右美托咪定在撤机躁动患儿中的应用
|
摘要
目的探讨右美托咪定在机械通气撤机躁动患儿应用的有效性及安全性。方法采取前瞻性开放性观察性研究,纳入2017年3月至2018年8月入住重症监护室接受机械通气由于躁动导致自主呼吸试验(SBT)失败而应用右美托咪定的病例。将镇静-躁动评分≥5分定义为躁动。观察入组患儿使用右美托咪定0.5、1、2、6、12h后的镇静情况,拔管前及拔管后1、24、48h血气分析结果,SBT前、拔管前、拔管后10min、拔管后60min、拔管后120min、拔管后24h的重要生命体征(心率、呼吸频率、平均动脉压)及使用右美托咪定过程中不良反应发生情况。结果 19例患儿纳入研究。患儿入组时均为躁动状态,使用右美托咪定0.5、1、2、6、12h后分别有12、17、17、18、18例患儿达到目标镇静状态。拔管前后各时间点的氧合指数、PaCO_2及心率、呼吸频率、平均动脉压差异均无统计学意义(P>0.05)。所有患儿均未发生严重低血压、呼吸抑制等不良反应,仅1例患儿发生可逆性心动过缓。结论右美托咪定在机械通气撤机躁动患儿中的应用是安全有效的,但尚需前瞻性随机对照试验加以验证。[中国当代儿科杂志,2019,21(6):522-527]
Objective To study the clinical effect and safety of dexmedetomidine in children with agitation during ventilator weaning. Methods A prospective open observational study was performed for children who were admitted to the intensive care unit and experienced mechanical ventilation between March 2017 and August 2018. They were given dexmedetomidine due to the failure in the spontaneous breathing test(SBT) caused by agitation. A sedation-agitation scale score of ≥5 was defined as agitation. The children were observed in terms of the sedation state at 0.5, 1, 2, 6, and 12 hours after the administration of dexmedetomidine, blood gas parameters before extubation and at 1, 24, and 48 hours after extubation, vital signs(heart rate, respiratory rate and mean arterial pressure) before SBT, before extubation, and at 10, 60, and 120 minutes and 24 hours after extubation, and incidence rates of adverse events related to the use of dexmedetomidine. Results A total of 19 children were enrolled in this study. All the children were in a state of agitation at the time of enrollment. At 0.5, 1, 2, 6, and 12 hours after the administration of dexmedetomidine, 12, 17, 17, 18, and 18 children respectively reached the sedation state. There were no significant differences in the oxygenation index, arterial partial pressure of carbon dioxide, heart rate, respiratory rate, and mean arterial pressure at each time point before and after extubation(P>0.05). No adverse events were observed, such as severe hypotension and respiratory depression, and only one child experienced reversible bradycardia. Conclusions Dexmedetomidine is safe and effective in children with agitation during ventilator weaning, but prospective randomized controlled trials are needed for verification.[Chin J Contemp Pediatr, 2019, 21(6): 522-527]
Objective To study the clinical effect and safety of dexmedetomidine in children with agitation during ventilator weaning. Methods A prospective open observational study was performed for children who were admitted to the intensive care unit and experienced mechanical ventilation between March 2017 and August 2018. They were given dexmedetomidine due to the failure in the spontaneous breathing test(SBT) caused by agitation. A sedation-agitation scale score of ≥5 was defined as agitation. The children were observed in terms of the sedation state at 0.5, 1, 2, 6, and 12 hours after the administration of dexmedetomidine, blood gas parameters before extubation and at 1, 24, and 48 hours after extubation, vital signs(heart rate, respiratory rate and mean arterial pressure) before SBT, before extubation, and at 10, 60, and 120 minutes and 24 hours after extubation, and incidence rates of adverse events related to the use of dexmedetomidine. Results A total of 19 children were enrolled in this study. All the children were in a state of agitation at the time of enrollment. At 0.5, 1, 2, 6, and 12 hours after the administration of dexmedetomidine, 12, 17, 17, 18, and 18 children respectively reached the sedation state. There were no significant differences in the oxygenation index, arterial partial pressure of carbon dioxide, heart rate, respiratory rate, and mean arterial pressure at each time point before and after extubation(P>0.05). No adverse events were observed, such as severe hypotension and respiratory depression, and only one child experienced reversible bradycardia. Conclusions Dexmedetomidine is safe and effective in children with agitation during ventilator weaning, but prospective randomized controlled trials are needed for verification.[Chin J Contemp Pediatr, 2019, 21(6): 522-527]
引文
[1]Motta E,Luglio M,Delgado AF,et al.Importance of the use of protocols for the management of analgesia and sedation in pediatric intensive care unit[J].Rev Assoc Med Bras(1992),2016,62(6):602-609.
