)
601-1000, n (%)	29 (18.4)
> 1001 (%)	26 (16.4)

ICU: intensive care unit, Q1, Q3 = First and third quartiles (interquartile range).

Hospital/practice setting variables

In terms of institutional affiliation, participants were distributed across private hospitals (n = 67; 42.4%), teaching hospitals (n = 61; 38.6%), and governmental facilities (n = 30; 19.0%). The median number of intensive care unit beds reported per unit was 7.0 [6.0, 10.0], indicating moderate capacity across participating sites. Regarding patient volume, most respondents estimated 301-600 annual intensive care unit admissions (62; 39.2%), while 41 (25.9%) reported fewer than 300 admissions annually (Table 1).

Sedation practices and use of dexmedetomidine

Among the sedative agents routinely administered in participating intensive care units, propofol (n = 137; 86.7%) and midazolam (n = 112; 70.9%) were the most frequently reported (Table 2), followed by fentanyl (n = 93; 58.9%) and dexmedetomidine (n = 89; 56.3%). Less commonly used agents included ketamine (n = 31; 19.6%), clonidine (n = 12; 7.6%), and morphine (n = 5; 3.2%).

Table 2.

Sedation practices and use of dexmedetomidine.

Variable	n (%)
Commonly used sedatives in your ICU
Propofol, n (%)	137 (86.7)
Midazolam, n (%)	112 (70.9)
Fentanyl, n (%)	93 (58.9)
Dexmedetomidine, n (%)	89 (56.3)
Ketamine, n (%)	31 (19.6)
Clonidine, n (%)	12 (7.6)
Morphine, n (%)	5 (3.2)
Indications for dexmedetomidine use in your ICU
Management of agitation, n (%)	83 (52.5)
Adjunctive sedative in patients requiring weaning from other sedative medications, n (%)	69 (43.7)
Weaning of sedation, n (%)	57 (36.1)
Delirium prevention, n (%)	57 (36.1)
Adjunctive sedative to facilitate extubation/mechanical ventilation weaning, n (%)	56 (35.4)
Adjunctive sedative in patients requiring large doses of other sedative medications, n (%)	53 (33.5)
Mechanical ventilation, n (%)	45 (28.5)
Primary sedative, n (%)	29 (18.4)
Analgesia, n (%)	24 (15.2)
For symptomatic chest trauma, n (%)	11 (7.0)
Dexmedetomidine is usually used as
First line agent, n (%)	33 (20.9)
Adjunctive agent, n (%)	116 (73.4)
Rescue agent, n (%)	9 (5.7)
Age-group in which dexmedetomidine is used
Neonates (0 to 28 days), n (%)	2 (1.3)
Infants (1 month to < 1 year), n (%)	7 (4.4)
Children (1 to 12 years), n (%)	21 (13.3)
Adolescents (13 to 17 years), n (%)	33 (20.9)
Adults (18 to 64 years), n (%)	135 (85.4)
Elderly (≥65 years), n (%)	58 (36.7)
Sites where dexmedetomidine is used
ICU, n (%)	110 (69.6)
Sedation outpatient, n (%)	36 (22.8)
Operation room, n (%)	32 (20.3)
Ward, n (%)	10 (6.3)
Preoperative holding area, n (%)	7 (4.4)

ICU: intensive care unit.

Dexmedetomidine was primarily used as an adjunct (n = 116; 73.4%), with fewer respondents reporting its use as a first-line sedative (n = 33; 20.9%) or rescue therapy (n = 9; 5.7%). The most frequently cited indications included management of agitation (n = 83; 52.5%), weaning from other sedatives (n = 69; 43.7%), and delirium prevention (n = 57; 36.1%). It was also used to facilitate extubation or mechanical ventilation weaning (n = 56; 35.4%), and in patients requiring high doses of other sedatives (n = 53; 33.5%).

Intensive care units remained the primary site of administration (n = 110; 69.6%), with notable use also reported in sedation outpatient settings (n = 36; 22.8%) and operating rooms (n = 32; 20.3%). Additional details on less frequent indications, age groups, and administration sites are presented in Table 2.

