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对危重机械通气患者采取非镇静或浅镇静的比较
Nonsedation or Light Sedation in Critically Ill, Mechanically Ventilated Patients


Hanne T. Olsen ... 其他 • 2020.03.19
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摘要


背景

在危重的机械通气患者中,每日唤醒已被证明能够缩短通气时间和住在重症监护病房(ICU)的时间。目前尚无数据表明与浅镇静计划相比,非镇静计划是否会影响死亡率。

 

方法

在一项多中心、随机、对照试验中,我们以1∶1的比例将接受机械通气的ICU患者分组,两组分别采用非镇静计划(非镇静组)或者每日唤醒的浅镇静计划(即将患者镇静至可被唤醒的水平,其定义为里士满激越和镇静量表[Richmond Agitation and Sedation Scale,RASS]评分为-2~-3分,RASS评分范围为-5分[无应答]~+4分[好斗])(镇静组)。主要结局是90日时的死亡率。次要结局包括主要血栓栓塞事件数量、无昏迷且无谵妄的天数、根据严重程度分类的急性肾损伤、离开ICU的天数、不使用呼吸机的天数。组间差异的计算方法是非镇静组的数值减去镇静组的数值。

 

结果

共计710例患者被随机分组,700例被纳入改良意向治疗分析。除急性生理和慢性健康状况评估(Acute Physiology and Chronic Health Evaluation,APACHE)Ⅱ评分(非镇静组比镇静组高1分,表示前者的院内死亡概率较高)之外,两个试验组患者的基线特征相似。非镇静组的平均RASS评分从第1日的-1.3分提高至第7日的-0.8分,镇静组则从第1日的-2.3分提高至第7日的-1.8分。非镇静组和镇静组的90日死亡率分别为42.4%和37.0%(差异,5.4个百分点;95%置信区间[CI],-2.2~12.2;P=0.65)。两组患者离开ICU的天数和不使用呼吸机的天数无显著差异。非镇静组患者无昏迷且无谵妄的中位天数为27日,镇静组患者无昏迷且无谵妄的中位天数为26日。非镇静组1例患者(0.3%)和镇静组10例患者(2.8%)发生了主要血栓栓塞事件(差异,-2.5个百分点;95% CI,-4.8~-0.7[未进行多重比较校正])。

 

结论

在接受机械通气的ICU患者中,在被分配采用非镇静计划和被分配采用每日唤醒的浅镇静计划的患者之间,90日时的死亡率无显著差异(由丹麦医学研究委员会[Danish Medical Research Council]等资助;NONSEDA在ClinicalTrials.gov注册号为NCT01967680)。





作者信息

Hanne T. Olsen, M.D., Helene K. Nedergaard, M.D., Ph.D., Thomas Strøm, M.D., Ph.D., Jakob Oxlund, M.D., Karl-Andre Wian, M.D., Lars M. Ytrebø, M.D., Ph.D., Bjørn A. Kroken, M.D., Michelle Chew, M.D., Ph.D., Serkan Korkmaz, Jørgen T. Lauridsen, M.Sc., and Palle Toft, M.D., D.M.Sc.
From the Departments of Anesthesiology and Intensive Care, Odense University Hospital–Svendborg Hospital, Svendborg (H.T.O.), the Departments of Clinical Research (H.T.O., H.K.N., T.S., J.O., P.T.) and Business and Economics (S.K., J.T.L.), University of Southern Denmark, and the Department of Anesthesiology and Intensive Care, Odense University Hospital (T.S., P.T.), Odense, the Department of Anesthesiology and Intensive Care, Hospital Lillebaelt, Kolding (H.K.N.), and the Department of Anesthesiology and Intensive Care, Esbjerg Hospital, Esbjerg (J.O.) — all in Denmark; the Department of Anesthesiology and Intensive Care, Vestfold Hospital, Tønsberg (K.-A.W.), and the Department of Anesthesiology and Intensive Care, University Hospital of North Norway, Tromsø (L.M.Y., B.A.K.) — both in Norway; and the Department of Anesthesiology and Intensive Care, Linköping University Hospital, Linköping, Sweden (M.C.). Address reprint requests to Dr. Toft at the Department of Anesthesiology and Intensive Care, Odense University Hospital, 5000 Odense C, Denmark, or at palle.toft@rsyd.dk.

 

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