A ventilator strategy combining low tidal volume ventilation, recruitment maneuvers, and high positive end-expiratory pressure does not increase sedative, opioid, or neuromuscular blocker use in adults with acute respiratory distress syndrome and may imp

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• 作者：Sangeeta Mehta (1)
  Deborah J Cook (2)
  Yoanna Skrobik (3)
  John Muscedere (4)
  Claudio M Martin (5)
  Thomas E Stewart (6)
  Lisa D Burry (7)
  Qi Zhou (8)
  Maureen Meade (2)
  for the Lung Open Ventilation Study Investigators
  
  1. Department of Medicine and Interdepartmental Division of Critical Care Medicine ; Mount Sinai Hospital ; University of Toronto ; 600 University Avenue ; Suite 18-216 ; Toronto ; Ontario ; M5G 1X5 ; Canada
  2. Interdepartmental Division of Critical Care ; Hamilton Health Sciences and Departments of Medicine and Clinical Epidemiology and Biostatistics ; McMaster University ; Hamilton ; Ontario ; L8S 4K1 ; Canada
  3. D茅partement de Medicine ; Soins Intensifs ; H么pital Maisonneuve Rosemont ; Universite de Montreal ; Montreal ; Quebec ; H1T 2M4 ; Canada
  4. Department of Medicine ; Kingston General Hospital ; Queen鈥檚 University ; Kingston ; Ontario ; K7L 2V7 ; Canada
  5. Department of Medicine ; London Health Sciences Centre ; Western University ; London ; Ontario ; N6A 5A5 ; Canada
  6. Niagara Health System ; St. Catharines ; Ontario ; L2S 0A9 ; Canada
  7. Department of Pharmacy and Medicine ; Mount Sinai Hospital ; Toronto ; Ontario ; M5G 1X5 ; Canada
  8. Department of Clinical Epidemiology and Biostatistics ; McMaster University ; Hamilton ; Ontario ; L8S 4K1 ; Canada
  
• 关键词：ARDS ; Neuromuscular blocker ; Sedation ; Opioid ; Mechanical ventilation ; Clinician comfort
• 刊名：Annals of Intensive Care
• 出版年：2014
• 出版时间：December 2014
• 年：2014
• 卷：4
• 期：1
• 全文大小：194 KB
• 参考文献：Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 342: pp. 1301-1308 56/NEJM200005043421801" target="_blank" title="It opens in new window">CrossRef
  1. Kahn, JM, Andersson, L, Karir, V, Polissar, NL, Neff, MJ, Rubenfeld, GD (2005) Low tidal volume ventilation does not increase sedation use in patients with acute lung injury. Crit Care Med 33: pp. 766-771 57786.41506.24" target="_blank" title="It opens in new window">CrossRef
  2. Cheng, IW, Eisner, MD, Thompson, BT, Ware, LB, Matthay, MA (2005) Acute effects of tidal volume strategy on hemodynamics, fluid balance, and sedation in acute lung injury. Crit Care Med 33: pp. 63-70 CrossRef
  3. Segredo, V, Caldwell, JE, Matthay, MA, Sharma, ML, Gruenke, LD, Miller, RD (1992) Persistent paralysis in critically ill patients after long-term administration of vecuronium. N Engl J Med 327: pp. 524-528 56/NEJM199208203270804" target="_blank" title="It opens in new window">CrossRef
  4. Papazian, L, Forel, J, Gacouin, A, Penot-Ragon, C, Perrin, G, Loundou, A, Jaber, S, Arnal, J, Perez, D, Seghboyan, J, Constantin, J, Courant, P, Lefrant, J, Guerin, C, Prat, G, Morange, S, Rochet, A (2010) Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med 363: pp. 1107-1116 56/NEJMoa1005372" target="_blank" title="It opens in new window">CrossRef
  5. Meade, MO, Cook, DJ, Guyatt, GH, Slutsky, AS, Arabi, YM, Cooper, DJ, Davies, AR, Hand, LE, Zhou, Q, Thabane, L, Austin, P, Lapinsky, S, Baxter, A, Russell, J, Skrobik, Y, Ronco, JJ, Stewart, TE (2008) Ventilation strategy using low tidal volumes, recruitment maneuvers, and high positive end-expiratory pressure for acute lung injury and acute respiratory distress syndrome. JAMA 299: pp. 637-645 CrossRef
  6. Barr, J, Fraser, GL, Puntillo, K, Ely, EW, G茅linas, C, Dasta, JF, Davidson, JE, Devlin, JW, Kress, JP, Joffe, AM, Coursin, DB, Herr, DL, Tung, A, Robinson, BR, Fontaine, DK, Ramsay, MA, Riker, RR, Sessler, CN, Pun, B, Skrobik, Y, Jaeschke, R (2013) Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 41: pp. 263-306 CrossRef
  7. Mehta, S, Burry, L, Cook, D, Fergusson, D, Steinberg, M, Granton, J, Herridge, M, Ferguson, N, Devlin, J, Tanios, M, Dodek, P, Fowler, R, Burns, K, Jacka, M, Olafson, K, Skrobik, Y, H茅bert, P, Sabri, E, Meade, M (2012) Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol: a randomized controlled trial. JAMA 308: pp. 1985-1992 CrossRef
  8. Brower, RG, Lanken, PN, MacIntyre, N, Matthay, MA, Morris, A, Ancukiewicz, M, Schoenfeld, D, Thompson, BT (2004) Higher vs. lower positive end-expiration pressures in patients with the acute respiratory distress syndrome. N Engl J Med 351: pp. 327-336 56/NEJMoa032193" target="_blank" title="It opens in new window">CrossRef
  9. Mercat, A, Richard, JC, Vielle, B, Jaber, S, Osman, D, Diehl, JL, Lefrant, JY, Prat, G, Richecoeur, J, Nieszkowska, A, Gervais, C, Baudot, J, Bouadma, L, Brochard, L (2008) Positive end-expiratory pressure setting in adults with acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. JAMA 299: pp. 646-655 CrossRef
  10. Briel, M, Meade, M, Mercat, A, Brower, RG, Talmor, D, Walter, SD, Slutsky, AS, Pullenayegum, E, Zhou, Q, Cook, D, Brochard, L, Richard, JC, Lamontagne, F, Bhatnagar, N, Stewart, TE, Guyatt, G (2010) Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis. JAMA 303: pp. 865-873 CrossRef
  11. Arroliga, AC, Thompson, BT, Ancukiewicz, M, Gonzales, JP, Guntupalli, KK, Park, PK, Wiedemann, HP, Anzueto, A (2008) Use of sedatives, opioids, and neuromuscular blocking agents in patients with acute lung injury and acute respiratory distress syndrome. Crit Care Med 36: pp. 1083-1088 53895" target="_blank" title="It opens in new window">CrossRef
  12. Neto, AS, Pereira, VGM, Esposito, DC, Damasceno, MC, Schultz, MJ (2012) Neuromuscular blocking agents in patients with acute respiratory distress syndrome: a summary of the current evidence from three randomized controlled trials. Annals of Intensive Care 2: pp. 33 5820-2-33" target="_blank" title="It opens in new window">CrossRef
  13. Alhazzani, W, Alshahrani, M, Jaeschke, R, Forel, J-M, Papazian, L, Sevransky, J, Meade, M (2013) Neuromuscular blocking agents in acute respiratory distress syndrome: a systematic review and meta-analysis of randomized controlled trials. Crit Care 17: pp. R43 557" target="_blank" title="It opens in new window">CrossRef
  14. Gama De Abreu, M, Rocco, PRM, Pelosi, P Pros and cons of assisted mechanical ventilation in acute lung injury. In: Vincent, JL eds. (2011) Annual Update in Intensive Care and Emergency Medicine. Springer-Verlag, Berlin, pp. 159-173
  
