中国呼吸与危重监护杂志

中国呼吸与危重监护杂志

早期目标导向镇静策略在 ICU 机械通气患者中的应用

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目的探讨早期目标导向镇静策略(EGDS)在重症加强治疗病房(ICU)机械通气患者中应用的适用性。方法采用前瞻性双盲研究,采取整群抽样法选择 2015 年 9 月至 2017 年 9 月锦州医科大学附属第一医院 ICU 收治的接受机械通气的患者作为研究对象。按分层随机化法将患者分为试验组和对照组。两组患者均在充分镇痛基础上进行镇静,试验组采取 EGDS 策略,首选右美托咪定开始以 1 μg·kg–1·h–1 的速度持续静脉泵入,每 4 h 进行 1 次 Richmond 躁动-镇静评分(RASS),RASS≥2 分则加用丙泊酚和咪达唑仑,RASS≤–3 分则右美托咪定每 30 min 减少 0.2 μg·kg–1·h–1,RASS 评分 –2~0 分停止镇静。对照组采取常规镇静策略,首选丙泊酚,联合右美托咪定和咪达唑仑镇静,维持 RASS 评分在 –2~–3 分。比较两组患者镇静药物使用剂量、机械通气时间、ICU 住院时间、总住院时间以及谵妄、意外拔管、ICU 死亡等不良事件发生情况。结果试验组入选 66 例,对照组入选 71 例,两组患者性别、年龄、急性生理学和慢性健康状况评分系统Ⅱ(APACHEⅡ)评分、基础疾病等基线资料均衡。与对照组比较,试验组右美托咪定、丙泊酚、咪达唑仑的人均使用总剂量明显降低[右美托咪定(μg):154.45±27.86 比 378.85±39.76;丙泊酚(mg):4 490.03±479.88 比 7 349.76±814.31;咪达唑仑(mg):255.38±46.24 比 562.79±97.26;均 P<0.01],机械通气时间、ICU 住院时间、总住院时间明显缩短[机械通气时间(d):7.7±3.3 比 11.7±3.6;ICU 住院时间(d):10.2±3.9 比 19.2±4.1;总住院时间(d):29.9±4.6 比 50.4±9.1;均P<0.01]。Kaplan-Meier 生存分析显示,试验组谵妄发生率明显低于对照组(log-rankχ2=5.481,P<0.05);两组间意外拔管率、ICU 病死率差异无统计学意义(log-rankχ2=0.078、0.999,均 P>0.05)。结论EGDS 策略可减少 ICU 机械通气患者镇静药物的使用剂量,缩短机械通气时间、ICU 住院时间和总住院时间,减少谵妄发生,对 ICU 机械通气患者有积极影响。

ObjectiveTo explore the applicability of early goal-directed sedation (EGDS) in intensive care unit (ICU) patients with mechanical ventilation.MethodsAn prospective double blind study was conducted. ICU patients with mechanical ventilation in the First Affiliated Hospital of Jinzhou Medical University were recruited as research objects by chester sampling from September 2015 to September 2017, and divided into an experimental group and a control group by stratified randomization. Two groups were sedated on the basis of adequate analgesia. The experimental group adopted the EGDS strategy that dexmedetomidin was the first choice to be infused at the rate of 1 μg·kg–1·h–1. And the patients were given Richmond agitation-sedation score (RASS) on the interval of 4 hours: used additionally propofol and midazolam if RASS>2, or reduced right metomomidin at the speed of 0.2 μg·kg–1·h–1 per 30 min if RASS<–3, and stopped sedation until RASS of –2 to 0. The control group adopted routine sedation strategy that propofol was the first choice to be infused and combined with dexmedetomidine and midazolam until RASS score in –2 to –3. The doses of sedative drugs, mechanical ventilation time, ICU-stayed time, total hospitalization time and the incidence of adverse events such as delirium, accidental extubation, and ICU death were compared between two groups.ResultsSixty-sis cases were selected in the experimental group and 71 in the control group. The baseline data such as gender, age, acute physiology chronic health evaluation Ⅱ (APACHEⅡ), or basic diseases in two groups had no significant differences. Compared with the control group, the per capita total doses of dexmedetomidine, propofol and midazolam in the experimental group were significantly less [right metopromicine (μg): 154.45±27.86 vs. 378.85±39.76; propofol (mg): 4 490.03±479.88 vs. 7 349.76±814.31; midazolam (mg): 255.38±46.24 vs. 562.79±97.26; all P<0.01], mechanical ventilation time, ICU-stayed time, total hospitalization time were significantly lower [mechanical ventilation time (d): 7.7±3.3vs. 11.7±3.6; ICU-stayed time (d): 10.2±3.9 vs. 19.2±4.1, total hospitalization time (d): 29.9±4.6 vs. 50.4±9.1; all P<0.01]. The Kaplan-Meier survival curves showed that the incidence of delirium in the experimental group was significantly lower than that in the control group (log-rankχ2=5.481, P<0.05). The accidental extubation rate and accidental fatality rate in two groups had no significant differences (log-rankχ2=0.078, 0.999, P>0.05).ConclusionEGDS can not only reduce the dose of sedative drugs, shorten the mechanical ventilation time, the ICU-stayed time and the total hospitalization time, but also reduce the incidence of delirium, so it has a positive impact in ICU patients with mechanical ventilation.

关键词: 早期目标导向镇静策略; 镇静; 机械通气; 重症加强治疗病房; 谵妄

Key words: Early goal-directed sedation; Sedation; Mechanical ventilation; Intensive care unit; Delirium

引用本文: 孙铭浛, 郝春艳, 邸兴伟. 早期目标导向镇静策略在 ICU 机械通气患者中的应用. 中国呼吸与危重监护杂志, 2018, 17(6): 588-592. doi: 10.7507/1671-6205.201805023 复制

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