在接受高频振荡通气的危重症成人中使用镇静和神经肌肉阻滞剂。

Use of sedation and neuromuscular blockers in critically ill adults receiving high-frequency oscillatory ventilation.

机构信息

Department of Pharmacy, Mount Sinai Hospital, New York, NY.

出版信息

Ann Pharmacother. 2013 Sep;47(9):1122-9. doi: 10.1177/1060028013503121.

DOI:10.1177/1060028013503121

PMID:24259726

Abstract

BACKGROUND

Nearly all patients receive sedation and neuromuscular blockers (NMBs) during high-frequency oscillatory ventilation (HFOV).

OBJECTIVE

To describe analgo-sedation and NMB use prior to and during HFOV in adults with acute respiratory distress syndrome.

METHODS

Retrospective single-center study of 131 consecutive adults whose care was managed with HFOV from 2002 to 2011.

RESULTS

During the first 4 days of HFOV, 89% and 95% of patients received sedation and opioids, respectively. Upon HFOV initiation, 119 (90.8%) patients received fentanyl doses higher than 200 µg/h; of these, 48 also received more than 20 mg/h of midazolam. Analgo-sedation doses increased significantly over time such that doses were double by day 3. Factors independently associated with fentanyl doses higher than 200 µg/h were NMB ever used (OR 4.43; 95% CI 1.26-15.65, p = 0.02), pH less than 7.15 (OR 2.08; 95% CI 1.22-3.5, p = 0.007), worsening partial pressure of oxygen/fraction of inspired oxygen (OR 1.05; 95% CI 1.00-1.10, p = 0.04), and Acute Physiology and Chronic Health Evaluation (APACHE) II score (OR 0.87; 95% CI 0.79-0.97, p = 0.009). Deep sedation was commonly administered when NMBs were not being used, with 99.2% of sedation-agitation scores of 1 or 2. Eighty-six patients (65.6%) received NMBs and use was greatest on day 1 (59.5%). Train-of-Four was measured every hour for 53.4% of patients; 29.2% of the measurements were 0 of 4. NMB use declined over the 10-year study period.

CONCLUSIONS

High analgo-sedation doses were associated with APACHE II scores, worsening gas exchange, and NMB use. Two thirds of patients received NMBs; use was highest on day 1 and subsequently declined. The percentage of patients who received NMB during HFOV in our study was lower than that previously reported. Future research should evaluate patient outcomes with and without use of NMBs, as well as the potential to manage patients with less sedation.

摘要

背景

几乎所有接受高频振荡通气（HFOV）的患者都接受镇静和神经肌肉阻滞剂（NMB）治疗。

目的

描述急性呼吸窘迫综合征成人患者在接受 HFOV 治疗前和治疗期间使用镇痛镇静和 NMB 的情况。

方法

这是一项回顾性单中心研究，纳入了 2002 年至 2011 年期间接受 HFOV 治疗的 131 例连续成人患者。

结果

在 HFOV 的前 4 天，分别有 89%和 95%的患者接受了镇静和阿片类药物治疗。在开始 HFOV 时，有 119 名（90.8%）患者接受了高于 200μg/h 的芬太尼剂量；其中，48 名患者还接受了高于 20mg/h 的咪达唑仑。镇痛镇静剂量随时间显著增加，第 3 天增加了一倍。与芬太尼剂量高于 200μg/h 相关的独立因素包括：曾使用 NMB（比值比 4.43；95%置信区间 1.26-15.65，p=0.02）、pH 值低于 7.15（比值比 2.08；95%置信区间 1.22-3.5，p=0.007）、氧分压/吸入氧分数恶化（比值比 1.05；95%置信区间 1.00-1.10，p=0.04）和急性生理学和慢性健康评估（APACHE）Ⅱ评分（比值比 0.87；95%置信区间 0.79-0.97，p=0.009）。当不使用 NMB 时，常给予深度镇静，镇静躁动评分 1 或 2 的占 99.2%。86 名患者（65.6%）接受了 NMB 治疗，第 1 天的使用率最高（59.5%）。53.4%的患者每小时测量一次四成肌松监测，29.2%的测量值为 0/4。在 10 年的研究期间，NMB 的使用呈下降趋势。