Dexmedetomidine protocols, dosing, and monitoring

Fewer than one-third of respondents reported a formal protocol for dexmedetomidine administration (n = 47; 29.7%) (Table 3). These findings suggest limited institutional governance over sedation practices involving dexmedetomidine.

Table 3.

Dexmedetomidine protocols, dosing, and monitoring.

Variable	Median [Q1, Q3] or n (%)
Presence of a formal protocol for the use of dexmedetomidine
No, n (%)	111 (70.3)
Yes, n (%)	47 (29.7)
Typical starting dose (mcg/kg/h), median [Q1, Q3]	0.5 [0.2, 0.7]
Typical maximal dose (mcg/kg/h), median [Q1, Q3]	0.7 [0.7, 1.2]
Usual duration of infusion (h)
< 24, n (%)	39 (24.7)
24-48, n (%)	78 (49.4)
48-120, n (%)	37 (23.4)
> 120, n (%)	4 (2.5)
Monitoring practices
Multiparameter monitors (blood pressure, respiratory rate, pulse oximetry, oxygen saturation, temperature, ECG), n (%)	118 (74.7)
RASS, n (%)	69 (43.7)
GCS, n (%)	33 (20.9)

Q1, Q3 = First and third quartiles (interquartile range), RASS = Richmond Agitation-Sedation Scale, ECG = Electrocardiogram, GCS: Glasgow coma scale.

The median typical starting dose was 0.5 mcg/kg/h [0.2, 0.7], with a median maximal dose of 0.7 mcg/kg/h [0.7, 1.2], indicating moderate dosing intensity across sites. The most common infusion duration was 24-48 hours (n = 78; 49.4%), whereas shorter infusions (<24 h) were reported by 39 respondents (24.7%). Prolonged infusions exceeding 120 h were rare (n = 4; 2.5%).

Regarding monitoring practices, the majority of respondents (n = 118; 74.7%) employed multiparameter monitors, while Richmond Agitation-Sedation Scale (RASS) assessments were used by 69 (43.7%) and Glasgow Coma Scale evaluations by 33 (20.9%). These data reflect variability in sedation monitoring approaches across institutions (see Table 3).

Incidence, symptoms, and management of dexmedetomidine withdrawal

Withdrawal symptoms following dexmedetomidine infusion were reported by 60 (38.0%) of respondents, while 98 (62.0%) indicated no such incidents (Table 4). Among those affected, withdrawal most commonly occurred after 48-72 h of infusion (n = 25; 15.8%), with a smaller proportion experiencing symptoms within 48 h (n = 18; 11.4%) or beyond 72 h (n = 17; 10.8%).

Table 4.

Incidence, symptoms, and management of dexmedetomidine withdrawal.

Variable	n (%)
Incidents of dexmedetomidine withdrawal
No, n (%)	98 (62.0)
Yes, n (%)	60 (38.0)
Infusion duration when the patient entered withdrawal (h)
< 48, n (%)	18 (11.4)
48-72, n (%)	25 (15.8)
72-120, n (%)	11 (7.0)
> 120, n (%)	6 (3.8)
Medications used for withdrawal management
Clonidine, n (%)	108 (68.4)
Quetiapine, n (%)	67 (42.4)
Methadone, n (%)	20 (12.7)
Lorazepam, n (%)	2 (1.3)

Management strategies varied. In terms of pharmacologic support, clonidine was used by 108 respondents (68.4%), whereas quetiapine (42.4%), methadone (12.7%), and lorazepam (1.3%) were less commonly administered.

Perceptions, barriers, and availability of dexmedetomidine

Respondents expressed mixed views regarding the comparative effectiveness of dexmedetomidine (Table 5). While 37 (23.4%) considered it more effective than other sedatives, 27 (17.1%) perceived it as less effective, and 22 (13.9%) reported no difference in efficacy. In contrast, perceptions of safety were more favorable: 82 (51.9%) indicated that dexmedetomidine was safer than alternative agents, and only 3 (1.9%) indicated it was less safe.

Table 5.

Perceptions, barriers, and availability of dexmedetomidine.

