CAJ | 학술논문

目的观察模拟昼夜节律的镇静方案在重症监护病房(ICU)机械通气患者撤除镇静后昼夜节律的形成、机械通气时间及ICU停留时间等方面是否具有优势.方法采用前瞻性随机对照方法,将120例收入ICU的机械通气患者用信封法完全随机分为昼夜节律组(CR)、每日中断组(DI)、持续输注组(CS)、按需镇静组(DS)4组,每组30例,因DS组不良反应多,入组10例后去除该组,最终入组患者共90例.记录患者的年龄、性别、体重、急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分、镇静药物剂量、每日清醒时间、机械通气持续时间、ICU停留时间、并发症(呼吸机相关性肺炎、需置入胸引管的气压伤)和不良反应(患者意外拔管、再次插管、气管切开、死亡),并测定生化指标,10:00和22:00各记录1次在岗护士人数.结果 CR、DI、CS3组患者性别比例、年龄、体重、APACHEⅡ评分、ICU停留时间、机械通气时间差异无统计学意义.CS组镇静药物总剂量(mg:5466.7±620.4)、平均镇静药物剂量(mg·h-1·kg-1:2.19±0.61)均明显高于CR组(4344.5±816.0、1.00±0.51 )、DI组(4154.3±649.4、1.23±0.62),差异均有统计学意义(均P＜0.01);CR组与DI组无差异.CR组每日清醒时间(h:4.40±1.30)较DI组(0.59±0.26)、CS组(0.15±0.02)均明显延长(均P＜0.05).各组并发症的发生未见统计学差异;DI组不良反应的发生(2例次)较CR组(1例)、CS组(0例)明显增加(P=0.0477).撤除镇静后,CR组昼夜节律正常者较CS组明显增加(19比9,P=0.0339).CR、DI、CS 3组间白天在岗护士人数两两比较差异均有统计学意义(1.65、1.41、1.14,均P＜0.01),夜间则无差异.各组生化指标未见差异.结论模拟昼夜节律的镇静方案有助于ICU机械通气患者脱离镇静后昼夜节律的形成,且不增加不良反应及并发症发生率,不延长机械通气时间及ICU停留时间,具有一定临床适用性.
목적 관찰모의주야절률적진정방안재중증감호병방(ICU)궤계통기환자철제진정후주야절률적형성、궤계통기시간급ICU정류시간등방면시부구유우세.방법 채용전첨성수궤대조방법,장120례수입ICU적궤계통기환자용신봉법완전수궤분위주야절률조(CR)、매일중단조(DI)、지속수주조(CS)、안수진정조(DS)4조,매조30례,인DS조불량반응다,입조10례후거제해조,최종입조환자공90례.기록환자적년령、성별、체중、급성생이학여만성건강상황평분계통Ⅱ(APACHEⅡ)평분、진정약물제량、매일청성시간、궤계통기지속시간、ICU정류시간、병발증(호흡궤상관성폐염、수치입흉인관적기압상)화불량반응(환자의외발관、재차삽관、기관절개、사망),병측정생화지표,10:00화22:00각기록1차재강호사인수.결과 CR、DI、CS3조환자성별비례、년령、체중、APACHEⅡ평분、ICU정류시간、궤계통기시간차이무통계학의의.CS조진정약물총제량(mg:5466.7±620.4)、평균진정약물제량(mg·h-1·kg-1:2.19±0.61)균명현고우CR조(4344.5±816.0、1.00±0.51 )、DI조(4154.3±649.4、1.23±0.62),차이균유통계학의의(균P＜0.01);CR조여DI조무차이.CR조매일청성시간(h:4.40±1.30)교DI조(0.59±0.26)、CS조(0.15±0.02)균명현연장(균P＜0.05).각조병발증적발생미견통계학차이;DI조불량반응적발생(2례차)교CR조(1례)、CS조(0례)명현증가(P=0.0477).철제진정후,CR조주야절률정상자교CS조명현증가(19비9,P=0.0339).CR、DI、CS 3조간백천재강호사인수량량비교차이균유통계학의의(1.65、1.41、1.14,균P＜0.01),야간칙무차이.각조생화지표미견차이.결론 모의주야절률적진정방안유조우ICU궤계통기환자탈리진정후주야절률적형성,차불증가불량반응급병발증발생솔,불연장궤계통기시간급ICU정류시간,구유일정림상괄용성.
Objective To sedate the mechanically ventilation patients in intensive care unit (ICU) with simulative circadian rhythm,and evaluate whether the protocol has advantages in recovering natural circadian rhythm,duration of mechanical ventilation,and length of ICU stay after weaning of sedation.Methods A prospective random control trial was conducted.One hundred and twenty ventilated patients in ICU were randomly assigned to four groups:circadian rhythm ( CR ),daily interruption ( DI ),continuous sedation (CS) or demand sedation ( DS ) group,each n =30.Given more complications,DS group was deleted after recruiting 10 eases and 90 patients were admitted ultimately.Patients' age,gender,body weight,acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ ) scores,sedatives dosages,daily arousal time,duration of mechanical ventilation,length of ICU stay,complications (ventilator-associated pneumonia,barotrauma with intrathoracic drain tube) and untoward reations (accidental extubation,reintubation,tracheotomy,death) were recorded,the biochemical indicators were determined,as well as number of nurses on duty at 10:00 and 22:00.Results The patients' sex ratio,age,body weight,APACHE Ⅱ scores,duration of mechanical ventilation,length of ICU stay showed no difference among CR,DI and CS groups.The total sedatives dosages (mg:5466.7 ± 620.4) and average sedatives dosages (mg·h 1·kg-1:2.19 ± 0.61 ) in CS group were significantly higher than those in CR group (4344.5 ± 816.0,1.00 ± 0.51 ) and DI group (4154.3 ± 649.4,1.23 ±0.62,all P＜0.01 ),and there was no difference between CR group and DI group.Daily arousal time in the CR group ( hours:4.40 ± 1.30) was significantly lengthened compared with that in DI group (0.59 ± 0.26 ) and CS group (0.15 ±0.02,both P＜0.05 ).The complications showed no differences in each group,but incidences of the untoward reactions in DI group ( 2 cases ) were significantly increased compared with that in CR group ( 1 case ) and CS group (0 case,P=0.0477 ).After weaning of sedation,patients with normal circadian rhythm were significantly more in CR group than that in CS group ( 19 vs.9,P=0.0339).Among CR group,DI group and CS group,there were significant differences in the numbers of nurses on duty in the daytime ( 1.65,1.41,1.14,all P＜0.01 ),but there was no difference in the night.The biochemistry index showed no difference in each group.Conclusions It demonstrated that sedation with simulative circadian rhythm be helpful to create circadian rhythm after weaning of sedation.While complications and untoward reactions did not increase,as well as duration of mechanical ventilation and length of ICU stay.Therefore,the clinical applicability of this sedative strategy was highlighted.