右美托咪定在中型颅脑损伤患者镇静治疗中的应用

Application of dexmedetomidine on sedation in patients with moderate brain injury

目的探讨右美托咪定在中型颅脑损伤患者镇痛镇静中的疗效。方法选取2014年1月～2015年12月笔者医院收治的120例颅脑损伤患者为研究对象,其中男性81例,女性39例;平均35.1岁。按照随机数字表法随机分为右美组(n=60例)和冬眠组(n=60例),右美组给予右美托咪定(2m L:200μg,江苏恒瑞医药股份有限公司)负荷剂量为0.5～1.0μg/kg,持续泵注10min,后以0.2～0.7μg/(kg·h)速度维持3d;冬眠组肌注冬眠合剂(盐酸氯丙嗪注射液,2m L:50mg,上海禾丰制药有限公司;盐酸异丙嗪注射液,2m L:50mg,天津金耀药业有限公司;盐酸哌替啶注射液,2m L:100mg,宜昌人福药业有限责任公司),间隔8h给药1次,维持3d。对两组患者年龄、性别、体重、GCS评分、生命体征(心率、平均动脉压、血氧饱和度)、C-反应蛋白、不良反应及并发症、住院天数、预后情况等因素进行统计学分析。结果 (1)右美组患者年龄(36.2±10.8)岁、性别(男女比例38/22)、体重(68.3±13.2)kg、GCS评分(10.8±3.2)分,与冬眠组年龄(34.6±11.2)岁、性别(男女比例43/17)、体重(65.5±11.5)kg、GCS评分(10.2±2.6)分等比较差异无统计学意义(P>0.05)。(2)用药后心率及血压比较,用药后1h右美组,心率(72.4±7.8)次/min,血压(87.8±8.1)mm Hg,相较于用药前无较大变化,但冬眠组心率(66.2±7.6)次/min,血压(87.8±8.1)mm Hg明显降低。而用药后两组患者血氧饱和度(右美组96.4±2.9,冬眠组96.2±2.1)均无明显变化。(3)两组患者C-反应蛋白入院后均持续升高,第3天达峰值,右美组为(32.8±7.1)mg/L,冬眠组为(41.2±7.9)mg/L,但右美组用药1d后C-反应蛋白增幅较冬眠组明显降低,用药后右美组和冬眠组的C-反应蛋白含量分别为(28.5±6.2)mg/L、(34.8±7.2)mg/L。(4)心动过缓、低血压、应激性溃疡、肺部感染发生率比较,右美组发生人次分别为13、10、7、8,冬眠组则为23、20、16、17,右美组显著低于冬眠组,而在右美组组内比较时,浅镇静组(心动过缓3人次、低血压2人次、应激性溃疡1人、肺部感染1人)明显低于深镇静组(心动过缓10人次、低血压8人次、应激性溃疡6人、肺部感染7人)。(5)右美组患者的ICU住院时间(12.8±5.5)d及总住院时间(21.2±6.5)d相较于冬眠组的ICU住院时间(15.3±6.1)d及总住院时间(28.5±7.4)d均显著缩短。(6)伤后6个月随访,两组预后,GOS评分1～5分的人数比较,右美组分别为3、5、10、15、27人,而冬眠组则分别为5、9、13、16、17人,组间比较采用Ridit分析(R值右美=0.552,R值冬眠=0.448,P=0.048),右美组好于冬眠组,但右美组与冬眠组的病死率无显著差别(5%vs.8.3%)。结论右美托咪定镇静效果满意,且对呼吸及循环系统无明显影响,还可降低C-反应蛋白水平,抑制炎性反应,改善患者预后,适用于中型颅脑损伤患者的镇静治疗。

Objective To study the efficacy of dexmedetomidine on sedation in patients with moderate brain injury. Methods Totally 120 cranioeerebral trauma patients who were admitted from Jan. 2014 to Dec. 2015 were selected as research subjects. In accordance with the random number table, the patients were randomly divided into dexmedetomidine group （n = 60 ） and lytic cocktail group （n = 60）. In dexmedetomidine group, dexme- detomidine load 0. 5-1.0 μg/kg was injected within 10 minutes, and maintaining at 0. 2-0. 7μg/（ kg·h） for 3 days. In ]ytic cocktail group ,lytic cocktail was injected into muscle every 8 hours for 3 days. The factors of the two groups in- eluding age, gender,weight, GCS, vital signs （ heart rate, mean arterial pressure, blood oxygen saturation）, C-reactive protein,adverse reaction,complication,length of stay,prognosis,were analyzed by statistical analysis. Results （1）In dexmedetomidine group , the data were age （ 36. 2 ± 10. 8 ） years, gender （ male/female 38/22 ） , weight （ 68. 3 ± 13.2） kg,GCS score （ 10. 8 ±3.2）. Compared with the lytic cocktail group （34. 6 ± 11.2）years,male/female 43/17, （ 65.5± 11.5 ） kg , （ 10. 2 ±2. 6 ） , differences were insignificant （ P 〉 0. 05 ）. （ 2 ） Compared with pre-treatment, in dexmedetomidine group the heart rate （ 72. 4± 7. 8 ） and MAP （ 87. 8 ±8. 1 ） mmHghad no difference, but in lytic cocktail group HR （66.2± 7.6）, MAP （ 87.8 ±8. 1 ） mmHg they all declined greatly. No marked changes were de- tected in blood oxygen saturation of the two groups, the data were （96.4 ±2. 9 ） , （ 96.2 ±2. 1 ）. （ 3 ） C-reactive pro- tein of dexmedetomidine group（32. 8 ± 7. 1 ）mg/L and lyric cocktail group（41.2 ± 7. 9）mg/L increased and peaked in the 3rd day,but 1 day after admission the growth in dexmedetomidiue group（28.5±6. 2）mg/L was markedly lower than lytic cocktail group （34. 8 ± 7.2 ）mg/L. （4）The incidence of adverse reaction and complication in dexme- detomidine group were lower than in lyric cocktail group. Tile numbers of bradycardia, hypotension, stress ulcer, pul- monary infection were 13,10,7,8 in dexmedetomidine group, compared with the numbers of 23,20,16,17 in lytic cocktail group. The incidence rate of light sedation group（ 3,2,1,1 ） was significantly lower than that of deep seda- tion group （ 10,8,6,7 ）. （5） Length of ICU stay （ 12.8 ±5.5 ） days and total length of stay （21.2 ±6. 5 ） days of dexmedetomidine group were obviously reduced. The data in lytic cocktail group were （ 15.3±6. 1 ） days, （28. 5 ±7.4） days. （6）At 6-month follow-up,the numbers of the patients scoring 1 to 5 according to Glasgow Outcome Scale were respectively 3,5,10,15,27 in dexmedetomidine group, while in lytic cocktail group were respectively 5,9,13,16, 17. The result of the dexmedetomidine group was better than that of the lytic cocktail group for GOS by Ridit analysis [ Ridit （dexmedetomidine） = 0. 552, Ridit （ lytic cocktail） -- 0. 448,P = 0. 048 ]. There was no significant difference in mortality between dexmedetomidine group and lyric cocktail group （5% vs. 8. 3% ）. Conclusion Dexmedetomi- dine has satisfactory sedative effect, at the same time, it has no effect on respiratory system and circulatory system. Dexmedetomidine can obviously reduce CRP levels,inhibit inflammation response and improve the prognosis of pa- tients. It is suitable for sedation in patients with moderate brain injury.