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右美托咪定用于危重患者的早期镇静
Early Sedation with Dexmedetomidine in Critically Ill Patients


Yahya Shehabi ... 其他 • 2019.06.27
相关阅读
• 将右美托咪定作为唯一镇静剂在死亡率方面无获益

摘要


背景

右美托咪定可在保持一定程度可唤醒性的同时产生镇静作用,并且可能缩短重症监护治疗病房(ICU)患者的机械通气和谵妄持续时间。将右美托咪定作为唯一或主要镇静剂用于机械通气患者尚未经过广泛研究。

 

方法

在一项开放标签、随机试验中,我们纳入了在ICU接受通气治疗不到12小时,并且预期通气支持将持续至超过下一个日历日的危重成人患者,并随机分配这些患者接受右美托咪定(作为唯一或主要镇静剂)或常规治疗(异丙酚、咪达唑仑或其他镇静剂)。Richmond躁动镇静量表(Richmond Agitation and Sedation Scale,评分范围为-5分[无反应]~+4分[有攻击性])镇静评分的目标范围是-2~+1分(浅镇静至不安焦虑)。主要结局是90日时的全因死亡率。

 

结果

我们纳入了4,000例患者,确认患者符合纳入条件和随机化之间的中位间隔时间是4.6小时。在包括3,904例患者的改良意向治疗分析中,右美托咪定组1,948例患者中的566例(29.1%)和常规治疗组1,956例患者中的569例(29.1%)发生了主要结局事件(校正的风险差异,0.0个百分点;95%置信区间,-2.9~2.8)。研究中的一项附带观察结果如下,为了达到规定的镇静水平,右美托咪定组患者在随机分组后2日内补充使用了异丙酚(64%的患者)、咪达唑仑(3%)或者上述两种药物(7%);在常规治疗组中,上述药物分别被用作60%、12%和20%患者的主要镇静剂。右美托咪定组的心动过缓和低血压较常见。

 

结论

在接受机械通气的ICU患者中,早期接受右美托咪定镇静的患者在90日时的死亡率与常规治疗组患者相似,且需要补充使用其他镇静剂才能达到规定的镇静水平。右美托咪定组报告的不良事件超过常规治疗组(由澳大利亚国家健康与医学研究委员会[National Health and Medical Research Council of Australia]等资助;SPICE III在ClinicalTrials.gov注册号为NCT01728558)。





作者信息

Yahya Shehabi, Ph.D., M.B., B.S., Belinda D. Howe, R.N., M.P.H., Rinaldo Bellomo, M.D., Ph.D., Yaseen M. Arabi, M.D., Michael Bailey, Ph.D., Frances E. Bass, R.N., Suhaini Bin Kadiman, M.D., Colin J. McArthur, M.B., Ch.B., Lynnette Murray, B.S., Michael C. Reade, M.B., B.S., M.P.H., D.Phil., Ian M. Seppelt, M.B., B.S., Jukka Takala, M.D., Ph.D., Matt P. Wise, M.D., D.Phil., and Steven A. Webb, M.P.H., Ph.D. for the ANZICS Clinical Trials Group, and the SPICE III Investigators*
From the School of Clinical Sciences (Y.S.) and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine (B.D.H., R.B., M.B., L.M., S.A.W.), Monash University, Monash Health (Y.S.), the Faculty of Medicine, University of Melbourne (R.B., M.B.), Melbourne, VIC, and Austin Hospital, Heidelberg, VIC (R.B.), the Prince of Wales Clinical School of Medicine, University of New South Wales (Y.S.), Royal North Shore Hospital, the George Institute for Global Health (F.E.B.), the Sydney Medical School–Nepean, University of Sydney, and the Department of Clinical Medicine, Macquarie University (I.M.S.), Sydney, the Faculty of Medicine, University of Queensland, Royal Brisbane and Women’s Hospital, Brisbane (M.C.R.), the Joint Health Command, Australian Defence Force, Canberra, ACT (M.C.R.), and St. John of God Subiaco Hospital, Subiaco, WA (S.A.W.) — all in Australia; the College of Medicine, King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia (Y.M.A.); the Department of Anesthesiology and Intensive Care, IJN-UTM Cardiovascular Engineering Center, National Heart Institute, Kuala Lumpur, Malaysia (S.B.K.); the Department of Critical Care Medicine, Auckland City Hospital, University of Auckland, Auckland, New Zealand (C.J.M.); Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (J.T.); and Adult Critical Care, University Hospital of Wales, Cardiff, United Kingdom (M.P.W.). Address reprint requests to Dr. Shehabi at Monash University, School of Clinical Sciences, Level 5, E Block, Monash Medical Centre, Clayton 3168, VIC, Australia, or at yahya.shehabi@monashhealth.org or y.shehabi@unsw.edu.au. *A complete list of the trial investigators is provided in the Supplementary Appendix, available at NEJM.org.

 

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