Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA; Department of Medicine, Brigham and Women's Hospital, Boston, MA.
Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA.
Chest. 2016 Jun;149(6):1373-9. doi: 10.1378/chest.15-1389. Epub 2016 Jan 11.
Current sedation guidelines recommend avoiding benzodiazepines but express no preference for propofol vs dexmedetomidine. In addition, few data exist on whether randomized controlled trials of sedatives can be successfully generalized to routine practice, in which conditions tend to be more varied and complex.
Data regarding daily sedative exposure were gathered from all patients undergoing mechanical ventilation for ≥ 3 days over a 7-year period in a large academic medical center. Hazard ratios (HRs) were compared for ventilator-associated events (VAEs), extubation, hospital discharge, and hospital death among patients receiving benzodiazepines, propofol, and dexmedetomidine. Proportional subdistribution hazard models with competing risks were used for analysis. All analyses were adjusted for ICU type, demographic characteristics, comorbidities, procedures, severity of illness, hypotension, oxygenation, renal function, opioids, neuroleptic agents, neuromuscular blockers, awakening and breathing trials, and calendar year.
A total of 9,603 consecutive episodes of mechanical ventilation were evaluated. Benzodiazepines and propofol were associated with increased VAE risk, whereas dexmedetomidine was not. Propofol was associated with less time to extubation compared with benzodiazepines (HR, 1.4; 95% CI, 1.3-1.5). Dexmedetomidine was associated with less time to extubation compared with benzodiazepines (HR, 2.3; 95% CI, 2.0-2.7) and propofol (HR, 1.7; 95% CI, 1.4-2.0), but relatively few dexmedetomidine exposures were available for analysis. There were no differences between any two agents in HRs for hospital discharge or mortality.
In this large, real-world cohort, propofol and dexmedetomidine were associated with less time to extubation compared with benzodiazepines, but dexmedetomidine was also associated with less time to extubation vs propofol. These possible differences merit further study.
目前的镇静指南建议避免使用苯二氮䓬类药物，但并未对丙泊酚与右美托咪定的使用偏好做出推荐。此外，关于镇静剂的随机对照试验是否可以成功推广到常规实践中，存在的相关数据很少，因为常规实践中的情况往往更加多样化和复杂。
在一家大型学术医疗中心，对 7 年间接受机械通气治疗超过 3 天的所有患者的每日镇静暴露数据进行了收集。使用风险比（HR）比较了接受苯二氮䓬类药物、丙泊酚和右美托咪定的患者的呼吸机相关性事件（VAE）、拔管、出院和住院死亡的发生率。采用带有竞争风险的比例亚分布风险模型进行分析。所有分析均根据 ICU 类型、人口统计学特征、合并症、操作、疾病严重程度、低血压、氧合、肾功能、阿片类药物、神经安定药、神经肌肉阻滞剂、唤醒和呼吸试验以及日历年份进行了调整。
共评估了 9603 例连续机械通气发作。与苯二氮䓬类药物和丙泊酚相比，右美托咪定与 VAE 风险增加无关。与苯二氮䓬类药物相比，丙泊酚可使拔管时间更短（HR，1.4；95%CI，1.3-1.5）。与苯二氮䓬类药物（HR，2.3；95%CI，2.0-2.7）和丙泊酚（HR，1.7；95%CI，1.4-2.0）相比，右美托咪定也可使拔管时间更短，但可用于分析的右美托咪定暴露相对较少。在任何两种药物的 HR 方面，在出院或死亡率方面没有差异。
在这项大型真实世界队列研究中，与苯二氮䓬类药物相比，丙泊酚和右美托咪定与拔管时间更短相关，但与丙泊酚相比，右美托咪定与拔管时间更短相关。这些可能的差异值得进一步研究。