Variable	n (%)
Compared to other sedatives, dexmedetomidine is
More effective, n (%)	37 (23.4)
The same effect, n (%)	22 (13.9)
Less effective, n (%)	27 (17.1)
Safer, n (%)	82 (51.9)
Less safe, n (%)	3 (1.9)
Do you consider the cost a barrier
No, n (%)	85 (53.8)
Yes, n (%)	73 (46.2)
Is dexmedetomidine always available in your ICU
No, n (%)	69 (43.7)
Yes, n (%)	89 (56.3)

ICU: intensive care unit.

Cost was identified as a barrier to use by 73 (46.2%) of respondents, although a slight majority (n = 85; 53.8%) did not consider cost prohibitive. Regarding availability, dexmedetomidine was reported to be consistently available in 89 (56.3%) intensive care units, whereas 69 (43.7%) reported intermittent or absent availability. These findings underscore the influence of both economic and logistical factors on clinical practice (Table 5).

Professional role-based variation in sedation practices and withdrawal recognition

Clear distinctions emerged when sedation and withdrawal practices were examined across professional groups (Supplemental Table S3). Fentanyl was reported as a commonly used sedative by less than half of ICU nurses (n = 44; 47.3%), compared with two-thirds of anesthesiologists (n = 24; 66.7%) and the vast majority of ICU physicians (n = 25; 86.2%) (p = 0.001). Age-related application also varied. Dexmedetomidine use in infants (1 month to <1 year) was reported by 5 ICU physicians (17.2%), compared with only 2 nurses (2.2%) and none of the anesthesiologists (p = 0.001). Differences were also evident in the site of administration as ICU use was reported by 54 nurses (58.1%), 30 anesthesiologists (83.3%), and 26 ICU physicians (89.7%) (p = 0.001). Recognition of withdrawal timing showed further divergence. Nurses most frequently reported withdrawal within < 48 hours of infusion (n = 16; 17.2%), anesthesiologists most often reported 48-72 hours (n = 7; 19.4%), and ICU physicians reported later withdrawal beyond 120 hours (n = 3; 10.3%) (p = 0.028).

Presence of protocol, practices, and recognition of withdrawal

The presence of a formal dexmedetomidine protocol was associated with notable differences in practice variables and recognition of withdrawal (Supplemental Table S4). Adjunctive use in patients requiring large doses of other sedatives was reported by 10 respondents (21.3%) in protocol-equipped units compared with 43 respondents (38.7%) in units without a protocol (p = 0.034). Use in neonates (0-28 days) was reported exclusively in protocol units (n = 2; 4.3%), whereas no respondents from non-protocol units reported neonatal use (p = 0.029). Differences were also evident in the reporting of withdrawal incidence. Among respondents working in units with a formal protocol, 28 (59.6%) reported incidents of withdrawal, compared with 32 (28.8%) in units without a protocol (p < 0.001).

Monitoring practices and safety perceptions

Associations between monitoring approaches, clinical indications, withdrawal recognition, and perceptions of safety revealed consistent patterns across intensive care units (Supplemental Table S5). Respondents from teaching hospitals most frequently perceived dexmedetomidine as safer than other sedatives (n = 39; 47.6%), compared with 18 respondents (22.0%) from governmental hospitals and 25 respondents (30.4%) from private hospitals (p = 0.007).

Clinical indications also aligned with safety perceptions. Use during mechanical ventilation was reported by 29 respondents (35.4%) who considered dexmedetomidine safer, compared with 16 respondents (21.1%) who did not (p = 0.046). Similarly, reliance on multiparameter monitoring was more common among those perceiving dexmedetomidine as safer (n = 67; 81.7%) compared with those who did not (n = 51; 67.1%) (p = 0.035).

Differences were also evident in withdrawal recognition. Among respondents who perceived dexmedetomidine as safer, 25 (30.5%) reported incidents of withdrawal, compared with 35 (46.1%) among those who did not (p = 0.044).

