模拟昼夜节律的镇静在重症监护病房机械通气患者中的应用

Sedation with simulative circadian rhythm in mechanically ventilation patients in intensive care unit

目的观察模拟昼夜节律的镇静方案在重症监护病房（ICU）机械通气患者撤除镇静后昼夜节律的形成、机械通气时间及ICU停留时间等方面是否具有优势。方法采用前瞻性随机对照方法，将120例收入ICU的机械通气患者用信封法完全随机分为昼夜节律组（CR）、每日中断组（DI）、持续输注组（CS）、按需镇静组（DS）4组，每组30例，因DS组不良反应多，入组10例后去除该组，最终入组患者共90例。记录患者的年龄、性别、体重、急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分、镇静药物剂量、每日清醒时间、机械通气持续时间、ICU停留时间、并发症（呼吸机相关性肺炎、需置入胸引管的气压伤）和不良反应（患者意外拔管、再次插管、气管切开、死亡），并测定生化指标，10：00和22：00各记录1次在岗护士人数。结果CR、DI、CS3组患者性别比例、年龄、体重、APACHEⅡ评分、ICU停留时间、机械通气时间差异无统计学意义。CS组镇静药物总剂量（mg：5466．7±620．4）、平均镇静药物剂量（mg·h^-1·kg^-1：2．19±0．61）均明显高于CR组（4344．5±816．0、1．00±0．51）、DI组（4154．3±649．4、1．23±0．62），差异均有统计学意义（均P〈0．01）；CR组与DI组无差异。CR组每日清醒时间（h：4．40±1．30）较DI组（0．59±0．26）、CS组（0．15±0．02）均明显延长（均P〈0．05）。各组并发症的发生未见统计学差异；DI组不良反应的发生（2例次）较CR组（1例）、CS组（0例）明显增加（P=0．0477）。撤除镇静后，CR组昼夜节律正常者较CS组明显增加（19比9，P=0．0339）。CR、DI、CS3组间白天在岗护士人数两两比较差异均有统计学意义（1．65、1．41、1．14，均P〈0．01），夜间则无差异。各组生化指标未见差异。结论模拟昼夜节律的镇静方案有助于ICU机械通气患者脱离镇静后昼夜节律的形成，且不增加不良反应及并发症发生率，不延长机械通气时间及ICU停留时间，具有一定临床适用性。

Objective To sedate the mechanically ventilation patients in intensive care unit （ICU） with simulative circadian rhythm, and evaluate whether the protocol has advantages in recovering natural circadian rhythm, duration of mechanical ventilation, and length of ICU stay after weaning of sedation. Methods A prospective random c, ontrol trial was conducted. One hundred and twenty ventilated patients in ICU were randomly assigned to four groups ： circadian rhythm （ CR ）, daily interruption （ DI ）, continuous sedation （CS） or demand sedation （DS） group, each n = 30. Given more complications, DS group was deleted after recruiting 10 cases and 90 patients were admitted uhimately. Patients＇ age, gender, body weight, acute physiology and chronic health evaluation Ⅱ（APACHE Ⅱ ） scores, sedatives dosages, daily arousal time, duration of mechanical ventilation, length of ICU stay, complications （ventilator-associated pneumonia, harotrauma with intrathoracie drain tube） and untoward reactions （accidental extuhation, reintubation, tracheotomy, death） were recorded, the biochemical indicators were determined, as well as number of nurses on duty at 10：00 and 22：00. Results The patients＇ sex ratio, age, body weight, APACHE Ⅱ scores, duration of mechanical ventilation, length of ICU stay showed no difference among CR, DI and CS groups. The total sedatives dosages （rag： 5466.7±620.4） and average sedatives dosages （mg·h^-1·kg^-1： 2.19 ± 0.61 ） in CS group were significantly higher than those in CR group （4344.5 ± 816.0, 1.00 ± 0.51 ） and DI group （4154.3 ± 649.4, 1.23 ± 0.62, all P〈0.01 ）, and there was no difference between CR group and DI group. Daily arousal time in the CR group （hours： 4.40 ± 1.30 ） was significantly lengthened compared with that in DI group （0.59 ± 0.26 ） and CS group （0.15 ± 0.02, both P〈0.05 ）. The complications showed no differences in each group, but incidences of the untoward reactions in DI group （2 cases ） were significantly increased compared with that in CR group （ 1 case＇） and CS group （0 case, P= 0.0477 ）. After weaning of sedation, patients with normal circadian rhythm were significantly more in CR group than that in CS group （ 19 vs. 9, P=0.0339）. Among CR group, DI group and CS group, there were significant differences in the numbers of nurses on duty in the daytime （1.65, 1.41, 1.14, all P〈0.01 ）, but there was no difference in the night. The biochemistry index showed no difference in each group. Conclusions It demonstrated that sedation with simulative circadian rhythm be helpful to create circadian rhythm after weaning of sedation. While complications and untoward reactions did not increase, as well as duration of mechanical ventilation and length of ICU stay. Therefore, the clinical applicability of this sedative strategy was highlighted.