中华危重病急救医学
中華危重病急救醫學
중화위중병급구의학
Chinese Critical Care Medicine
2015年
10期
845-849
,共5页
吕杰%刘丹%安友仲%冯艺
呂傑%劉丹%安友仲%馮藝
려걸%류단%안우중%풍예
瑞芬太尼%咪唑安定%镇静%镇痛%谵妄%危重症
瑞芬太尼%咪唑安定%鎮靜%鎮痛%譫妄%危重癥
서분태니%미서안정%진정%진통%섬망%위중증
Remifentanil%Midazolam%Sedation%Analgesia%Delirium%Critical care medicine
目的：观察在瑞芬太尼镇痛基础上给予咪唑安定镇静治疗方案对重症加强治疗病房（ICU）危重患者谵妄发生的影响。方法采用单中心前瞻性随机对照研究方法。选择2014年2月至2015年1月北京大学人民医院ICU连续收治的机械通气时间≥24 h、需要镇静治疗的危重症患者140例，按计算机生成的随机数字表法将患者分为两组，每组70例。观察组给予瑞芬太尼1μg·kg-1·min-1镇痛，同时静脉推注1 mg/mL咪唑安定0.05 mg/kg，继而0.02～0.10 mg·kg-1·h-1持续泵入镇静；对照组则单纯应用咪唑安定镇静治疗。主要观察指标：谵妄发生率和谵妄持续时间；次要观察指标：镇静、镇痛药物用量，镇静前后平均动脉压（MAP），唤醒时间，机械通气时间，ICU住院时间，28 d全因病死率。采用Kaplan-Meier生存曲线分析患者28 d生存情况。结果观察组瑞芬太尼用量为（98.6±24.9）mg/d，且咪唑安定用量明显少于对照组（mg/d：160.6±33.3比178.9±43.4，t＝2.829，P＝0.005），谵妄发生率则明显低于对照组〔22.9%（16/70）比57.1%（40/70），χ2＝15.700， P＜0.001〕，谵妄持续时间略短于对照组（h：162.9±78.0比194.8±117.3，t＝0.947，P＝0.348）。发生谵妄的患者中，观察组右美托咪定用量明显少于对照组（mg/d：0.54±0.11比0.64±0.14，t＝2.112，P＝0.041）。观察组与对照组镇静前后MAP〔mmHg（1 mmHg＝0.133 kPa）〕均无明显改变，且两组间差异也无统计学意义（治疗前：84.7±16.2比89.5±37.7，治疗后：82.3±10.7比80.8±13.9，均P＞0.05）。观察组患者唤醒时间与对照组无明显差异（h：2.3±0.9比2.4±0.8，t＝0.487，P＝0.627）；机械通气时间（h：143.4±138.3比163.9±158.9， t＝0.812，P＝0.418）、ICU住院时间（d：8.8±7.7比10.0±7.8，t＝0.917，P＝0.361）和28 d病死率〔11.4%（8/70）比20.0%（14/70），χ2＝1.941，P＝0.245〕略低于对照组，但差异均无统计学意义。Kaplan-Meier生存曲线分析显示，观察组患者28 d累积存活率略高于对照组（χ2＝1.647，P＝0.199）。结论在瑞芬太尼镇痛基础上应用咪唑安定镇静较单纯咪唑安定镇静可以降低危重患者谵妄发生率，即使发生谵妄，其谵妄程度也可能较轻。
目的：觀察在瑞芬太尼鎮痛基礎上給予咪唑安定鎮靜治療方案對重癥加彊治療病房（ICU）危重患者譫妄髮生的影響。方法採用單中心前瞻性隨機對照研究方法。選擇2014年2月至2015年1月北京大學人民醫院ICU連續收治的機械通氣時間≥24 h、需要鎮靜治療的危重癥患者140例，按計算機生成的隨機數字錶法將患者分為兩組，每組70例。觀察組給予瑞芬太尼1μg·kg-1·min-1鎮痛，同時靜脈推註1 mg/mL咪唑安定0.05 mg/kg，繼而0.02～0.10 mg·kg-1·h-1持續泵入鎮靜；對照組則單純應用咪唑安定鎮靜治療。主要觀察指標：譫妄髮生率和譫妄持續時間；次要觀察指標：鎮靜、鎮痛藥物用量，鎮靜前後平均動脈壓（MAP），喚醒時間，機械通氣時間，ICU住院時間，28 d全因病死率。採用Kaplan-Meier生存麯線分析患者28 d生存情況。結果觀察組瑞芬太尼用量為（98.6±24.9）mg/d，且咪唑安定用量明顯少于對照組（mg/d：160.6±33.3比178.9±43.4，t＝2.829，P＝0.005），譫妄髮生率則明顯低于對照組〔22.9%（16/70）比57.1%（40/70），χ2＝15.700， P＜0.001〕，譫妄持續時間略短于對照組（h：162.9±78.0比194.8±117.3，t＝0.947，P＝0.348）。髮生譫妄的患者中，觀察組右美託咪定用量明顯少于對照組（mg/d：0.54±0.11比0.64±0.14，t＝2.112，P＝0.041）。觀察組與對照組鎮靜前後MAP〔mmHg（1 mmHg＝0.133 kPa）〕均無明顯改變，且兩組間差異也無統計學意義（治療前：84.7±16.2比89.5±37.7，治療後：82.3±10.7比80.8±13.9，均P＞0.05）。觀察組患者喚醒時間與對照組無明顯差異（h：2.3±0.9比2.4±0.8，t＝0.487，P＝0.627）；機械通氣時間（h：143.4±138.3比163.9±158.9， t＝0.812，P＝0.418）、ICU住院時間（d：8.8±7.7比10.0±7.8，t＝0.917，P＝0.361）和28 d病死率〔11.4%（8/70）比20.0%（14/70），χ2＝1.941，P＝0.245〕略低于對照組，但差異均無統計學意義。Kaplan-Meier生存麯線分析顯示，觀察組患者28 d纍積存活率略高于對照組（χ2＝1.647，P＝0.199）。結論在瑞芬太尼鎮痛基礎上應用咪唑安定鎮靜較單純咪唑安定鎮靜可以降低危重患者譫妄髮生率，即使髮生譫妄，其譫妄程度也可能較輕。
