Shehabi Yahya, Grant Peter, Wolfenden Hugh, Hammond Naomi, Bass Frances, Campbell Michelle, Chen Jack
University of New South Wales Clinical School, Sydney, Australia.
Anesthesiology. 2009 Nov;111(5):1075-84. doi: 10.1097/ALN.0b013e3181b6a783.
Commonly used sedatives/analgesics can increase the risk of postoperative complications, including delirium. This double-blinded study assessed the neurobehavioral, hemodynamic, and sedative characteristics of dexmedetomidine compared with morphine-based regimen after cardiac surgery at equivalent levels of sedation and analgesia.
A total of 306 patients at least 60 yr old were randomized to receive dexmedetomidine (0.1-0.7 microg x kg(-1) x h(-1)) or morphine (10-70 microg x kg(-1) x h(-1)) with open-label propofol titrated to a target Motor Activity Assessment Scale of 2-4. Primary outcome was the prevalence of delirium measured daily via Confusion Assessment Method for intensive care. Secondary outcomes included ventilation time, additional sedation/analgesia, and hemodynamic and adverse effects.
Of all sedation assessments, 75.2% of dexmedetomidine and 79.6% (P = 0.516) of morphine treatment were in the target range. Delirium incidence was comparable between dexmedetomidine 13 (8.6%) and morphine 22 (15.0%) (relative risk 0.571, 95% confidence interval [CI] 0.256-1.099, P = 0.088), however, dexmedetomidine-managed patients spent 3 fewer days (2 [1-7] versus 5 [2-12]) in delirium (95% CI 1.09-6.67, P = 0.0317). The incidence of delirium was significantly less in a small subgroup requiring intraaortic balloon pump and treated with dexmedetomidine (3 of 20 [15%] versus 9 of 25 [36%]) (relative risk 0.416, 95% CI 0.152-0.637, P = 0.001). Dexmedetomidine-treated patients were more likely to be extubated earlier (relative risk 1.27, 95% CI 1.01-1.60, P = 0.040, log-rank P = 0.036), experienced less systolic hypotension (23% versus 38.1%, P = 0.006), required less norepinephrine (P < 0.001), but had more bradycardia (16.45% versus 6.12%, P = 0.006) than morphine treatment.
Dexmedetomidine reduced the duration but not the incidence of delirium after cardiac surgery with effective analgesia/sedation, less hypotension, less vasopressor requirement, and more bradycardia versus morphine regimen.
常用的镇静剂/镇痛药会增加术后并发症的风险，包括谵妄。这项双盲研究评估了在心脏手术后，在同等镇静和镇痛水平下，右美托咪定与吗啡方案相比的神经行为、血流动力学和镇静特性。
总共306名至少60岁的患者被随机分配接受右美托咪定（0.1 - 0.7微克×千克⁻¹×小时⁻¹）或吗啡（10 - 70微克×千克⁻¹×小时⁻¹），同时开放使用丙泊酚滴定至目标运动活动评估量表为2 - 4。主要结局是通过重症监护的意识模糊评估方法每日测量的谵妄患病率。次要结局包括通气时间、额外的镇静/镇痛以及血流动力学和不良反应。
在所有镇静评估中，75.2%的右美托咪定治疗和79.6%（P = 0.516）的吗啡治疗处于目标范围内。右美托咪定组谵妄发生率为13例（8.6%），吗啡组为22例（15.0%）（相对风险0.571，95%置信区间[CI] 0.256 - 1.099，P = 0.088），然而，接受右美托咪定治疗的患者谵妄持续时间少3天（2[1 - 7]天对5[2 - 1]天）（95% CI 1.09 - 6.67，P = 0.0317）。在一小部分需要主动脉内球囊反搏并接受右美托咪定治疗的亚组中，谵妄发生率显著更低（20例中的3例[15%]对25例中的9例[36%]）（相对风险0.416，95% CI 0.152 - 0.637，P = 0.001）。接受右美托咪定治疗的患者更有可能更早拔管（相对风险1.27，95% CI 1.01 - 1.60，P = 0.040，对数秩检验P = 0.036），经历更少的收缩期低血压（23%对38.1%，P = 0.006），需要更少的去甲肾上腺素（P < 0.001），但比吗啡治疗有更多的心动过缓（16.45%对6.12%，P = 0.006）。
与吗啡方案相比，右美托咪定在心脏手术后有效镇痛/镇静的情况下，减少了谵妄的持续时间，但未降低其发生率，低血压更少，血管升压药需求更少，心动过缓更多。
