Veelo Denise P, Dongelmans Dave A, Binnekade Jan M, Korevaar Johanna C, Vroom Margreeth B, Schultz Marcus J
Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
Crit Care. 2006;10(4):R99. doi: 10.1186/cc4961.
Translaryngeal intubated and ventilated patients often need sedation to treat anxiety, agitation and/or pain. Current opinion is that tracheotomy reduces sedation requirements. We determined sedation needs before and after tracheotomy of intubated and mechanically ventilated patients.
We performed a retrospective analysis of the use of morphine, midazolam and propofol in patients before and after tracheotomy.
Of 1,788 patients admitted to our intensive care unit during the study period, 129 (7%) were tracheotomized. After the exclusion of patients who received a tracheotomy before or at the day of admittance, 117 patients were left for analysis. The daily dose (DD; the amount of sedatives for each day) divided by the mean daily dose (MDD; the mean amount of sedatives per day for the study period) in the week before and the week after tracheotomy was 1.07 +/- 0.93 DD/MDD versus 0.30 +/- 0.65 for morphine, 0.84 +/- 1.03 versus 0.11 +/- 0.46 for midazolam, and 0.62 +/- 1.05 versus 0.15 +/- 0.45 for propofol (p < 0.01). However, when we focused on a shorter time interval (two days before and after tracheotomy), there were no differences in prescribed doses of morphine and midazolam. Studying the course in DD/MDD from seven days before the placement of tracheotomy, we found a significant decline in dosage. From day -7 to day -1, morphine dosage (DD/MDD) declined by 3.34 (95% confidence interval -1.61 to -6.24), midazolam dosage by 2.95 (-1.49 to -5.29) and propofol dosage by 1.05 (-0.41 to -2.01). After tracheotomy, no further decrease in DD/MDD was observed and the dosage remained stable for all sedatives. Patients in the non-surgical and acute surgical groups received higher dosages of midazolam than patients in the elective surgical group. Time until tracheotomy did not influence sedation requirements. In addition, there was no significant difference in sedation between different patient groups.
In our intensive care unit, sedation requirements were not further reduced after tracheotomy. Sedation requirements were already sharply declining before tracheotomy was performed.
经喉插管并通气的患者常需使用镇静剂来治疗焦虑、躁动和/或疼痛。目前的观点认为气管切开术可降低镇静需求。我们确定了气管切开术前和术后经插管及机械通气患者的镇静需求。
我们对气管切开术前和术后患者使用吗啡、咪达唑仑和丙泊酚的情况进行了回顾性分析。
在研究期间入住我们重症监护病房的1788例患者中，129例（7%）接受了气管切开术。排除在入院前或入院当天接受气管切开术的患者后，剩余117例患者用于分析。气管切开术前一周和术后一周，吗啡的每日剂量（DD；每天使用的镇静剂数量）除以平均每日剂量（MDD；研究期间每天镇静剂的平均使用量）为1.07±0.93 DD/MDD，术后为0.30±0.65；咪达唑仑分别为0.84±1.03和0.11±0.46；丙泊酚分别为0.62±1.05和0.15±0.45（p<0.01）。然而，当我们关注较短的时间间隔（气管切开术前和术后两天）时，吗啡和咪达唑仑的处方剂量没有差异。研究从气管切开术前七天开始的DD/MDD变化过程，我们发现剂量有显著下降。从第-7天到第-1天，吗啡剂量（DD/MDD）下降了3.34（95%置信区间-1.61至-6.24），咪达唑仑剂量下降了2.95（-1.49至-5.29），丙泊酚剂量下降了1.05（-0.41至-2.01）。气管切开术后，未观察到DD/MDD进一步下降，所有镇静剂的剂量保持稳定。非手术组和急性手术组患者使用咪达唑仑的剂量高于择期手术组患者。至气管切开术的时间不影响镇静需求。此外，不同患者组之间的镇静情况无显著差异。
在我们的重症监护病房，气管切开术后镇静需求未进一步降低。在进行气管切开术之前，镇静需求就已急剧下降。
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