Richman Paul S, Baram Daniel, Varela Marie, Glass Peter S
Departments of Medicine, Stony Brook University, Stony Brook, NY, USA.
Crit Care Med. 2006 May;34(5):1395-401. doi: 10.1097/01.CCM.0000215454.50964.F8.
To compare the efficacy of continuous intravenous sedation with midazolam alone vs. midazolam plus fentanyl ("co-sedation") during mechanical ventilation.
A randomized, prospective, controlled trial.
A ten-bed medical intensive care unit at a university hospital.
Thirty patients with respiratory failure who were expected to require >48 hrs of mechanical ventilation and who were receiving a sedative regimen that did not include opiate pain control.
An intravenous infusion of either midazolam alone or co-sedation was administered by a nurse-implemented protocol to achieve a target Ramsay Sedation Score set by the patient's physician. Study duration was 3 days, with a brief daily "wake-up."
We recorded the number of hours/day that patients were "off-target" with their Ramsay Sedation Scores, the number of dose titrations per day, the incidence of patient-ventilator asynchrony, and the time required to achieve adequate sedation as measures of sedative efficacy. We also recorded sedative cost in U.S. dollars and adverse events including hypotension, hypoventilation, ileus, and coma. Compared with the midazolam-only group, the co-sedation group had fewer hours per day with an "off-target" Ramsay Score (4.2 +/- 2.4 and 9.1 +/- 4.9, respectively, p < .002). Fewer episodes per day of patient-ventilator asynchrony were noted in the co-sedation group compared with midazolam-only (0.4 +/- 0.1 and 1.0 +/- 0.2, respectively, p < .05). Co-sedation also showed nonsignificant trends toward a shorter time to achieve sedation, a need for fewer dose titrations per day, and a lower total sedative drug cost. There was a trend toward more episodes of ileus with co-sedation compared with midazolam-only (2 vs. 0).
In mechanically ventilated patients, co-sedation with midazolam and fentanyl by constant infusion provides more reliable sedation and is easier to titrate than midazolam alone, without significant difference in the rate of adverse events.
比较机械通气期间单纯咪达唑仑持续静脉镇静与咪达唑仑加芬太尼（“联合镇静”）的疗效。
一项随机、前瞻性对照试验。
一所大学医院的拥有10张床位的医疗重症监护病房。
30例呼吸衰竭患者，预计需要机械通气超过48小时，且正在接受不包括阿片类药物镇痛的镇静方案。
由护士按照方案进行静脉输注，单独使用咪达唑仑或联合镇静，以达到患者医生设定的目标 Ramsay 镇静评分。研究持续3天，每天进行一次短暂的“唤醒”。
我们记录了患者 Ramsay 镇静评分“偏离目标”的每日小时数、每日剂量滴定次数、患者 - 呼吸机不同步的发生率以及达到充分镇静所需的时间，作为镇静效果的指标。我们还记录了镇静的美元成本以及包括低血压、通气不足、肠梗阻和昏迷在内的不良事件。与单纯咪达唑仑组相比，联合镇静组每日 Ramsay 评分“偏离目标”的小时数更少（分别为4.2±2.4和9.1±4.9，p<0.002）。与单纯咪达唑仑组相比，联合镇静组每日患者 - 呼吸机不同步的发作次数更少（分别为0.4±0.1和1.0±0.2，p<0.05）。联合镇静在达到镇静的时间更短、每日所需剂量滴定次数更少以及总镇静药物成本更低方面也显示出不显著的趋势。与单纯咪达唑仑组相比，联合镇静组肠梗阻发作次数有增加趋势（2次对0次）。
在机械通气患者中，持续输注咪达唑仑和芬太尼联合镇静比单纯使用咪达唑仑提供更可靠的镇静，且更易于滴定，不良事件发生率无显著差异。