Institutional and system-level variation in dexmedetomidine use

Marked differences were observed across hospital sectors and ICU capacities (Supplemental Tables S6-S7). Common use of dexmedetomidine was reported in 49 respondents (55.1%) from teaching hospitals and 39 respondents (43.8%) from private hospitals, but only 1 respondent (1.1%) from governmental hospitals (p < 0.001) (Supplemental Table S6). Specific clinical indications also varied. Weaning of sedation was reported by 44 respondents (49.4%) in units where dexmedetomidine was used, compared with 13 respondents (18.8%) in units without use (p < 0.001). Mechanical ventilation was cited as an indication by 32 respondents (36.0%) in dexmedetomidine units versus 13 respondents (18.8%) in non-dexmedetomidine units (p = 0.018). Analgesia was reported by 18 respondents (20.2%) in dexmedetomidine units compared with 6 respondents (8.7%) in non-dexmedetomidine units (p = 0.045). Availability also differed substantially as 67 respondents (75.3%) in dexmedetomidine units reported consistent availability compared with 22 respondents (31.9%) in non-dexmedetomidine units (p < 0.001).

Patterns of positioning further reflected institutional variation (Supplemental Table S7). First-line use was most frequently reported in private hospitals (n = 22; 66.7%), compared with teaching hospitals (n = 6; 18.2%) and governmental hospitals (n = 5; 15.2%) (p = 0.026). Adjunctive use was predominant in teaching hospitals (n = 52; 44.8%) and governmental hospitals (n = 23; 19.8%). ICU admission volume also influenced positioning as units with 601-1000 annual admissions reported the highest proportion of first-line use (n = 13; 39.4%), whereas units with 301-600 admissions favored adjunctive use (n = 52; 44.8%) (p = 0.046).

Monitoring practices were associated with positioning. Multiparameter monitoring was reported in 92 respondents (79.3%) using dexmedetomidine adjunctively and in 8 respondents (88.9%) using it as rescue therapy, compared with 18 respondents (54.5%) using it as a first-line agent (p = 0.009) (Supplemental Table S7).

Finally, safety perceptions differed by positioning. Adjunctive users most frequently perceived dexmedetomidine as safer (70; 60.3%), compared with 9 respondents (27.3%) among first-line users and 3 respondents (33.3%) among rescue users (p = 0.002).

Institutional, protocol, and perception factors in withdrawal recognition

Patterns of withdrawal reporting varied across hospital type, protocol presence, and perceptions of safety (Supplemental Table S8). Among respondents from governmental hospitals, 15 (25.0%) reported incidents of withdrawal compared with 15 (15.3%) who did not. In teaching hospitals, withdrawal was reported by 27 (45.0%) compared with 34 (34.7%) without, while in private hospitals withdrawal was reported by 18 (30.0%) compared with 49 (50.0%) without (p = 0.041).

The presence of a formal protocol was also associated with differences in reporting. Withdrawal was noted by 28 respondents (46.7%) in protocol units compared with 19 (19.4%) without, whereas in non-protocol units withdrawal was reported by 32 respondents (53.3%) compared with 79 (80.6%) without (p < 0.001).

Perceptions of safety relative to other sedatives further distinguished reporting patterns. Withdrawal was reported by 35 respondents (58.3%) who did not consider dexmedetomidine safer, compared with 25 respondents (41.7%) who did (p = 0.044).

Cost barriers and withdrawal recognition across hospital types

Economic and systemic constraints were reflected in associations between hospital type, perceived cost barriers, and withdrawal incidence (Supplemental Table S9). Respondents from governmental hospitals were most likely to consider cost a barrier to dexmedetomidine use (n = 21; 28.8%), compared with 28 respondents (38.4%) from teaching hospitals and 24 respondents (32.9%) from private hospitals (p = 0.008).

Clinical indications also showed variation by cost perception. Adjunctive use in patients requiring large doses of other sedatives was reported by 31 respondents (42.5%) who considered cost a barrier, compared with 22 respondents (25.9%) who did not (p = 0.028). Similarly, use in symptomatic chest trauma was reported by 9 respondents (12.3%) who considered cost a barrier, compared with only 2 respondents (2.4%) who did not (p = 0.014).

Differences were also evident in withdrawal recognition. Among respondents who considered cost a barrier, 34 (46.6%) reported incidents of withdrawal, compared with 26 (30.6%) among those who did not (p = 0.039).

