Effect of dexmedetomidine on patients with invasive mechanical ventilation
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摘要:
目的 比较右美托咪定与咪达唑仑在有创机械通气患者的镇静效果及安全性。 方法 选择我院重症医学科2013年7月~2016年6月收治的124例行有创机械通气治疗≥72 h的危重患者为研究对象，按随机数字表法分为右美托咪定组（63例）和咪达唑仑组（61例）进行镇静治疗。两组均持续静脉泵注芬太尼0.7~1.5 mg·kg–1·h–1镇静治疗，每隔1 h根据白天及夜间RASS评分调整镇静药物剂量，维持恰当的目标镇静深度；按照ICU程序化镇静流程，镇静目标为白天RASS评分0~−1分，夜间RASS评分−1~−3分。右美托咪定组予右美托咪定（4 μg/mL）于初始20 min缓慢静脉泵注0.5~1.0 μg/kg负荷量，继而以0.2~0.7 μg·kg–1·h–1静脉泵注维持，直至获得满意的镇静目标；咪达唑仑组予咪达唑仑（1 mg/mL）2~3 mg负荷量，继而以0.05 mg·kg–1·h–1静脉泵注维持，直至获得满意的镇静目标。记录患者用药前后心率、平均动脉压、谵妄的发生率、机械通气时间及ICU住院时间。 结果 右美托咪定与咪达唑仑均能使有创机械通气患者达到镇静目标，并且镇静效果相似。与咪达唑仑相比，右美托咪定可缩短机械通气时间（119.37±47.76 h vs 142.66±43.77 h，t=−2.829，P=0.005），可缩短ICU住院时间（145.08±57.92 h vs 172.00±53.69 h，t=−2.682，P=0.008），并且降低谵妄发生率（9.52% vs 32.79%，χ2=10.12，P=0.0015），但显著增加心动过缓发生率（22.22% vs 4.92%，χ2=7.844，P=0.0051）和低血压发生率（22.22% vs 8.20%，χ2=4.699，P=0.0302）。 结论 右美托咪定用于有创机械通气患者镇静效果满意，可缩短机械通气时间及ICU住院时间，降低谵妄发生率，同时需密切监测生命体征，防止心动过缓、低血压等不良事件的发生，从而改善危重患者预后。 Abstract:Objective To explore the effect of dexmedetomidine in patients with invasive mechanical ventilation. Methods A total of 124 patients receiving invasive mechanical ventilation more than 72 hours in our hospital from July 2013 to June 2016 were enrolled. The patients were randomly divided into 2 groups for sedative treatment. The patients in both groups received continuous intravenous infusion of fentanyl with 0.7~1.5 mg·kg–1·h–1 for analgesia. Drug dose was adjusted according to RASS every 1 h to maintain the appropriate sedation depth.Satisfactory sedation target was Richmond agitation-sedation scale (RASS) score 0~−1 during the day, and −1~−3 at night.In dexmedetomidine group, the patients received dexmedetomidine(4 μg/mL) whose loading dose was intravenous pump infusion of 0.5~1.0 μg/kg in first 20 min, followed by continuous pump IV infusion of 0.2~0.7 ug·kg–1·h–1 to achieve a goal of satisfactory sedation.In midazolam group, the patients received midazolam (1mg/mL) 2~3 mg intravenously first, then 0.05 mg·kg–1·h–1 for maintenance to achieve a goal of satisfactory sedation.Heart rate before and after treatment, mean arterial pressure, the incidence of delirium, duration of mechanical ventilation and ICU stay were recorded. Results Both dexmedetomidine and midazolam gave rise to sedation with same score of analgesia in similar effect. Compared with midazolam, dexmedetomidine dereased duration of invasive mechanical ventilation (119.37±47.76 h vs 142.66±43.77 h, t=−2.829, P=0.005), ICU stay (145.08±57.92 h vs 172.00±53.69 h, t=−2.682, P=0.008) and incidence of delirium significantly (9.52% vs 32.79%, χ2=10.12, P=0.0015). Dexmedetomidine increased incidence of bradycardia (22.22%1 vs 4.92%, χ2=7.844, P=0.0051) and hypotension (22.22% vs. 8.20%, χ2=4.699, P=0.0302). Conclusion Sedative effects of dexmedetomidine in the ICU patients treated with invasive mechanical ventilation are satisfactory.It can decrease duration of invasive mechanical ventilation, extubation time, ICU stay and incidence of delirium. Vital signs should be monitored to prevent bradycardia, hypotension and other adverse events. It can improve the prognosis of severe patients . -
Key words:
- dexmedetomidine /
- midazolam /
- delirium /
- invasive mechanical ventilation
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表 1 右美托咪定与咪达唑仑两组在有创机械通气患者基线特征资料比较
组别 n 性别（n） 年龄（岁， $\bar x \pm s$ ）体质量（kg， $\bar x \pm s$ ）APACHE II评分（分） 男 女 右美托咪定组 63 32 31 69.08±13.89 62.06±13.05 19.68±4.89 咪达唑仑组 61 36 25 66.93±15.84 65.03±11.38 20.18±5.39 χ2/t 0.8461 0.803 –1.348 –0.539 P 0.3577 0.424 0.180 0.591 
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表 2 ICU医生对两组药物镇静效果满意度的比较（n,%）
组别 n 满意 一般 不满意 右美托咪定组 63 34（53.97） 23（36.51） 6（9.52） 咪达唑仑组 61 35（57.38） 22（36.07） 4（6.56） Z -0.484 P 0.628
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表 3 两组有创机械通气时间、ICU住院时间比较（h，
$\bar x \pm s$ ）组别 n 有创机械通气时间 ICU住院时间 右美托咪定组 63 119.37±47.76 145.08±57.92 咪达唑仑组 61 142.66±43.77 172.00±53.69 χ2/t –2.829 –2.682 P 0.005 0.008
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表 4 两组患者心动过缓发生率、低血压发生率、谵妄发生率的比较（%，例）
组别 n 心动过缓发生率 低血压发生率 谵妄发生率 右美托咪定组 63 22.22（14） 22.22（14） 9.52（6） 咪达唑仑组 61 4.92（3） 8.20（5） 32.79（20） χ2 7.844 4.699 10.12 P 0.0051 0.0302 0.0015
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