右美托咪定治疗老年急性左心衰竭合并Ⅰ型呼吸衰竭的临床研究

Clinical study of dexmedetomidine in treatment of senile acute left heart failure combined with type Ⅰ respiratory failure

目的观察右美托咪定对老年急性左心衰竭(左心衰)合并Ⅰ型呼吸衰竭(呼衰)患者心功能及呼吸功能的影响.方法选择滨州市中心医院重症医学科2016年1月至2017年12月收治的急性左心衰合并Ⅰ型呼衰患者66例,将患者按治疗方法的不同分为常规治疗组(36例)和右美托咪定组(30例).常规治疗组给予呋塞米、地高辛、西地兰、血管紧张素转换酶/血管紧张素Ⅱ受体拮抗剂(ACEI/ARB)等药物;右美托咪定组在常规治疗组用药的基础上,首剂给予盐酸右美托咪定注射液1μg/kg、于10 min内静脉推注(静推)完毕,之后采用微量泵静推,以0.1~0.6μg·kg^(-1)·h^(-1)的剂量维持,并以Ramsay镇静评分2~3分为目标调整给药剂量.于治疗前和治疗24 h后观察两组患者生命体征(心率、收缩压、呼吸频率);采用心电图和超声心动图测定左室舒张期末容积(LVEDV)、左室收缩期末容积(LVESV)、射血分数(EF)、心排血量(CO)和心排血指数(CI);同时测定血浆N末端脑钠肽前体(NT-proBNP)和超敏C-反应蛋白(hs-CRP)水平以及血气分析指标〔动脉血氧分压(PaO_(2))、动脉血二氧化碳分压(PaCO_(2))、pH值〕,计算急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ).结果两组患者治疗后生命体征、APACHEⅡ评分、心功能指标、血气分析指标及炎症指标水平均较治疗前明显改善,未引起二氧化碳(CO_(2))潴留,其中右美托咪定组治疗后心率(次/min:82.77±10.42比89.47±7.28)、收缩压〔mmHg(1 mmHg≈0.133 kPa):121.70±10.09比135.25±9.82〕、呼吸频率(次/min:19.07±2.08比20.31±2.64)、APACHEⅡ评分(分:10.77±1.99比12.33±2.46)、LVESV(mL:53.50±6.77比57.25±8.17)均明显低于常规治疗组,pH值(7.40±0.04比7.37±0.05)、PaO_(2)(mmHg:73.07±7.12比69.39±5.31)、EF(0.50±0.04比0.48±0.04)、CO(4.59±0.76比4.16±0.59)、CI(mL·s^(-1)·m^(-2):3.37±0.47比3.10±0.34)均明显高于常规治疗组(均P<0.05).治疗24 h后,右美托咪定组机械通气比例明显低于常规治疗组〔13.33%(4/30)比36.11%(13/36),均P<0.05〕.结论右美托咪定用于治疗老年急性左心衰合并Ⅰ型呼衰患者的心血管稳定性较好,可有效改善患者通气、血流动力学及心功能指标,并可减少患者有创机械通气比例.

Objective To observe the therapeutie effect of dexmedetomidine on cardiac and respiratory functions in senile patients with acute left heart failure(LHF)combined with type I respiratory failure(ARF).Methods Sixty-six patients with senile acute left heart failure complicated by type I respiratory failure admitted.in Intensive Care Unit(ICU)of Binzhou Central Hospital from January 2016 to December 2017 were selected,and according to difference in treatment,they were divided into a routine treatment group(36 cases)and a dexmedetomidine group(30 cases).Routine treatment group was routinely given furosemide,digoxin,cedilan,angiotensin-converting enzyme/angiotensin II receptor antagonist(ACEI/ARB),etc.In the dexmedetomidine,on the basis of routine treatment group,dexmedetomidine hydrochloride injection was firstly given lμg/kg intravenous injection(IV)within 10 minutes,followed by miero pump IV,maintained at a dose of 0.1-0.6μg·kg^(-1)·h^(-1),and the dosage was adjusted to the target of Ramsay sedation score of 2-3.In the two groups,before and after treatment for 24 hours,the vital signs(heart rate,systolic blood pressure,frequency of respiration)were observed;the left ventricular end-diastolic volume(LV EDV),left ventricular end-systolic volume(LV ESV),ejection fraction(EF),cardiac output(CO)and cardiac output index(CI)were measured by electrocardiogram and echocardiography;in the mean time,the levels of plasma N terminal brain natriuretic peptide precursor(NT-proBNP)and hypersensitive C-reactive protein(hs-CRP),as well as blood gas analysis indicators[arterial partial pressure of oxygen(PaO_(2)),arterial partial pressure of carbon dioxide(PaCO_(2)),pH values]were also measured,and the acute physiology and chronic health status score II(APACHE II)was caleulated.Results After treatment in the two groups,the levels of vital signs,APACHE II scores,indexes of cardiac function,blood gas analysis and inflammation were significantly improved compared with those before treatment,and no carbon dioxide(CO_(2))retention was induced,and after treatment in dexmedetomidine group,the heart rate(bpm:82.77±10.42 vs.89.47±7.28),systolic blood pressure[mmHg(1 mmHg≈0.133 kPa:121.70±10.09 vs.135.25±9.82],respiratory rate frequency/min:19.07±2.08 vs.20.31±2.64),APACHE II score(score:10.77±1.99 vs.12.33±2.46)and LVESV(mL:53.50±6.77 vs.57.25±8.17)were significantly lower than those in the conventional treatment group,pH values(7.40±0.04 vs.7.37±0.05),PaO_(2)(mmHg:73.07±7.12 vs.69.39±5.31),EF(0.50±0.04 vs.0.48±0.04),CO(4.59±0.76 vs.4.16±0.59),CI(mL·s^(-1)·m^(-2):3.37±0.47 vs.3.10±0.34).all of them were significantly higher than those in I hr conventional treatment group(all P<0.05).After 24 hours of treatment,the ratio of mechanical ventilation in dexmedetomidine group was significantly lower than that in conventional therapy group[13.33%(4/30)vs.36.11%(13/36).P<0.05].Conclusion The treatment of Dexmedetomidine for elderly patients with acute left heart failure combined with type I respiratory failure can maintain their cardiovascular system stability relatively good,and effectively improve their indexe of ventilation,hemodynamics and cardiac function,and obviously reduce the proportion of using invasive mechanical ventilation.