Discussion

This study provides the first multicenter evidence on sedation practices and dexmedetomidine use in Palestinian intensive care units. The findings highlight variation in sedative choice, protocol availability, monitoring practices, and perceptions of safety and cost. The study offers context-specific data that can support future efforts in national guideline development, hospital-level protocol design, and workforce training. In addition, the findings of this study might contribute to a clearer understanding of current practice and the barriers that shape sedation management in resource-limited settings.

In this study, propofol and midazolam remained the predominant sedatives, followed by fentanyl and dexmedetomidine. This pattern mirrors reports from other middle-income countries,²⁵ but contrasts with high-income settings such as the United States, where dexmedetomidine is more frequently positioned as a second-line agent after propofol.^26,27 These differences highlight how sedative choice is shaped not only by clinical guidelines but also by economic constraints, drug availability, and the presence or absence of institutional protocols. Within Palestine, these contextual factors appear to explain the greater use of dexmedetomidine in private and teaching hospitals compared with governmental facilities.

Cost and supply limitations emerged as central barriers. Although most respondents reported that dexmedetomidine was generally available, inconsistent supply and procurement challenges were evident, particularly in governmental hospitals. These findings diverge from high-income settings, where economic evaluations have shown that dexmedetomidine can reduce overall intensive care unit costs by shortening ventilation duration and length of stay, despite higher purchase prices.^13,28–30 Systematic reviews and cost-utility analyses similarly suggest that drug acquisition costs represent only a small fraction of total intensive care unit expenditure.^31,32 In contrast, our findings indicate that in resource-limited public hospitals, upfront drug price and rigid budgeting practices remain decisive obstacles to routine use. Taken together, these results underscore the importance of aligning economic evidence with institutional decision-making. Without mechanisms to translate cost-effectiveness data into procurement policies, sector-based variability in sedation practice is likely to persist. Strengthening budgetary frameworks and ensuring consistent supply chains could therefore be key steps toward harmonizing sedation practices across Palestinian intensive care units.

In most Palestinian intensive care units, dexmedetomidine was reported as an adjunct agent, consistent with current guidelines and international evidence.^33,34 Its positioning varied across sectors, with greater first-line use in private hospitals and in centers with higher admission volumes, suggesting that institutional capacity and resource availability influence prescribing decisions. This heterogeneity underscores the need for standardized protocols to ensure consistent application across settings. Reported indications, agitation control, sedation weaning, delirium prevention, and facilitation of mechanical ventilation weaning, align with established literature. However, international studies also describe broader applications, including perioperative and procedural sedation, adjunct use in regional anesthesia, severe alcohol withdrawal, and sleep modulation in intensive care unit patients.³⁵ The absence of these uses in our data highlights a narrower clinical scope in Palestine, likely reflecting both resource constraints and limited protocol guidance. Expanding awareness and training around these evidence-based indications could enhance the integration of dexmedetomidine into routine practice and optimize its clinical utility.

Fewer than one-third of respondents reported the presence of a formal protocol for dexmedetomidine administration. This limited governance reflects a broader gap in structured sedation practices and may contribute to variability in dosing, monitoring, and recognition of withdrawal. Although adverse effects such as hypotension and bradycardia are well documented,^36,37 our data suggest that protocol absence rather than protocol presence is the greater challenge, as units with protocols reported withdrawal more frequently, likely reflecting improved detection rather than increased incidence. Withdrawal management practices were generally consistent with international recommendations, with clonidine commonly used to support weaning.³⁸ However, fewer than half of respondents reported using validated assessment tools such as the Richmond Agitation–Sedation Scale (RASS). This limited uptake may hinder systematic recognition of withdrawal and sedation depth. In contrast, international studies highlight the value of instruments such as RASS, the Withdrawal Assessment Tool-1 (WAT-1), and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) in improving detection and guiding intervention.^39,40

Dexmedetomidine dosing practices in Palestinian intensive care units were generally consistent with international recommendations, with initial rates between 0.2 and 0.7 mcg/kg/h. Reported maximum doses ranged from 0.7 to 1.2 mcg/kg/h, slightly lower than the upper limits described in global literature, where doses up to 1.5 mcg/kg/h are occasionally used but rarely free of adverse cardiovascular effects.³⁵ This conservative approach suggests a safety-oriented prescribing culture, reflecting clinician familiarity with appropriate initiation and titration strategies while remaining cautious about dose-related risks. Continued education and reinforcement through standardized protocols could help sustain this alignment across sectors.

