纳布啡对心胸外科术后机械通气患者呼吸驱动的影响

Effects of Nalbuphine on respiratory drive in post-cardiothoracic surgery patients received mechanical ventilation

目的探讨纳布啡持续输注对心胸外科术后机械通气患者呼吸中枢驱动的影响。方法纳入2019年3月至12月因心胸外科术后入住东南大学附属中大医院ICU需要镇痛的机械通气患者26例,其中男性17例,年龄59(49,69)岁,急性生理学与慢性健康状况(APACHEⅡ)评分为(9.5±4.5)分,序贯器官衰竭评估(SOFA)评分为(3.1±2.5)分。患者采用压力支持通气(PSV),给予2个剂量的纳布啡持续静脉泵入镇痛,维持重症监护疼痛观察工具(CPOT)评分在0分。在纳布啡镇痛治疗前(T0)、纳布啡镇痛达到CPOT评分0分后1 h(T1)、纳布啡剂量增加50%后1 h(T2)及纳布啡恢复初始剂量后1 h(T3)等时间点,通过膈肌电活动(EAdi)及气道阻断压(P0.1)反映呼吸驱动,记录患者生命体征、血气分析等指标,并通过COPT及Richmond躁动-镇静评分(RASS)评估纳布啡的疗效。结果与T0时比较,纳布啡持续输注剂量为0.10 mg/(kg·h)及0.15 mg/(kg·h)时患者CPOT及RASS评分均明显降低,所有患者均达到临床需求的镇痛/镇静效果。患者T0时的EAdi为6.0(4.5,8.0)μV,镇痛后T1时为6.4(3.6,7.4)μV,T2时为5.3(3.6,6.0)μV,T3时为6.1(4.6,7.2)μV,与T0相比,T1、T2、T3时的EAdi差异均无统计学意义(P>0.05)。患者T0时的P0.1为2.0(1.1,2.9)cmH_(2)O,镇痛后T1时为2.0(0.9,3.2)cmH_(2)O,T2时为2.0(1.1,3.4)cmH2O,T3时为2.2(1.2,3.6)cmH_(2)O,与T0相比,T1、T2、T3时的P0.1差异均无统计学意义(P>0.05)。各时间点之间患者的心率、血压、血气指标及膈肌活动度、膈肌增厚分数、神经通气效能、神经机械效能比较,差异均无统计学意义(P>0.05)。结论对于心胸外科术后需要机械通气的患者,纳布啡持续输注可实现有效镇痛,增加剂量不抑制患者呼吸驱动,且对生命体征及膈肌功能无明显影响。

Objective To evaluate the physiological effects of continuous Nalbuphine infusion on respiratory drive in post-cardiothoracic surgery patients received mechanical ventilation.Methods This was a prospective study which enrolled 26 post-cardiothoracic surgery patients received mechanical ventilation admitted to intensive care unit(ICU),Zhongda Hospital from March to December 2019.There were 17 men,aged 59(49,69),with acute physiology and chronic health(APACHEⅡ)score of(9.5±4.5)and sequential organ failure assessment(SOFA)score of(3.1±2.5).All included patients received mechanical ventilation with PSV mode and continuous Nalbuphine infusion at two dosages.Vital signs and blood gas analysis were recorded before intervention(T0);1 hour after infusion of nalbuphine with CPOT score of zero(T1);1 hour after the dose of Nalbuphine was increased by 50%(T2);and 1 hour after the dose of Nalbuphine was adjusted as at T1(T3).Respiratory drive was evaluated by diaphragm electrical activity(EAdi)and P0.1;the effects of Nalbuphine was evaluated by CPOT and RASS score.Results Compared with T0,the CPOT and RASS scores were significantly decreased at 0.10 mg/(kg·h)and 0.15 mg/(kg·h),and patients all achieved satisfactory analgesia/sedation.EAdi at T0 was 6.0(4.5,8.0)μV,6.4(3.6,7.4)μV at T1,5.3(3.6,6.0)μV at T2,and 6.1(4.6,7.2)μV at T3,showing no significant differences in EAdi at T1,T2 or T3 compared with T0(P>0.05).P0.1 at T0 was 2.0(1.1,2.9)cmH2O,2.0(0.9,3.2)cmH_(2)O at T1,2.0(1.1,3.4)cmH_(2)O at T2,and 2.2(1.2,3.6)cmH_(2)O at T3,showing no significant difference in P0.1 at T1,T2 or T3 compared with T0(P>0.05).Meanwhile,there were no significant differences in HR,blood pressure,blood gas index,diaphragm activity,diaphragm thickening fraction(DTF),neuro-ventilator efficiency(NVE),neuro-muscular efficiency(NME)between groups(P>0.05).Conclusion Nalbuphine has a satisfactory analgesic effect on post-cardiothoracic surgery patients received mechanical ventilation without obvious effects on respiratory drive,vital sign and diaphragmatic function with increasing the dose.