• 刊物主题：Intensive / Critical Care Medicine; Emergency Medicine; Anesthesiology;
• 出版者：Springer Paris
• ISSN：2110-5820

文摘

Background The Lung Open Ventilation Study (LOV Study) compared a low tidal volume strategy with an experimental strategy combining low tidal volume, lung recruitment maneuvers, and higher plateau and positive end-expiratory pressures (PEEP) in adults with acute respiratory distress syndrome (ARDS). Herein, we compared sedative, opioid, and neuromuscular blocker (NMB) use among patients managed with the intervention and control strategies and clinicians' assessment of comfort in both groups. Methods This was an observational substudy of the LOV Study, a randomized trial conducted in 30 intensive care units in Canada, Australia, and Saudi Arabia. In 16 centers, we recorded daily doses of sedatives, opioids, and NMBs and surveyed bedside clinicians about their own comfort with the assigned ventilator strategy and their perceptions of patient comfort. We compared characteristics and outcomes of patients who did and did not receive NMBs. Results Study groups received similar sedative, opioid, and NMB dosing on days 1, 3, and 7. Patient comfort as assessed by clinicians was not different in the two groups: 93% perceived patients had no/minimal discomfort. In addition, 92% of clinicians were comfortable with the assigned ventilation strategy without significant differences between the two groups. When clinicians expressed discomfort, more expressed discomfort about PEEP levels in the intervention vs control group (2.9% vs 0.7%, P P = 0.049). On multivariable analysis, the strongest associations with NMB use were higher plateau pressure (hazard ratio (HR) 1.15; 95% confidence interval (CI) 1.07 to 1.23; P = 0.0002) and higher daily sedative dose (HR 1.03; 95% CI 1.02 to 1.05; P Conclusions In the LOV Study, high PEEP, low tidal volume ventilation did not increase sedative, opioid, or NMB doses in adults with ARDS, compared with a lower PEEP strategy, and appeared at least as comfortable for patients. NMB use may reflect worse lung injury, as these patients had more barotrauma, longer durations of ventilation, and higher mortality. Trial registration ClinicalTrials.gov Identifier NCT00182195