Ostermann M E, Keenan S P, Seiferling R A, Sibbald W J
Department of Medicine, University of Western Ontario, Canada.
JAMA. 2000 Mar 15;283(11):1451-9. doi: 10.1001/jama.283.11.1451.
Sedation has become an integral part of critical care practice in minimizing patient discomfort; however, sedatives have adverse effects and the potential to prolong mechanical ventilation, which may increase health care costs.
To determine which form of sedation is associated with optimal sedation, the shortest time to extubation, and length of intensive care unit (ICU) stay.
A key word search of MEDLINE, EMBASE, and the Cochrane Collaboration databases and hand searches of 6 anesthesiology journals from 1980 to June 1998. Experts and industry representatives were contacted, personal files were searched, and reference lists of relevant primary and review articles were reviewed.
Studies included were randomized controlled trials enrolling adult patients receiving mechanical ventilation and requiring short-term or long-term sedation. At least 2 sedative agents had to be compared and the quality of sedation, time to extubation, or length of ICU stay analyzed.
Data on population, intervention, outcome, and methodological quality were extracted in duplicate by 2 of 3 investigators using 8 validity criteria.
Of 49 identified randomized controlled trials, 32 met our selection criteria; 20 studied short-term sedation and 14, long-term sedation. Of these, 20 compared propofol with midazolam. Most trials were not double-blind and did not report or standardize important cointerventions. Propofol provides at least as effective sedation as midazolam and results in a faster time to extubation, with an increased risk of hypotension and higher cost. Insufficient data exist to determine effect on length of stay in the ICU. Isoflurane demonstrated some advantages over midazolam, and ketamine had a more favorable hemodynamic profile than fentanyl in patients with head injuries.
Considering the widespread use of sedation for critically ill patients, more large, high-quality, randomized controlled trials of the effectiveness of different agents for short-term and long-term sedation are warranted.
镇静已成为重症监护实践中减轻患者不适的一个重要组成部分；然而，镇静剂有不良反应，且有可能延长机械通气时间，这可能会增加医疗费用。
确定哪种镇静方式与最佳镇静效果、最短拔管时间及重症监护病房（ICU）住院时间相关。
对MEDLINE、EMBASE和Cochrane协作网数据库进行关键词检索，并对1980年至1998年6种麻醉学杂志进行手工检索。联系了专家和行业代表，检索了个人档案，并查阅了相关原始文献和综述文章的参考文献列表。
纳入的研究为随机对照试验，纳入接受机械通气且需要短期或长期镇静的成年患者。至少必须比较2种镇静剂，并分析镇静质量、拔管时间或ICU住院时间。
3名研究人员中的2名使用8项有效性标准，对关于研究对象、干预措施、结局和方法学质量的数据进行了重复提取。
在49项确定的随机对照试验中，32项符合我们的选择标准；20项研究短期镇静，14项研究长期镇静。其中，20项将丙泊酚与咪达唑仑进行了比较。大多数试验并非双盲试验，也未报告或规范重要的联合干预措施。丙泊酚提供的镇静效果至少与咪达唑仑一样有效，且拔管时间更快，但低血压风险增加且成本更高。尚无足够数据确定其对ICU住院时间的影响。异氟烷显示出比咪达唑仑有一些优势，在头部受伤患者中，氯胺酮的血流动力学表现比芬太尼更有利。
鉴于镇静在危重症患者中的广泛应用，有必要开展更多关于不同药物短期和长期镇静有效性的大型、高质量随机对照试验。
