机械通气患者镇痛/镇静策略优化的研究进展

Updates in optimizing analgesia/sedation strategy for mechanically ventilated patients

镇静深度的优化已成为当前重症医学研究的热点之一。大量研究证实深镇静不利于机械通气患者的预后,但受多种因素(部分未知)的影响,临床上不必要的深镇静仍频繁发生。因此,尽可能保持机械通气患者处于浅镇静目标/避免深镇静被强烈推荐。但由于当前缺乏对于浅镇静禁忌证的准确界定,部分接受浅镇静方案的机械通气患者可能被错误设定镇静目标,并因此增加了不良事件发生的风险。此外,慢性重症患者群体受到越来越密切的关注,镇痛/镇静与机体免疫、胃肠以及周围神经-肌肉等器官功能的关系等得到了广泛探讨,现有资料表明对该类患者应尽量少给予镇痛和镇静药物。更加重要的是,一项强调以患者为中心、以充分镇痛和浅镇静为基础、以全面人文关怀为核心的针对机械通气患者远期预后改善的综合性管理策略——"e CASH"被提出,为改变当前尚不完美的医疗、护理行为和认知,改善患者的舒适性、安全性与临床预后提出了临床研究的方向和工作目标,但其可行性与有效性尚待高质量的临床研究验证。

Optimization of sedation depth has become one of hot spots for critical care medicine research. Previous multiple studies have demonstrated that deep sedation is associated with poor outcomes in patients with mechanical ventilation. But unnecessary deep sedation remained not rare in our clinical practices owing to complex reasons（partially unknown）. Maintaining light rather than deep sedation stragey for patients with mechanical ventilation, therefore, was highly recommended. Meanwhile, it was concerned that the depth of sedation was probably proscribed inappropriately in some of lightly sedated patients largely due to lack of well-predefined contraindications, which even likely increased risk of adverse events in our clinical practices. In addition, increasing publications updated the impacts of analgesia/sedation on immune, gastrointestinal and neural-muscular function in the patients with chronic critical illness, a highly concerned critically ill population. Based on available data, less sedatives and opioids were suggested for these patients. Moreover, ＂e CASH＂ concept, a patient-centered, adequate analgesia and light sedation based and humanistic care strengthened comprehensive management strategy was currently proposed to improve the long-term outcomes for patients with mechanical ventilation. It provided us valuable information, in either optimization of clinical practices or research interests, on promoting our medical behaviors and cognition in order to improve patient comfort, safety and clinical outcomes. However, future high-quality clinical researches are needed to verify its feasibility and validity.