Sharshar T
Service de réanimation, hôpital Raymond-Poincaré, 104, boulevard Raymond-Poincaré, 92380 Garches, France.
Ann Fr Anesth Reanim. 2008 Jul-Aug;27(7-8):617-22. doi: 10.1016/j.annfar.2008.05.010. Epub 2008 Jun 26.
ICU-acquired neuromyopathy (NMAR) and delirium are the two most frequent and severe neurological complications of intensive care medicine. Their mechanisms still remain to be elucidated. The objective of this review is to address the potential role of sedation in occurrence of these complications. There is no evidence that sedation is involved in NMARs. However, the hypothesis that muscle inactivity induced by sedation fosters NMAR is an argument to discontinue or reduce sedatives infusion whenever possible. It is also recommended not to administer propofol more than 48 h at an infusion rate above 5 mg/kg per hour in patients with systemic inflammatory response syndrome, because of the risk of propofol infusion syndrome, which includes notably rhabdomyolysis. The relationship between delirium and sedation are controversial because in most studies, patients were considered delirious though being still sedated and multivariate analysis was lacking. One study showed that lorazepam given continuously was an independent risk factor for daily transition to delirium 24 h later with a 20% increase risk of every unit dose (expressed as log(e)mg). The impact of deepness, daily interruption or titration of sedation on the prevalence of delirium has never been assessed but it seems that deep sedation has to be avoided.
重症监护病房获得性神经肌肉病（NMAR）和谵妄是重症医学中最常见且最严重的两种神经并发症。其发病机制仍有待阐明。本综述的目的是探讨镇静在这些并发症发生过程中的潜在作用。目前尚无证据表明镇静与NMAR的发生有关。然而，镇静引起的肌肉不活动促进NMAR发生这一假说，成为尽可能停用或减少镇静剂输注的一个依据。对于全身性炎症反应综合征患者，还建议丙泊酚输注时间不要超过48小时，输注速率不要超过每小时5毫克/千克，因为存在丙泊酚输注综合征的风险，其中尤其包括横纹肌溶解。谵妄与镇静之间的关系存在争议，因为在大多数研究中，患者在仍处于镇静状态时就被判定为谵妄，且缺乏多变量分析。一项研究表明，持续给予劳拉西泮是24小时后每日发生谵妄转变的独立危险因素，每单位剂量（以log(e)毫克表示）会使风险增加20%。从未评估过镇静深度、每日中断或滴定对谵妄患病率的影响，但似乎必须避免深度镇静。