목적：관찰재서분태니진통기출상급여미서안정진정치료방안대중증가강치료병방（ICU）위중환자섬망발생적영향。방법채용단중심전첨성수궤대조연구방법。선택2014년2월지2015년1월북경대학인민의원ICU련속수치적궤계통기시간≥24 h、수요진정치료적위중증환자140례，안계산궤생성적수궤수자표법장환자분위량조，매조70례。관찰조급여서분태니1μg·kg-1·min-1진통，동시정맥추주1 mg/mL미서안정0.05 mg/kg，계이0.02～0.10 mg·kg-1·h-1지속빙입진정；대조조칙단순응용미서안정진정치료。주요관찰지표：섬망발생솔화섬망지속시간；차요관찰지표：진정、진통약물용량，진정전후평균동맥압（MAP），환성시간，궤계통기시간，ICU주원시간，28 d전인병사솔。채용Kaplan-Meier생존곡선분석환자28 d생존정황。결과관찰조서분태니용량위（98.6±24.9）mg/d，차미서안정용량명현소우대조조（mg/d：160.6±33.3비178.9±43.4，t＝2.829，P＝0.005），섬망발생솔칙명현저우대조조〔22.9%（16/70）비57.1%（40/70），χ2＝15.700， P＜0.001〕，섬망지속시간략단우대조조（h：162.9±78.0비194.8±117.3，t＝0.947，P＝0.348）。발생섬망적환자중，관찰조우미탁미정용량명현소우대조조（mg/d：0.54±0.11비0.64±0.14，t＝2.112，P＝0.041）。관찰조여대조조진정전후MAP〔mmHg（1 mmHg＝0.133 kPa）〕균무명현개변，차량조간차이야무통계학의의（치료전：84.7±16.2비89.5±37.7，치료후：82.3±10.7비80.8±13.9，균P＞0.05）。관찰조환자환성시간여대조조무명현차이（h：2.3±0.9비2.4±0.8，t＝0.487，P＝0.627）；궤계통기시간（h：143.4±138.3비163.9±158.9， t＝0.812，P＝0.418）、ICU주원시간（d：8.8±7.7비10.0±7.8，t＝0.917，P＝0.361）화28 d병사솔〔11.4%（8/70）비20.0%（14/70），χ2＝1.941，P＝0.245〕략저우대조조，단차이균무통계학의의。Kaplan-Meier생존곡선분석현시，관찰조환자28 d루적존활솔략고우대조조（χ2＝1.647，P＝0.199）。결론재서분태니진통기출상응용미서안정진정교단순미서안정진정가이강저위중환자섬망발생솔，즉사발생섬망，기섬망정도야가능교경。
ObjectiveTo investigate the influence of the midazolam sedation based on remifentanil analgesia on the occurrence of delirium in critically ill patients in intensive care unit (ICU).Methods A single-center prospective randomized controlled trial was conducted. 140 consecutive critically ill patients admitted to ICU of Peking University People's Hospital, undergoing mechanical ventilation longer than 24 hours, with the need of sedation, from February 2014 to January 2015 were enrolled. They were randomly divided into two groups by computer generated random numbers table, eachn = 70. The patients in observation group received midazolam 1μg·kg-1·min-1 for sedation, and 1 mg/mL remifentanil for analgesia with 0.05 mg/kg intravenous bolus, then continuous infusion of 0.02-0.10 mg·kg-1·h-1. The patients in control group received midazolam for sedation only. The data were