Perceptions of dexmedetomidine effectiveness were mixed, with respondents reporting it as more effective, less effective, or comparable to other sedatives in roughly equal proportions. These views differ from large randomized trials, which generally show similar efficacy to propofol and midazolam without clear superiority or inferiority.^41,42 Safety perceptions, however, were more favorable, with many respondents considering dexmedetomidine safer than alternatives. This aligns with evidence linking dexmedetomidine to lower delirium rates, shorter ventilation duration, and improved respiratory safety,^13,43 as well as reduced mortality in septic shock compared with benzodiazepines.⁴⁴ Nonetheless, vigilance remains essential given the known risks of bradycardia and hypotension.⁴⁵ Bridging the gap between clinician perceptions and established trial evidence will be critical. Integrating international data into local training and protocols could promote more consistent, evidence-informed sedative selection and strengthen decision-making across Palestinian intensive care units.

Strengths and limitations

This study has several notable strengths that enhance the credibility and relevance of its findings. First, this study represents the first multicenter, cross-sector evaluation of dexmedetomidine use and sedation practices in Palestinian intensive care units. By including governmental, teaching, and private hospitals, it captures a wide range of institutional settings and represents real-world variation in available resources. This variety strengthens the external validity of the findings within the West Bank and provides essential baseline national data that were previously lacking. Second, including multiple professions, such as anesthesiologists, intensivists, and intensive care nurses, enhances the comprehensiveness of the findings. Sedation management in intensive care unit settings is multidisciplinary, and capturing perspectives from frontline clinicians directly involved in decision-making improves construct validity and enables meaningful interprofessional comparisons. Third, the questionnaire was developed through a rigorous process that drew on international surveys and evidence-based literature. It underwent expert review and pilot testing to confirm clarity and contextual relevance. Following STROBE reporting guidelines further supports the study’s transparency and methodological robustness. Fourth, the study did more than report descriptive frequencies. It incorporated comparative statistical analyses across hospital sectors and intensive care unit admission volumes, which helped identify system-level factors-such as protocol availability, sector type, and patient load-that may influence dexmedetomidine use. These comparisons increase the practical and policy relevance of the findings. Finally, in a healthcare system facing resource limitations and political constraints, this study fills an important knowledge gap. It provides an evidence base to support the development of standardized national sedation protocols, structured weaning pathways, and targeted training initiatives designed for Palestinian intensive care units.

Despite these strengths, some limitations should be acknowledged. First, the cross-sectional design limits causal inference. Cross-sectional studies capture exposure and outcome simultaneously and therefore cannot establish temporal relationships or causality. However, this design was intentionally selected because the principal objective of this study was descriptive, to assess current practices, perceptions, and institutional patterns rather than to evaluate the effect of an intervention or determine cause and effect relationships. For mapping opinions, behaviors, and protocol gaps across multiple institutions at a single time point, the cross-sectional approach is methodologically appropriate and efficient. Second, the use of self-reported data may introduce recall or perception bias, as participants might unintentionally overestimate or underestimate practices such as the frequency of withdrawal events, adherence to protocols, or dosing patterns. However, this method aligns with the study’s aim of understanding clinicians’ experiences, perceptions, and perceived barriers. Conducting multicenter research in resource-limited settings poses logistical and ethical challenges, making direct chart audits or patient-level data collection difficult to implement. Moreover, clinicians’ perceptions themselves provide meaningful insight into institutional culture, safety awareness, and areas where implementation may be lacking. This limitation could be mitigated in future studies through methodological triangulation, combining clinician-reported data with structured medical record audits, sedation scale documentation, or pharmacy dispensing records to enhance measurement reliability and internal validity. Third, the study did not include patient-level clinical outcomes. As a result, it cannot assess the impact of dexmedetomidine on mortality, ventilation duration, delirium incidence, or intensive care unit length of stay. Addressing such outcomes would require a different study design, such as a prospective cohort or randomized trial, which was beyond the extent of the present descriptive investigation. This study should therefore be viewed as a basic systems assessment upon which future outcome-focused research can build. Fourth, geographic restriction to the North West Bank may limit broader generalizability. Although major hospitals across governmental, teaching, and private sectors were included, intensive care unit structures and resource restrictions may differ in other Palestinian regions. Nonetheless, the included institutions represent the region’s principal tertiary and secondary centers, providing a reasonably representative overview of current practices in this healthcare context. Finally, although the questionnaire was carefully developed, reviewed by experts, and pilot-tested, it was not a validated scale or scale-like instrument. This limits the ability to directly compare findings with studies that employed standardized psychometric tools, and future research should consider the development and validation of context-specific instruments for sedation practices.