[2]Harris J,Ramelet AS,van Dijk M,et al.Clinical recommendations for pain,sedation,withdrawal and delirium assessment in critically ill infants and children:an ESPNICposition statement for healthcare professionals[J].Intensive Care Med,2016,42(6):972-986.
[3]Parker AM,Sricharoenchai T,Raparla S,et al.Posttraumatic stress disorder in critical illness survivors:a meta analysis[J].Crit Care Med,2015,43(5):1121-1129.
[4]Girard TD,Alhazzani W,Kress JP,et al.An Official American Thoracic Society/American College of Chest Physicians Clinical Practice Guideline:liberation from mechanical ventilation in critically ill adults.Rehabilitation protocols,ventilator liberation protocols,and cuff leak tests[J].Am J Respir Crit Care Med,2017,195(1):120-133.
[5]Chen K,Lu Z,Xin YC,et al.Alpha-2 agonists for longterm sedation during mechanical ventilation in critically ill patients[J].Cochrane Database Syst Rev,2015,1:CD010269.
[6]Plambech MZ,Afshari A.Dexmedetomidine in the pediatric population:a review[J].Minerva Anestesiol,2015,81(3):320-332.
[7]Banasch HL,Dersch-Mills DA,Boulter LL,et al.Dexmedetomidine use in a pediatric intensive care unit:a retrospective cohort study[J].Ann Pharmacother,2018,52(2):133-139.
[8]Riker RR,Fraser GL,Cox PM,et al.Continuous infusion of haloperidol controls agitation in critically ill patients[J].Crit Care Med,1994,22(3):433-440.
[9]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.
[10]Riker RR,Picard JT,Fraser GL,et al.Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients[J].Crit Care Med,1999,27(7):1325-1329.
[11]Constantin JM,Momon A,Mantz J,et al.Efficacy and safety of sedation with dexmedetomidine in critical care patients:a metaanalysis of randomized controlled trials[J].Anaesth Crit Care Pain Med,2016,35(1):7-15.
[12]中华医学会儿科学分会急救学组,中华医学会急诊医学分会儿科学组,中国医师协会儿童重症医师分会.儿童脓毒性休克(感染性休克)诊治专家共识(2015版)[J].中国小儿急救医学,2015,22(11):739-743.
[13]Pun BT,Ely EW.The importance of diagnosing and managing ICU delirium[J].Chest,2007,132(2):624-636.
[14]Pun BT,Devlin JW.Delirium monitoring in the ICU:strategies for initiating and sustaining screening efforts[J].Semin Respir Crit Care Med,2013,34(2):179-188.
[15]Traube C,Silver G,Gerber LM,et al.Delirium and mortality in critically ill children:epidemiology and outcomes of pediatric delirium[J].Crit Care Med,2017,45(5):891-898.
[16]杨明全,周洁,曹建伟,等.ICU机械通气患者右美托咪定镇静的安全性评价[J].中华危重病急救医学,2016,28(9):839-844.
[17]中华医学会重症医学分会.中国成人ICU镇痛和镇静治疗指南[J].中华重症医学电子杂志(网络版),2018,4(2):90-113.
[18]Shehabi Y,Nakae H,Hammond N,et al.The effect of dexmedetomidine on agitation during weaning of mechanical ventilation in critically ill patients[J].Anaesth Intensive Care,2010,38(1):82-90.
[19]王志勇,张杰,李军.右美托咪定在谵妄患者撤机中的作用[J].中华危重病急救医学,2014,26(5):355-356.
[20]Grant MJ,Schneider JB,Asaro LA,et al.Dexmedetomidine use in critically ill children with acute respiratory failure[J].Pediatr Crit Care Med,2016,17(12):1131-1141.
[21]Weerink MAS,Struys MMRF,Hannivoort LN,et al.Clinical pharmacokinetics and pharmacodynamics of dexmedetomidine[J].Clin Pharmacokinet,2017,56(8):893-913.
[22]罗彬菱.右美托咪定应用于小儿术后镇静镇痛疗效和安全性的研究[D].重庆:重庆医科大学,2013.
[23]Ng KT,Shubash CJ,Chong JS.The effect of dexmedetomidine on delirium and agitation in patients in intensive care:systematic review and meta-analysis with trial sequential analysis[J].Anaesthesia,2018,74(3):380-392.
[24]Roosens E,Mulier JP,Heylens G,et al.The use of dexmedetomidine in extreme agitation[J].Tijdschr Psychiatr,2017,59(9):554-558.
