The role of dexmedetomidine in patients admitted to the intensive care unit (ICU) following non-cardiac surgery remains unclear. While dexmedetomidine is widely used for its sedative and potential delirium-sparing properties, its pooled effects on clinically relevant postoperative outcomes in this population are not well established. This systematic review and network meta-analysis evaluated the comparative effectiveness and safety of dexmedetomidine compared with other sedative strategies in postoperative non-cardiac surgical ICU patients.

We systematically searched PubMed, Cochrane CENTRAL, and Embase from inception to 26 May 2026 for randomised controlled trials (RCTs) comparing postoperative dexmedetomidine with normal saline or other sedatives in adults (≥18 years) admitted to the ICU after non-cardiac surgery. The primary outcome was incidence of delirium during the ICU stay. Secondary outcomes were time to extubation, ICU length of stay, duration of mechanical ventilation, and haemodynamic adverse events. Effect estimates were expressed as relative risks (RRs) or mean differences (MDs) using random-effects models. Risk of bias was assessed using the Cochrane RoB 2 tool, and certainty of evidence was evaluated using the GRADE framework. Interventions were ranked using the surface under the cumulative ranking curve (SUCRA) for each outcome.

Twenty-four RCTs involving 2,777 patients were included in the systematic review, of which 22 RCTs involving 2,544 patients contributed to the network meta-analysis. Compared with midazolam (RR 0.11, 95% CI 0.02 to 0.80; very low certainty) and normal saline (RR 0.46, 95% CI 0.36 to 0.59; low certainty), dexmedetomidine may reduce the risk of delirium. Evidence is insufficient to determine whether propofol differs from dexmedetomidine in its effect on delirium. There were no differences in time to extubation, duration of mechanical ventilation, or ICU length of stay across sedative strategies. Dexmedetomidine probably increases the risk of bradycardia compared with propofol (RR 3.03, 95% CI 1.39–6.25; low certainty), but the evidence is insufficient to determine whether the two agents differ in their effects on hypotension. In safety rankings, dexmedetomidine performed least favourably for bradycardia (SUCRA 0.03) and hypotension (SUCRA 0.13).

Dexmedetomidine may reduce postoperative delirium in non-cardiac surgical ICU patients but does not appear to improve ventilatory recovery or ICU length of stay and is associated with higher bradycardia risk. Its principal benefit lies in delirium prevention, supporting an individualised approach to sedative selection.