危重症患者的酒精戒断综合征：规范化管理与非规范化管理
Alcohol withdrawal syndrome in critically ill patients: protocolized versus nonprotocolized management.
作者信息
Duby Jeremiah J, Berry Andrew J, Ghayyem Paricheh, Wilson Machelle D, Cocanour Christine S
机构信息
From the Division of Trauma and Emergency Surgery Services (C.S.C.), Department of Surgery, University of California Davis Medical Center, Sacramento, California; Department of Public Health Sciences (M.D.W.), University of California Davis, Sacramento, California; Department of Pharmacy (J.J.D.), University of California Davis Medical Center, Sacramento, California; Touro University (J.J.D.), Vallejo, California; College of Pharmacy (J.J.D.), University of California San Francisco, San Francisco, California; University of California San Diego Thornton Medical Center (P.G.), La Jolla, California; and Banner Good Samaritan Medical Center (A.J.B.), Phoenix, Arizona.
出版信息
J Trauma Acute Care Surg. 2014 Dec;77(6):938-43. doi: 10.1097/TA.0000000000000352.
BACKGROUND
Approximately 18% to 25% of patients with alcohol use disorders admitted to the hospital develop alcohol withdrawal syndrome (AWS). Symptom-triggered dosing of benzodiazepines (BZDs) seems to lead to shorter courses of treatment, lower cumulative BZD dose, and more rapid control of symptoms in non-critically ill patients. This study compares the outcomes of critically ill patients with AWS when treated using a protocolized, symptom-triggered, dose escalation approach versus a nonprotocolized approach.
METHODS
This is a retrospective pre-post study of patients 18 years or older with AWS admitted to an intensive care unit (ICU). The preintervention cohort (PRE) was admitted between February 2008 and February 2010. The postintervention cohort (POST) was admitted between February 2012 and January 2013. The PRE patients were treated by physician preference and compared with POST patients who were given escalating doses of BZDs and/or phenobarbital according to an AWS protocol, titrating to light sedations (Richmond Agitation Sedation Scale score of 0 to -2).
RESULTS
There were 135 episodes of AWS in 132 critically ill patients. POST patients (n = 75) were younger (50.7 [13.8] years vs. 55.7 [8.7] years, p = 0.03) than PRE patients (n = 60). Sequential Organ Failure Assessment (SOFA) scores were higher in the PRE group (6.1 [3.7] vs. 3.9 [2.9], p = 0.0004). There was a significant decrease in mean ICU length of stay from 9.6 (10.5) days to 5.2 (6.4) days (p = 0.0004) in the POST group. The POST group also had significantly fewer ventilator days (5.6 [13.9] days vs. 1.31 [5.6] days, p < 0.0001) as well as a significant decrease in BZD use (319 [1,084] mg vs. 93 [171] mg, p = 0.002). There were significant differences between the two cohorts with respect to the need for continuous sedation (p < 0.001), duration of sedation (p < 0.001), and intubation secondary to AWS (p < 0.001). In all of these outcomes, the POST cohort had a notably lower frequency of occurrence.
CONCLUSION
A protocolized treatment approach of AWS in critically ill patients involving symptom-triggered, dose escalations of diazepam and phenobarbital may lead to a decreased ICU length of stay, decreased time spent on mechanical ventilation, and decreased BZD requirements.
LEVEL OF EVIDENCE
Epidemiologic study, level III; therapeutic study, level IV.
背景
因酒精使用障碍入院的患者中，约18%至25%会发生酒精戒断综合征（AWS）。对于非重症患者，症状触发的苯二氮䓬类药物（BZD）给药似乎可缩短治疗疗程、降低BZD累积剂量并更快控制症状。本研究比较了采用标准化、症状触发、剂量递增方法与非标准化方法治疗重症AWS患者的结局。
方法
这是一项针对入住重症监护病房（ICU）的18岁及以上AWS患者的回顾性前后对照研究。干预前队列（PRE）于2008年2月至2010年2月入院。干预后队列（POST）于2012年2月至2013年1月入院。PRE组患者按医生偏好进行治疗，并与POST组患者进行比较，POST组患者根据AWS方案给予递增剂量的BZD和/或苯巴比妥，滴定至轻度镇静（Richmond躁动镇静量表评分为0至 -2）。
结果
132例重症患者中有135次AWS发作。POST组患者（n = 75）比PRE组患者（n = 60）更年轻（50.7 [13.8]岁对55.7 [8.7]岁，p = 0.03）。PRE组的序贯器官衰竭评估（SOFA）评分更高（6.1 [3.7]对3.9 [2.9]，p = 0.0004）。POST组的平均ICU住院时间从9.6（10.5）天显著减少至5.2（6.4）天（p = 0.0004）。POST组的机械通气天数也显著减少（5.6 [13.9]天对1.31 [5.6]天，p < 0.0001），同时BZD使用量显著减少（319 [1,084] mg对93 [171] mg，p = 0.002）。两组在持续镇静需求（p < 0.001）、镇静持续时间（p < 0.001）以及AWS继发插管方面（p < 0.001）存在显著差异。在所有这些结局方面，POST队列的发生频率明显更低。
结论
对重症患者采用标准化的AWS治疗方法，即症状触发、地西泮和苯巴比妥剂量递增，可能会缩短ICU住院时间、减少机械通气时间并降低BZD需求量。
证据级别
流行病学研究，III级；治疗性研究，IV级。
Zotero 插件