[2]Harris J,Ramelet AS,van Dijk M,et al.Clinical recommendations for pain,sedation,withdrawal and delirium assessment in critically ill infants and children:an ESPNICposition statement for healthcare professionals[J].Intensive Care Med,2016,42(6):972-986.
[3]Parker AM,Sricharoenchai T,Raparla S,et al.Posttraumatic stress disorder in critical illness survivors:a meta analysis[J].Crit Care Med,2015,43(5):1121-1129.
[4]Girard TD,Alhazzani W,Kress JP,et al.An Official American Thoracic Society/American College of Chest Physicians Clinical Practice Guideline:liberation from mechanical ventilation in critically ill adults.Rehabilitation protocols,ventilator liberation protocols,and cuff leak tests[J].Am J Respir Crit Care Med,2017,195(1):120-133.
[5]Chen K,Lu Z,Xin YC,et al.Alpha-2 agonists for longterm sedation during mechanical ventilation in critically ill patients[J].Cochrane Database Syst Rev,2015,1:CD010269.
[6]Plambech MZ,Afshari A.Dexmedetomidine in the pediatric population:a review[J].Minerva Anestesiol,2015,81(3):320-332.
[7]Banasch HL,Dersch-Mills DA,Boulter LL,et al.Dexmedetomidine use in a pediatric intensive care unit:a retrospective cohort study[J].Ann Pharmacother,2018,52(2):133-139.
[8]Riker RR,Fraser GL,Cox PM,et al.Continuous infusion of haloperidol controls agitation in critically ill patients[J].Crit Care Med,1994,22(3):433-440.
[9]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.
[10]Riker RR,Picard JT,Fraser GL,et al.Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients[J].Crit Care Med,1999,27(7):1325-1329.
[11]Constantin JM,Momon A,Mantz J,et al.Efficacy and safety of sedation with dexmedetomidine in critical care patients:a metaanalysis of randomized controlled trials[J].Anaesth Crit Care Pain Med,2016,35(1):7-15.
[12]中华医学会儿科学分会急救学组,中华医学会急诊医学分会儿科学组,中国医师协会儿童重症医师分会.儿童脓毒性休克(感染性休克)诊治专家共识(2015版)[J].中国小儿急救医学,2015,22(11):739-743.
[13]Pun BT,Ely EW.The importance of diagnosing and managing ICU delirium[J].Chest,2007,132(2):624-636.
[14]Pun BT,Devlin JW.Delirium monitoring in the ICU:strategies for initiating and sustaining screening efforts[J].Semin Respir Crit Care Med,2013,34(2):179-188.
[15]Traube C,Silver G,Gerber LM,et al.Delirium and mortality in critically ill children:epidemiology and outcomes of pediatric delirium[J].Crit Care Med,2017,45(5):891-898.
[16]杨明全,周洁,曹建伟,等.ICU机械通气患者右美托咪定镇静的安全性评价[J].中华危重病急救医学,2016,28(9):839-844.
[17]中华医学会重症医学分会.中国成人ICU镇痛和镇静治疗指南[J].中华重症医学电子杂志(网络版),2018,4(2):90-113.
[18]Shehabi Y,Nakae H,Hammond N,et al.The effect of dexmedetomidine on agitation during weaning of mechanical ventilation in critically ill patients[J].Anaesth Intensive Care,2010,38(1):82-90.
[19]王志勇,张杰,李军.右美托咪定在谵妄患者撤机中的作用[J].中华危重病急救医学,2014,26(5):355-356.
[20]Grant MJ,Schneider JB,Asaro LA,et al.Dexmedetomidine use in critically ill children with acute respiratory failure[J].Pediatr Crit Care Med,2016,17(12):1131-1141.
[21]Weerink MAS,Struys MMRF,Hannivoort LN,et al.Clinical pharmacokinetics and pharmacodynamics of dexmedetomidine[J].Clin Pharmacokinet,2017,56(8):893-913.
[22]罗彬菱.右美托咪定应用于小儿术后镇静镇痛疗效和安全性的研究[D].重庆:重庆医科大学,2013.
[23]Ng KT,Shubash CJ,Chong JS.The effect of dexmedetomidine on delirium and agitation in patients in intensive care:systematic review and meta-analysis with trial sequential analysis[J].Anaesthesia,2018,74(3):380-392.
[24]Roosens E,Mulier JP,Heylens G,et al.The use of dexmedetomidine in extreme agitation[J].Tijdschr Psychiatr,2017,59(9):554-558.