Overall, while these limitations should be considered when interpreting the findings, the study provides a robust multicenter assessment of sedation practices and establishes an essential foundation for future protocol development and outcome-oriented research in Palestinian intensive care settings.

Conclusion

This study provides the first multicenter evidence on dexmedetomidine use in Palestinian intensive care units, showing that its application is moderate, largely adjunctive, and shaped by sectoral disparities, cost barriers, and limited availability. Protocolization and monitoring remain insufficient, with fewer than one-third of units reporting formal protocols and less than half using validated assessment tools, while perceptions of safety and effectiveness varied across professional groups. These findings underscore the urgent need for national sedation guidelines, hospital-level protocol development, and multidisciplinary workforce training, alongside procurement reforms to ensure equitable access. By highlighting practice variation, protocol gaps, and reported withdrawal challenges, this work offers context-specific evidence to guide immediate improvements in sedation governance and lays the groundwork for future prospective research in resource-limited settings.

Supplemental material

Supplemental material - Dexmedetomidine in Palestinian intensive care units: The first multicenter cross-sector survey of sedation practices, protocol gaps, and withdrawal challenges

Supplemental material for Dexmedetomidine in Palestinian intensive care units: The first multicenter cross-sector survey of sedation practices, protocol gaps, and withdrawal challenges by Isra’a Abu Eid, Malak Odeh, Mawada Doaar, Mohammad Jaber, Iyad Maqboul and Ramzi Shawahna in Sage Open Medicine.

Footnotes

Acknowledgments

An-Najah National University (https://www.najah.edu) and An-Najah National University Hospital () are acknowledged for making this study possible. The authors would like to thank the participating hospitals.

ORCID iDs

Isra’a Abu Eid

Ramzi Shawahna

Author contributions

Isra’a Abu Eid: Methodology; Investigation; Data curation; Formal analysis; Writing – original draft; Writing – review & editing. Malak Odeh: Methodology; Investigation; Data curation; Formal analysis; Writing – original draft; Writing – review & editing. Mawada Doaar: Methodology; Investigation; Data curation; Formal analysis; Writing – original draft; Writing – review & editing. Iyad Maqboul: Conceptualization; Methodology; Supervision; Writing – original draft; Writing – review & editing. Mohammad Jaber: Conceptualization; Methodology; Supervision; Writing – original draft; Writing – review & editing. Ramzi Shawahna: Conceptualization; Methodology; Investigation; Data curation; Formal analysis; Supervision; Writing – original draft; Writing – review & editing.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

All relevant data are contained within the paper and its Supplementary materials. The datasets used in the analysis can be obtained from the corresponding author upon making a suitable request.*

Declaration of generative AI and AI-assisted technologies in the writing process

In line with the journal’s policy on transparency, the authors wish to declare that during the preparation of the manuscript, the authors used Grammarly (Superhuman Platform Inc., San Francisco, California), Copilot (Microsoft Inc., Redmond, Washington), and ChatGPT (OpenAI, San Francisco, California) solely to edit the language and improve grammar, spelling, punctuation, readability, and style of the manuscript. After using these tools/services, the authors reviewed and edited the content as needed and take full responsibility for the scientific content, accuracy, and integrity of the manuscript. Artificial intelligence tools/services were not used for generative editorial work, autonomous content creation, data analysis, statistical interpretation, or the generation of scientific content.

Supplemental material

Supplemental material for this article is available online.

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