不同镇静深度对急性冠脉综合征机械通气患者心血管事件的影响
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摘要
目的比较不同镇静深度对急性冠脉综合征(ACS)并机械通气患者心血管事件的影响。方法56例需机械辅助通气ACS患者,随机分为浅镇静组29例(M组,RASS评分0～-2分),深镇静组27例(D组,RASS评分-3～-4分),所有患者使用地佐辛镇痛,使用丙泊酚+右美托咪定镇静,以镇静评分目标调整药物剂量。使用动态心电图进行48 h连续监测,比较两组心律失常、急性心肌缺血、机械通气时间、ICU住院时间、谵妄发生率及28 d生存率。结果两组在频发室性早搏的发生率、室性心动过速阵次、快速型室上性心律失常阵次及急性心肌缺血阵次的发生频次比较,差异有统计学意义(P <0.05),D组均低于M组;两组谵妄发生率、机械通气时间、ICU住院时间及28 d生存率比较差异无统计学意义(P>0.05)。结论 ACS并机械通气患者,早期深镇静可以有效减少心律失常(频发室性早搏、室性心动过速、快速型室上性心律失常)及急性心肌缺血的发生率,且不增加机械通气时间和ICU住院时间,不影响28 d生存率。
Objective To compare the effects of different degree of sedation on acute coronary syndrome(ACS) patients with mechanical ventilation. Methods Fifty-six patients with ACS who received mechanical ventilation were randomly divided into mild sedation group(group M, RASS score 0 to-2, n = 29) and deep sedation group(group D, RASS score-3 to-4, n = 27). Analgesia was achieved with Dezocine. Sedation was achieved with Dexmedetomidine and Propofol. The dose of sedation was determined based on Richmond agitation-sedation scale. Dynamic electrocardiogram continuous monitoring for 48 h was performed. Cardiovascular events including arrhythmia, acute myocardial ischemia, time duration of mechanical ventilation, ICU stay, delirium, and 28 days survival rate were compared and analyzed. Results Incidence of arrhythmia such as frequent ventricular premature beat, ventricular tachycardia, supraventricular tachyarrhythmia, and acute myocardial ischemia were decreased significantly in group D when compared with group M(P < 0.05) There was no significant difference in mechanical ventilation time, ICU length of hospital stay,delirium and 28 days survival rate between two groups(P > 0.05). Conclusion In ACS patients with mechanical ventilation, early deep sedation can reduce the incidence of arrhythmia and acute myocardial ischemia without increase of mechanical ventilation time and ICU stay.
Objective To compare the effects of different degree of sedation on acute coronary syndrome(ACS) patients with mechanical ventilation. Methods Fifty-six patients with ACS who received mechanical ventilation were randomly divided into mild sedation group(group M, RASS score 0 to-2, n = 29) and deep sedation group(group D, RASS score-3 to-4, n = 27). Analgesia was achieved with Dezocine. Sedation was achieved with Dexmedetomidine and Propofol. The dose of sedation was determined based on Richmond agitation-sedation scale. Dynamic electrocardiogram continuous monitoring for 48 h was performed. Cardiovascular events including arrhythmia, acute myocardial ischemia, time duration of mechanical ventilation, ICU stay, delirium, and 28 days survival rate were compared and analyzed. Results Incidence of arrhythmia such as frequent ventricular premature beat, ventricular tachycardia, supraventricular tachyarrhythmia, and acute myocardial ischemia were decreased significantly in group D when compared with group M(P < 0.05) There was no significant difference in mechanical ventilation time, ICU length of hospital stay,delirium and 28 days survival rate between two groups(P > 0.05). Conclusion In ACS patients with mechanical ventilation, early deep sedation can reduce the incidence of arrhythmia and acute myocardial ischemia without increase of mechanical ventilation time and ICU stay.
