Coimbra Claudia, Choinière Manon, Hemmerling Thomas M
Department of *Anesthesiology and †Burn Centre, Hôtel-Dieu, Centre Hospitalier de l'Université de Montréal (CHUM), Université de Montréal, Québec, Canada.
Anesth Analg. 2003 Sep;97(3):839-842. doi: 10.1213/01.ANE.0000074236.76333.53.
The first change of dressings after skin grafting in burn patients is a source of great anxiety because of pain anticipation and the immediate and first confrontation with the result of skin grafting. We designed this dose-finding study to determine the feasibility and safety of patient-controlled sedation (PCS) using propofol during these procedures. Twenty patients were familiarized with the PCS and asked to use PCS whenever they felt uncomfortable or anxious. Analgesia was provided by a single bolus of morphine IV 15 min before the procedure according to their daily intake. The first 10 patients used a fixed bolus of propofol 0.3 mg/kg and a lockout of 5 min. The degree of sedation was measured using bispectral index (BIS) monitoring. Demands versus delivery of propofol boluses were recorded. Within 1 h after the procedure, pain intensity was evaluated and satisfaction scores obtained from patients and nurses performing the dressing changes. In the first 10 patients, there were no respiratory rates <10 breaths/min, systolic and diastolic blood pressure were within 25% of baseline values, and peripheral saturation stayed more than 94% with additional small flow oxygen via nasal insufflation. There were double the demands than actual deliveries of propofol boluses. The BIS did not show significant decreases of <80 in any patient reflecting an insufficient state of sedation. Because the interim analysis of the efficacy of the PCS setup showed an insufficient state of sedation, a different PCS setup was evaluated in a second group of 10 patients (an individualized propofol bolus, titrated to achieve a significant decrease of BIS or a sleepy state, and no lockout period). The second group of patients showed a more effective sedation, with respiratory and hemodynamic variables being not significantly different from the first group of patients. PCS with propofol is feasible in burn patients and can be used safely. To provide an optimal sedation, we suggest to initially titrate the bolus to achieve a significant decrease of BIS or a clinically effective state of sedation and to abolish the lockout interval.
烧伤患者植皮后首次换药因对疼痛的预期以及首次直面植皮结果而成为极大的焦虑来源。我们设计了这项剂量探索研究，以确定在这些操作过程中使用丙泊酚进行患者自控镇静（PCS）的可行性和安全性。20名患者熟悉了PCS，并被要求在感到不舒服或焦虑时使用PCS。根据患者的每日摄入量，在操作前15分钟静脉注射一剂吗啡以提供镇痛。前10名患者使用固定剂量的丙泊酚0.3mg/kg，锁定时间为5分钟。使用脑电双频指数（BIS）监测来测量镇静程度。记录丙泊酚推注的需求与实际给予量。操作后1小时内，评估疼痛强度，并获得进行换药的患者和护士的满意度评分。在前10名患者中，呼吸频率均未低于10次/分钟，收缩压和舒张压在基线值的25%以内，经鼻吸氧小流量辅助下外周血氧饱和度维持在94%以上。丙泊酚推注的需求是实际给予量的两倍。BIS在任何患者中均未显示出显著降至<80，这反映出镇静不足。由于对PCS设置效果的中期分析显示镇静不足，在另一组10名患者中评估了不同的PCS设置（个体化丙泊酚推注，滴定至BIS显著下降或达到嗜睡状态，且无锁定期）。第二组患者显示出更有效的镇静效果，呼吸和血流动力学变量与第一组患者无显著差异。丙泊酚用于PCS在烧伤患者中是可行的且可安全使用。为提供最佳镇静效果，我们建议最初滴定推注剂量以实现BIS显著下降或达到临床有效的镇静状态，并取消锁定间隔。
