不同镇静药物对NSTE-ACS机械通气患者心血管效应的影响
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摘要
目的观察不同镇静药物对非ST段抬高型急性冠脉综合征(NSTE-ACS)并机械通气患者心血管效应的影响。方法选取长沙市第一医院47例需机械辅助通气NSTE-ACS患者,随机分为右美托咪定组(D组,24例),丙泊酚组(P组,23例)。47例患者均使用芬太尼镇痛,使用动态心电图及Picco连续监测。比较两组心律失常、急性心肌缺血、血流动力学指标、机械通气时间、ICU住院时间、谵妄发生率及28 d生存率差异。结果两组心律失常及急性心肌缺血比较差异有统计学意义,D组在快速型室上性心律失常[(8.04±6.05)VS(13.48±10.44)阵次]、急性心肌缺血[(3.58±3.26)VS(5.74±3.84)阵次]的发生频次均低于P组;两组窦性心动过缓、频发室性早搏、室性心动过速比较差异无统计学意义(P>0.05);D组在住ICU后12 h心指数(CI)高于P组[(2.76±0.27)VS(2.59±0.19)L/(min·m)2](P <0.05);但全身血管阻力指数差异无统计学意义(P>0.05);D组谵妄发生率(12.5%VS 34.8%)、ICU住院时间[(8.10±1.03)VS(9.47±1.56)d]低于P组(P <0.05);两组间机械通气时间、28 d生存率比较差异无统计学意义(P>0.05)。结论在需机械通气的NSTE-ACS患者镇静治疗中,与丙泊酚比较,盐酸右美托咪定具有更低的快速型室上性心律失常和急性心肌缺血的发生率,以及更小的心功能影响,能降低ICU内谵妄发生率,缩短ICU住院时间。
Objective To observe the effects of different sedative drugs on cardiovascular effects in patients with non-ST-segment elevation acute coronary syndrome(NSTE-ACS) and mechanical ventilation.Methods Forty-seven patients with mechanically assisted ventilation NSTE-ACS in Changsha First Hospital were randomly divided into Dexmedetomidine group(group D,24 cases) and Propofol group(group P,23 cases).All the 47 patients were treated with Fentanyl analgesia and monitored continuously using a dynamic electrocardiogram and Picco.The differences in arrhythmia,acute myocardial ischemia,hemodynamics,mechanical ventilation time,ICU hospitalization,sputum incidence and 28-day survival rate were compared.Results There were differences in arrhythmia and acute myocardial ischemia between the two groups.The frequency of supraventricular tachyarrhythmia(8.04 ± 6.05) VS(13.48 ± 10.44) and acute myocardial ischemia(3.58 ± 3.26) VS(5.74 ± 3.84) in group D were significantly lower than those in group P(P<0.05).There was no significant difference between two groups in Sinus bradycardia,frequent ventricular premature beat,and Ventricular tachycardia(P>0.05).The cardiac index in group D was significantly higher than that in group P 12 hours after in ICU(T12 h)(2.76 ± 0.27) VS(2.59 ± 0.19 L/min·m2)(P<0.05).There was no significant difference between two groups in systemic vascular resistance index at T12 h(P>0.05).There was no significant difference between two groups in mechanical ventilation time and 28 days survival rate(P<0.05).The delirium(12.5% VS 34.8%) and ICU length of hospital stay(8.10 ± 1.03) VS(9.47 ± 1.56 d) in group D were significantly lower than that in group P(P<0.05).Conclusion In the sedation of NSTE-ACS patients requiring mechanical ventilation,Dexmedetomidine hydrochloride has a lower incidence of rapid supraventricular arrhythmias and acute myocardial ischemia,as compared with Propofol.Heart function effects can reduce the incidence of sputum in the ICU and shorten the hospital stay in the ICU.
