镇静镇痛治疗辅助危重症患者无创机械通气的临床应用

Effect of sedation and analgesia for critically ill patients undergoing noninvasive ventilation

目的比较单独应用右美托咪定及咪达唑仑或丙泊酚复合芬太尼用于无创机械通气患者镇静、镇痛的效果和安全性。方法回顾性分析皖南医学院弋矶山医院ICU行无创机械通气患者64例,并根据接受镇静镇痛治疗方案分为右美托咪定组(Dex组,41例)和非右美托咪定组(non-Dex组,23例)。右美托咪定负荷量1μg/kg,续以维持剂量0.2~0.5μg/(kg·h);咪达唑仑负荷量0.05 mg/kg,续以维持剂量0.02~0.10 mg/(kg·h);丙泊酚负荷量3 mg/kg,续以维持剂量0.5~3.0 mg/(kg·h);咪达唑仑和丙泊酚复合应用芬太尼,负荷剂量为1μg/kg,续以维持剂量1~2μg/(kg·h)。监测并记录注射药物前、注射药物后第1、3、6、12、24小时患者的Ramsay评分,记录注射药物前、注射药物后第1、12、24小时患者的心率、血压、呼吸频率及血气分析结果。观察记录谵妄、过度镇静、低血压、高血压、心动过缓等不良事件的发生率。结果 2组药物均能使患者达到镇静目标评分,注射药物1 h Dex组与non-Dex组患者的Ramsay评分分别为(2.3±0.5)、(2.3±0.4)分,差异无统计学意义(t=0.00,P=1.000);12 h分别为(2.3±0.5)、(3.3±0.8)分;24 h分别为(2.4±0.5)、(3.2±0.6)分,差异具有统计学意义(t=6.16、5.71,均P<0.001)。Dex组患者ICU停留时间较non-Dex组短[(4.9±2.0)d vs(6.8±3.2)d,P=0.026]。2组患者在静脉输注药物后各时间点的氧合指数(Pa O2/Fi O2)、呼吸频率、平均动脉压,及气管插管、过度镇静、高血压、低血压、心动过缓等不良事件发生率差异无统计学意义(P>0.05)。输注药物1 h后Dex组与non-Dex患者的心率分别为(78.4±17.6)、(93.3±25.0)次;12 h分别为(77.1±10.7)、(86.5±13.4)次;24 h分别为(71.4±6.9)、(80.9±14.3)次,差异具有统计学意义(t=2.79、3.08、3.59,均P<0.01)。Dex组患者谵妄的发生率明显低于non-Dex组(7.3%vs 39.1%,P=0.023)。疾病亚组分析显示,急性心力衰竭患者应用镇静药物后低血压发生率均显著高于其他非急性心力衰竭疾病类型(Dex组:71.4%vs 8.8%,P=0.001;non-Dex组:66.7%vs 11.8%,P=0.008)。结论单独应用右美托咪定与咪达唑仑或丙泊酚复合芬太尼等镇静方案均能安全应用于辅助无创机械通气,但急性心力衰竭患者应用时需注意低血压。

Objective To evaluate the efficacy of sedation with dexmedetomidine and midazolam or propofol combined with fentanyl for sedation in critically ill patients undergoing non-invasive ventilation. Methods Six-four patients scheduled for non-invasive ventilation in ICU were received sedation, who was divided into two groups： group Dex（n=41, sedated signally by dexmedetomidine） and group non-Dex（n=23, sedated by midazolam or propofol combined with fentanyl）. A loading of dexmedetomidine 1 μg/kg followed by infusion lose at 0.2-0.5 μg/（kg·h）, a loading of midazolam 0.05 mg/kg followed by infusion lose at 0.02-0.10 mg/（kg·h） and a loading of propofol 3 mg/kg followed by infusion lose at 0.5-3.0 mg/（kg·h）. At the same time of administration of the midazolam and propofol, a loading dose of fentanyl 1 μg/kg was given, followed by fentanyl infusion at 1-2 μg/（kg·h）. Ramsay Sedation Score（RSS） was recorded at baseline and 1, 12, and 24 hours after the loading dose was administered. And the following parameters were measured at baseline and 1, 12 and 24 hours： heart rate, blood pressure, respiratory rate and arterial blood gases. During the course, delirium, tracheal intubation, over-sedation, hypotension, hypertension, bradycardia were observed and registered continuously. Results In both of the two groups patients, expected sedative scores were obtained. At 1 hour after the administration of drugs, RSS levels of group Dex and non-Dex were（2.3±0.5） scores vs（2.3±0.4） scores, t=0.00, P=1.000; at 12 hour were（2.3±0.5） scores vs（3.3±0.8） scores, t=6.16, P 〈 0.001; at 24 hour were（2.4±0.5） scores vs（3.2±0.6） scores, t=5.71, P 〈 0.001. Compared with the group non-Dex, the duration of ICU hospitalization in the group Dex were markedly decreased [（4.9±2.0） d vs（6.8±3.2） d, P=0.026]. In both groups, there was no significant difference in Pa O2/Fi O2, respiratory rate and mean blood pressure at different time point. The incidents of tracheal intubation, over-sedation, hypotension, hypertension, and bradycardia were not significantly different between the two groups. At one hour after the administration of drugs, the heart rates of group Dex and non-Dex were（78.4±17.6） times vs（93.3±25.0） times, t=2.79, P=0.007; at 12 hour were（77.1±10.7） times vs（86.5±13.4） times, t=3.08, P=0.003; at 24 hour were（71.4±6.9） times vs（80.9±14.3） times, t=3.59, P=0.001. The rate of delirium was significantly lower in group Dex（7.3% vs 39.1%, P 〈 0.05）. In subgroup analysis, compared to the patients without acute heart failure, the incident rate of hypotension in the patients with acute heart failure was significantly higher（group Dex, 71.4% vs 8.8%, P=0.001, group non-Dex, 66.7% vs 11.8%, P=0.008）. Conclusion Sedative effects of both dexmedetomidine and midazolam or propofol combined with fentanyl are satisfactory for patients undergoing NIV. However, it is necessary to enhance observation to prevent and control hypotension in patients with acute heart failure.