recorded as follows: the main indices for observation included the occurrence of delirium and its duration; the second item for observation was consumption of drug for sedation, followed by the mean arterial pressure (MAP) before and after sedation, the time of wake-up, duration of mechanical ventilation, the length of ICU stay, and 28-day fatality rate. The 28-day survival was analyzed by Kaplan-Meier survival curve.Results The dosage of remifentanil used in observation group was (98.6±24.9) mg/d, the dosage of midazolam was significantly lower than that of the control group (mg/d: 160.6±33.3 vs. 178.9±43.4, t = 2.829,P = 0.005), the incidence of delirium was obviously lower than that of the control group [22.9% (16/70) vs. 57.1% (40/70),χ2 = 15.700,P< 0.001], and the time of delirium was slightly shorter than that of the control group (hours: 162.9±78.0 vs. 194.8±117.3,t = 0.947,P = 0.348). Among the patients with delirium, the dosage of dexmedetomidine used in observation group was significantly less than that of the control group (mg/d: 0.54±0.11 vs. 0.64±0.14,t = 2.112,P = 0.041). The MAP before sedation was similar as the MAP after sedation in both groups, and there was no significant difference between observation group and control group [mmHg (1 mmHg = 0.133 kPa), before treatment: 84.7±16.2 vs. 89.5±37.7, after treatment: 82.3±10.7 vs. 80.8±13.9, bothP> 0.05]. There was no significant difference in the time of waking-up between observation group and control group (hours: 2.3±0.9 vs. 2.4±0.8,t = 0.487,P = 0.627). The duration of mechanical ventilation (hours: 143.4±138.3 vs. 163.9±158.9, t = 0.812,P = 0.418), the length of ICU stay (days: 8.8±7.7 vs. 10.0±7.8,t = 0.917,P = 0.361) and 28-day fatality rate [11.4% (8/70) vs. 20.0% (14/70),χ2 = 1.941,P = 0.245] in observation group were slightly lower than those of the control group without significant difference. Kaplan-Meier survival curve showed that the cumulative 28-day survival rate in observation group was slightly higher than that of control group (χ2 = 1.647,P = 0.199). ConclusionAnalgesia based on sedation may reduce the occurrence of delirium and its severity, furthermore, even if delirium occurs, it may be less severe.
