应用右美托咪定及丙泊酚在重症肺炎使用有创机械通气患者中的镇静疗效研究

A controlled study of sedation effect of dexmedetomidine and propofol in patients with severe pneumonia undergoing invasive mechanical ventilation

目的比较右美托咪定及丙泊酚应用于重症肺炎有创机械通气患者的镇静效果及安全性。方法前瞻性分析2015年1月至2017年12月江苏大学附属人民医院重症监护治疗病房(ICU)收治的重症肺炎有创机械通气患者100例,将患者随机分为右美托咪定镇静组(50例)及丙泊酚镇静组(50例)。对两组患者均给予抗感染、有创机械通气、集束化治疗,并予瑞芬太尼镇痛。在镇痛基础上,对两组患者分别给予右美托咪定和丙泊酚镇静治疗。维持患者Richmond躁动-镇静量表评分在-2～0分之间。对于右美托咪定组和丙泊酚组两组患者年龄、APACHEⅡ评分、临床肺部感染评分(CPIS)、机械通气时间、拔管时间、住ICU时间,以及应用镇静药物前和应用镇静药物15 min后平均动脉压(MAP)、心率(HR)、呼吸频率(RR)等资料,其中应用镇静药物前后资料的比较采用配对样本t检验,组间资料的比较采用两组独立样本t检验。对于两组患者的性别分布,谵妄、VAP发生情况以及30 d内死亡情况的比较采用χ~2检验。结果右美托咪定组和丙泊酚组两组患者在性别、年龄、APACHEⅡ评分、CPIS方面相比较,差异无统计学意义(P均> 0.05)。两组患者应用镇静药物前的MAP、HR、RR差异无统计学意义(P均> 0.05)。与用药前比较,应用镇静药物15 min后两组患者的MAP、HR、RR均下降,差异具有统计学意义(P均<0.01)。与右美托咪定组比较,应用镇静药物15 min后丙泊酚组患者MAP、RR下降更为显著,差异具有统计学意义(P均<0.05)。右美托咪定组患者与丙泊酚组比较,应用镇静药物15 min后HR下降更为显著,差异具有统计学意义(P <0.05)。与丙泊酚组比较,右美托咪定组的机械通气时间、拔管时间及住ICU时间均减少,差异具有统计学意义(P均<0.05)。与丙泊酚组比较,右美托咪定组患者谵妄发生率较低,差异具有统计学意义(P <0.05)。两组患者VAP发生率及30 d病死率差异无统计学意义(P均> 0.05)。结论将右美托咪定应用于重症肺炎有创机械通气患者,可减少机械通气时间及住ICU时间,谵妄的发生率低于丙泊酚治疗组。

Objective To compare the sedative effect and safety of dexmedetomidine and propofol in patients with severe pneumonia undergoing mechanical ventilation.Methods A total of 100 patients with severe pneumonia and invasive mechanical ventilation admitted to the Intensive Care Unit(ICU)of the Affiliated People's Hospital of Jiangsu University from January 2015 to December 2017 were prospectively analyzed.The patients were randomly divided into either a dexmedetomidine group(50 cases)or a propofol group(50 cases).RASS score was maintained at-2 to 0 points.Both groups of patients were given mechanical ventilation bundle therapy and remifentanil analgesia.General clinical data of patients,including gender,age,APACHEⅡscore,and clinical pulmonary infection score(CPIS)were collected.Mean arterial pressure(MAP),heart rate(HR),and spontaneous respiratory rate(RR)before treatment and 15 minutes after the sedation was applied were recorded.The patients'mechanical ventilation time,extubation time,and ICU stay time were also recorded.The incidence of delirium,ventilator-associated pneumonia(VAP),and 30-day mortality were also collected.Results There was no significant difference in gender,age,APACHEⅡscore,or CPIS between the two groups(P>0.05).Before sedative administration,there were no significant differences in MAP,HR,or RR(P>0.05).After 15 minutes of treatment,MAP,HR,and RR were all decreased;MAP and RR decreased more significantly in the propofol group,while HR decreased more significantly in the dexmedetomidine group(P<0.01).The mechanical ventilation time,extubation time,and ICU stay were significantly lower in the dexmedetomidine group than in the propofol group(P<0.05).The incidence of delirium was significantly lower in the dexmedetomidine group than in the propofol group(P<0.05),although there were no significant differences in the incidence of VAP or the rate of 30-day mortality between the two groups(P>0.05).Conclusion The application of dexmedetomidine in patients with severe pneumonia and mechanical ventilation can reduce the time of mechanical ventilation and ICU stay.Dexmedetomidine is associated with a lower rate of delirium than propofol.