引文
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[13]LIU Q,KONG A L,CHEN R,et al.Propofol and arrhythmias:two sides of the coin[J].Acta Pharmacologica Sinica,2011,32(6):817-823.
[14]LANZA G A,CIANFLONE D,REBUZZI A G,et al.Prognostic value of ventricular arrhythmias and heart rate variability in patients with unstable angina[J].Heart,2006,92(8):1055-1063.
[15]KRESS J P,VINAYAK A G,LEVITT J,et al.Daily sedative interruption in mechanically ventilated patients at risk for coronary artery disease[J].Crit Care Med,2007,35(2):365-371.
[16]HALL R I,MACLAREN C,SMITH M S,et al.Light versus heavy sedation after cardiac surgery:Myocardial ischemia and the stress response[J].Anesth Analg,1997,85(5):971-978.
[17]RODRIGO J,VALDERR B A,ALEJANDRO B,et al.Risk factors and clinical outcomes of arrhythmias in the medical intensive care unit[J].J Intensive Care,2016,22(4):9.
[2]LAMPERT R.Behavioral influences on cardiac arrhythmias[J].Trends Cardiovasc Med,2016,26(1):68-77.
[3]PATEL S B,KRESS J P.Sedation and analgesia in the mechanically ventilated patient[J].Am J Respir Crit Care Med,2012,185(5):486-497.
[4]杨杰,康焰.镇静对机械通气患者呼吸功能的影响[J].中华危重病急救医学,2017,29(9):857-860.
[5]BARR J,FRASER G L,PUNTILLO K,et al.Clinical practice guidelines for the management of pain,agitation and delirium in adult patients in the intensive care unit[J].Crit Care Med,2013,41(1):263-306.
[6]中国医师协会急诊医师分会.2015中国急诊急性冠状动脉综合征临床实践指南(二)-诊断篇[J].中国急救医学,2016,36(1):9-11.
[7]中华医学会重症医学分会.机械通气临床应用指南(2006)[J].中国危重病急救医学,2007,19(2):65-72.
[8]张兆国,马宏艳.动态心电图对急性短暂性心肌缺血的诊断价值(附1例报告)[J].江苏实用心电学杂志,2014,23(5):364-368.
[9]崔美红,魏玉杰.应激性心律失常机制及防治的研究进展[J].心血管康复医学杂志,2014,23(1):100-104.
[10]WINKLER C,FUNK M,SCHINDLER D M,et al.Arrhythmias in patients with acute coronary syndrome in the first 24 hours of hospitalization[J].Heart Lung,2013,42(6):422-427.
[11]古屋真吾.急性心肌梗死时的心律失常及其治疗[J].日本医学介绍,2003,24(4):154.
[12]GHASEM S,SAEED J,MOHAMMAD A T,et al.Effects of dexmedetomidine on heart arrhythmia prevention in off-pump coronary artery bypass surgery:A randomized clinical trial[J].Electron Physician,2017,9(10):5578-5587.
[13]LIU Q,KONG A L,CHEN R,et al.Propofol and arrhythmias:two sides of the coin[J].Acta Pharmacologica Sinica,2011,32(6):817-823.
[14]LANZA G A,CIANFLONE D,REBUZZI A G,et al.Prognostic value of ventricular arrhythmias and heart rate variability in patients with unstable angina[J].Heart,2006,92(8):1055-1063.
[15]KRESS J P,VINAYAK A G,LEVITT J,et al.Daily sedative interruption in mechanically ventilated patients at risk for coronary artery disease[J].Crit Care Med,2007,35(2):365-371.
[16]HALL R I,MACLAREN C,SMITH M S,et al.Light versus heavy sedation after cardiac surgery:Myocardial ischemia and the stress response[J].Anesth Analg,1997,85(5):971-978.
[17]RODRIGO J,VALDERR B A,ALEJANDRO B,et al.Risk factors and clinical outcomes of arrhythmias in the medical intensive care unit[J].J Intensive Care,2016,22(4):9.