Objective To observe the effects of different sedative drugs on cardiovascular effects in patients with non-ST-segment elevation acute coronary syndrome(NSTE-ACS) and mechanical ventilation.Methods Forty-seven patients with mechanically assisted ventilation NSTE-ACS in Changsha First Hospital were randomly divided into Dexmedetomidine group(group D,24 cases) and Propofol group(group P,23 cases).All the 47 patients were treated with Fentanyl analgesia and monitored continuously using a dynamic electrocardiogram and Picco.The differences in arrhythmia,acute myocardial ischemia,hemodynamics,mechanical ventilation time,ICU hospitalization,sputum incidence and 28-day survival rate were compared.Results There were differences in arrhythmia and acute myocardial ischemia between the two groups.The frequency of supraventricular tachyarrhythmia(8.04 ± 6.05) VS(13.48 ± 10.44) and acute myocardial ischemia(3.58 ± 3.26) VS(5.74 ± 3.84) in group D were significantly lower than those in group P(P<0.05).There was no significant difference between two groups in Sinus bradycardia,frequent ventricular premature beat,and Ventricular tachycardia(P>0.05).The cardiac index in group D was significantly higher than that in group P 12 hours after in ICU(T12 h)(2.76 ± 0.27) VS(2.59 ± 0.19 L/min·m2)(P<0.05).There was no significant difference between two groups in systemic vascular resistance index at T12 h(P>0.05).There was no significant difference between two groups in mechanical ventilation time and 28 days survival rate(P<0.05).The delirium(12.5% VS 34.8%) and ICU length of hospital stay(8.10 ± 1.03) VS(9.47 ± 1.56 d) in group D were significantly lower than that in group P(P<0.05).Conclusion In the sedation of NSTE-ACS patients requiring mechanical ventilation,Dexmedetomidine hydrochloride has a lower incidence of rapid supraventricular arrhythmias and acute myocardial ischemia,as compared with Propofol.Heart function effects can reduce the incidence of sputum in the ICU and shorten the hospital stay in the ICU.
引文
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[9]TOBIAS J D,CHRYSOSTOMOU C.Dexmedetomidine:antiarrhythmic effects in the pediatric cardiac patient[J].Pcdiatr Cardiol,2013,34(4):779-785.
[10]LBACACHE M,SANCHEZ G,PEDROZO Z,et al.Dexmedetomidine preconditioning activates prosurvival kinases and attenuates regional ischemia/reperfusion injury in rat heart[J].Biochim Biophys Acta,2012,1822(4):537-545.
[11]OH C S,LEE Y,KANG W S,et al.Impact of effect-site concentration of propofol on cardiac systolic function assessed by tissue Doppler imaging[J].Journal of International Medical Research 2016,44(3):453-461.
[12]YU S B.Dexmedetomidine sedation in ICU[J].Korean JAnesthesiol,2012,62(5):405-411.
[13]李娟,王平.PICCO在危重症患者中应用的研究进展[J].辽宁医学杂志,2016,30(6):43-45.
[14]王婧,奚望,殷亮,等.右美托咪定与丙泊酚对心脏瓣膜术后机械通气患者镇静效果及血流动力学的影响[J].第二军医大学学报,2017,38(5):563-569.
[15]FAN H,ZHAO Y,SUN M,et al.Dexmedetomidine based sedation for post-surgery critically ill adults:a meta-analysis of randomized controlled trials[J].Iran J Public Health,2017,46(12):1611-1622.
[16]READE M C,FINFER S.Sedation and delirium in the intensive care unit[J].N Engl J Med,2014,370(5):444-454.
[2]FOX K A A,EAGLE K A,GORE J M,et al.The global registry of acute coronary events,1999 to 2009-GRACE[J].Heart,2010,96(14):1095-1101.
[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]TERAO Y,MIURA K,SAITO M,et al.Quantitative analysis of the relation-ship between sedation and resting energy expenditure in postopera-tive patients[J].Crit Care Med,2003,31:830-833.
[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]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.
[7]CAKIRM,POLARA,TEKINS,etal.The effect of dexmedetomidine against oxidative and tubular damage induced by renal ischemia reperfusion in rats[J].Ren Fail,2015:1-5.
[8]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 Oct,9(10):5578-5587.
[9]TOBIAS J D,CHRYSOSTOMOU C.Dexmedetomidine:antiarrhythmic effects in the pediatric cardiac patient[J].Pcdiatr Cardiol,2013,34(4):779-785.
[10]LBACACHE M,SANCHEZ G,PEDROZO Z,et al.Dexmedetomidine preconditioning activates prosurvival kinases and attenuates regional ischemia/reperfusion injury in rat heart[J].Biochim Biophys Acta,2012,1822(4):537-545.
[11]OH C S,LEE Y,KANG W S,et al.Impact of effect-site concentration of propofol on cardiac systolic function assessed by tissue Doppler imaging[J].Journal of International Medical Research 2016,44(3):453-461.
[12]YU S B.Dexmedetomidine sedation in ICU[J].Korean JAnesthesiol,2012,62(5):405-411.
[13]李娟,王平.PICCO在危重症患者中应用的研究进展[J].辽宁医学杂志,2016,30(6):43-45.
[14]王婧,奚望,殷亮,等.右美托咪定与丙泊酚对心脏瓣膜术后机械通气患者镇静效果及血流动力学的影响[J].第二军医大学学报,2017,38(5):563-569.
[15]FAN H,ZHAO Y,SUN M,et al.Dexmedetomidine based sedation for post-surgery critically ill adults:a meta-analysis of randomized controlled trials[J].Iran J Public Health,2017,46(12):1611-1622.
[16]READE M C,FINFER S.Sedation and delirium in the intensive care unit[J].N Engl J Med,2014,370(5):444-454.