觉醒与呼吸控制试验的长期认知和心理结局。
Long-term cognitive and psychological outcomes in the awakening and breathing controlled trial.
机构信息
Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN 37232-8300, USA.
出版信息
Am J Respir Crit Care Med. 2010 Jul 15;182(2):183-91. doi: 10.1164/rccm.200903-0442OC. Epub 2010 Mar 18.
RATIONALE
Studies have shown that reducing sedation of critically ill patients shortens time on the ventilator and in the intensive care unit (ICU). Little is known, however, of how such strategies affect long-term cognitive, psychological, and functional outcomes.
OBJECTIVES
To determine the long-term effects of a wake up and breathe protocol that interrupts and reduces sedative exposure in the ICU.
METHODS
In this a priori planned substudy conducted at one tertiary care hospital during the Awakening and Breathing Controlled Trial, a multicenter randomized controlled trial, we assessed cognitive, psychological, and functional/quality-of-life outcomes 3 and 12 months postdischarge among 180 medical ICU patients randomized to paired daily spontaneous awakening trials with spontaneous breathing trials (SBTs) or to sedation per usual care plus daily SBTs.
MEASUREMENTS AND MAIN RESULTS
Cognitive impairment was less common in the intervention group at 3-month follow-up (absolute risk reduction, 20.2%; 95% confidence interval, 1.5-36.1%; P = 0.03) but not at 12-month follow-up (absolute risk reduction, -1.9%; 95% CI, -21.3 to 27.1%; P = 0.89). Composite cognitive scores, alternatively, were similar in the two groups at 3-month and 12-month follow-up (P = 0.80 and 0.61, respectively), as were symptoms of depression (P = 0.59 and 0.82) and posttraumatic stress disorder (P = 0.59 and 0.97). Activities of daily living, functional status, and mental and physical quality of life were similar between groups throughout follow-up.
CONCLUSIONS
In this trial, management of mechanically ventilated medical ICU patients with a wake up and breathe protocol resulted in similar cognitive, psychological, and functional outcomes among patients tested 3 and 12 months post-ICU. The proven benefits of this protocol, including improved 1-year survival, were not offset by adverse long-term outcomes. Clinical trial registered with www.clinicaltrials.gov (NCT 00097630).
背景
研究表明，减少危重症患者的镇静可以缩短其使用呼吸机和入住重症监护病房（ICU）的时间。然而，人们对这种策略如何影响长期认知、心理和功能结果知之甚少。
目的
确定中断并减少 ICU 镇静暴露的唤醒和呼吸协议的长期效果。
方法
在一项单中心、多中心随机对照试验（Awakening and Breathing Controlled Trial）的预先计划子研究中，我们评估了 180 名随机分配至接受每日配对自主唤醒试验和自主呼吸试验（SBT）或常规镇静加每日 SBT 的 ICU 成年患者在出院后 3 个月和 12 个月时的认知、心理和功能/生活质量结局。
测量和主要结果
干预组在 3 个月随访时认知障碍发生率较低（绝对风险降低率为 20.2%；95%置信区间为 1.5-36.1%；P = 0.03），但在 12 个月随访时无显著差异（绝对风险降低率为-1.9%；95%置信区间为-21.3 至 27.1%；P = 0.89）。两组在 3 个月和 12 个月随访时的复合认知评分相似（P = 0.80 和 0.61），抑郁症状（P = 0.59 和 0.82）和创伤后应激障碍（P = 0.59 和 0.97）也相似。两组在整个随访期间的日常生活活动能力、功能状态以及心理和生理生活质量均相似。
结论
在这项试验中，对机械通气的 ICU 成年患者采用唤醒和呼吸协议进行管理，在 ICU 后 3 个月和 12 个月时，患者的认知、心理和功能结局相似。该方案的益处已被证实，包括提高 1 年生存率，但并未导致不良的长期结局。该研究已在 www.clinicaltrials.gov 注册（NCT 00097630）。
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