早期无镇静方案在呼吸危重症患者中的应用研究

Clinical application and evaluation of an early non-sedation protocol for critically ill respiratory patients

目的 探讨早期无镇静方案在呼吸重症监护病房（RICU）气管插管机械通气患者中的应用价值.方法 采用前瞻性随机对照研究,将2013年8月至2016年1月入住福州肺科医院RICU的70例机械通气患者按照随机数字表法分为两组：观察组35例,实施早期无镇静方案;对照组35例,实施每日中断镇静方案.比较两组的机械通气时间、住RICU时间和总住院时间、RICU病死率和医院内病死率、镇静剂和镇痛剂用量、医疗费用、各种并发症和不良事件发生率,并对比两组机械通气48 h重要器官损害指标及炎症指标.结果 观察组机械通气时间[（7±5）d]、住RICU时间[（9±7）d]、总住院时间[（17±14）d]、咪达唑仑人均剂量[（99±104）mg]、医疗费用[住RICU费用5.3（8.4）元和总住院费用7.2（19.5）元]、呼吸机相关性肺炎发生率（23%,8/35）、气管切开率（14%,5/35）和消化道不良反应发生率（17%,5/35）均低于对照组[机械通气时间（11±9）d、住RICU时间（18±9）d、总住院时间（29±22）d、咪达唑仑人均剂量（482±337）mg、住RICU费用8.8（17.3）万元、总住院费用15.4（23.4）万元、呼吸机相关性肺炎发生率46%（16/35）、气管切开率37%（13/35）、消化道不良反应发生率40%（14/35）],差异有统计学意义（均P〈0.05）.两组RICU病死率、医院内病死率、非计划拔管等不良事件比较差异均无统计学意义（均P〉0.05）.两组机械通气48 h心、肝、肾功能损害指标及乳酸、CRP水平比较差异均无统计学意义（均P〉0.05）.结论 早期无镇静策略可以缩短RICU患者机械通气时间、RICU停留时间和总住院时间,且未增加各种并发症及不良事件的发生风险.

Objective To study the value of an early （ mechanical ventilation after 24 h ） non-sedation protocol for intubated , mechanically ventilated patients in the respiratory intensive care unit （RICU）.Methods Seventy intubated, mechanically ventilated patients were prospectively enrolled and randomly assigned to management with early non-sedation （ intervention group; n =35 ） or with daily interruption of sedation （DIS） （control group; n=35）.The duration of mechanical ventilation, length of the RICU and hospital stay , RICU and hospital mortality , drug consumption , RICU and hospitalization expenses , incidence of complications and adverse events and serum levels of vital organ damage and inflammatory markers after mechanical ventilation for 48 h were recorded and compared .Results Patients in the intervention group had a shorter duration of mechanical ventilation than those in the control group [（7 ±5） vs （11 ±9） d, P〈0.05] and were discharged from the RICU [（9 ±7） vs （18 ±9） d, P〈0.05] and hospital earlier [（17 ±14） vs （29 ±22） d, P〈0.05] than those in the control group.The doses of midazolam were significantly lower in the intervention group than in the control group [ （ 99 ±104 ） vs （482 ±337） mg, P〈0.05].The RICU and hospitalization expenses were both significantly lower in the intervention group than in the control group [53（84） vs 88（173）, 72（195） vs 154（234） thousand CHY, P〈0.05 ] .In the intervention group , the occurrence rates of ventilator associated pneumonia （ 23% vs 46%） , tracheotomy （ 14% vs 37%） and gastrointestinal adverse reactions （ 17% vs 40%） were significantly lower than those in the control group （ P〈0.05 ） .No differences were recorded in RICU and hospital mortality （P〉0.05）.The occurrence rates of unplanned extubation and reintubation and the need for CT brain scans were similar in the 2 groups （P〉0.05）.The levels of cardiac, liver and renal damage markers, lactic acid and C-reactive protein were the same in both groups （P〉0.05）.Conclusions The early non-sedation protocol decreased the duration of mechanical ventilation and the length of stay in the RICU and hospital , and it did not increase the incidence of complications and adverse events .