University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
Ann Pharmacother. 2012 Apr;46(4):530-40. doi: 10.1345/aph.1Q525. Epub 2012 Apr 10.
To critically evaluate the use of analgosedation in the management of agitation in critically ill mechanically ventilated patients.
Literature was accessed through MEDLINE (1948-November 2011) and Cochrane Library (2011, issue 1) using the terms analgosedation, analgosedation, or analgesia-based sedation alone or in combination with intensive care unit or critically ill. Reference lists of related publications were also reviewed.
All articles published in English were evaluated. Randomized controlled trials examining critically ill mechanically ventilated patients older than 18 years were included.
Limitations of current sedation practices include serious adverse drug events, prolonged mechanical ventilation time, and intensive care unit (ICU) length of stay. Studies have demonstrated that analgosedation, a strategy that manages patient pain and discomfort first, before providing sedative therapy, results in improved patient outcomes compared to standard sedative-hypnotic regimens. Nine randomized controlled trials comparing remifentanil-based analgosedation to other commonly used agents (fentanyl, midazolam, morphine, and propofol) for ICU sedation and 1 trial comparing morphine to daily sedation interruption with propofol or midazolam were reviewed. Remifentanil is an ideal agent for analgosedation due to its easy titratability and organ-independent metabolism. When compared to sedative-hypnotic regimens, remifentanil-based regimens were associated with shorter duration of mechanical ventilation, more rapid weaning from the ventilator, and shorter ICU length of stay. Compared to fentanyl-based regimens, remifentanil had similar efficacy with the exception of increased pain requirements upon remifentanil discontinuation. Analgosedation was well tolerated, with no significant differences in hemodynamic stability compared to sedative-hypnotic regimens.
Analgosedation is an efficacious and well-tolerated approach to management of ICU sedation with improved patient outcomes compared to sedative-hypnotic approaches. Additional well-designed trials are warranted to clarify the role of analgosedation in the management of ICU sedation, including trials with nonopioid analgesics.
批判性地评估在重症监护机械通气患者躁动管理中应用镇静的效果。
通过 MEDLINE（1948 年-2011 年 11 月）和 Cochrane 图书馆（2011 年，第 1 期）检索文献，使用术语镇静、镇静或单独使用镇痛或联合重症监护或危重病的镇静。还查阅了相关出版物的参考文献列表。
评估了所有以英文发表的文章。纳入了对 18 岁以上重症机械通气患者进行的随机对照试验。
目前镇静实践的局限性包括严重药物不良事件、机械通气时间延长和重症监护病房（ICU）住院时间延长。研究表明，与标准镇静-催眠药物方案相比，首先管理患者疼痛和不适，然后再提供镇静治疗的镇痛镇静策略可改善患者预后。共评价了 9 项比较瑞芬太尼为基础的镇痛镇静与其他常用药物（芬太尼、咪达唑仑、吗啡和丙泊酚）用于 ICU 镇静的随机对照试验和 1 项比较吗啡与每日镇静中断与丙泊酚或咪达唑仑的试验。瑞芬太尼由于其易滴定和器官独立代谢而成为镇痛镇静的理想药物。与镇静-催眠药物方案相比，瑞芬太尼为基础的方案与机械通气时间更短、呼吸机更快脱机和 ICU 住院时间更短相关。与芬太尼为基础的方案相比，瑞芬太尼除了在瑞芬太尼停药时需要增加疼痛要求外，其疗效相似。镇痛镇静耐受良好，与镇静-催眠药物方案相比，血流动力学稳定性无显著差异。
与镇静-催眠方法相比，镇痛镇静是 ICU 镇静管理的一种有效且耐受良好的方法，可改善患者预后。需要进行更多精心设计的试验来阐明镇痛镇静在 ICU 镇静管理中的作用，包括非阿片类镇痛药的试验。
