Cai Xiao-Fang, Zhang Fu-Rong, Zhang Long, Sun Ji-Min, Li Wen-Bin
Intensive Care Unit, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430016, China.
Zhongguo Dang Dai Er Ke Za Zhi. 2017 Nov;19(11):1138-1144. doi: 10.7499/j.issn.1008-8830.2017.11.003.
To compare the efficacy and safety of different analgesic and sedative treatments in children with mechanical ventilation in the pediatric intensive care unit (PICU).
Eighty children with mechanical ventilation in the PICU who needed analgesic and sedative treatments were equally and randomly divided into midazolam group and remifentanil+midazolam group. The sedative and analgesic effects were assessed using the Ramsay Scale and the Face, Legs, Activity, Cry and Consolability (FLACC) Scale. The following indices were recorded for the two groups: vital signs, ventilator parameters, organ function, total doses of remifentanil and midazolam, duration of mechanical ventilation, length of PICU stay, PICU cost, and incidence of adverse events.
Satisfactory sedation was achieved in the two groups, but the remifentanil+midazolam group had a significantly shorter time to analgesia and sedation than the midazolam group. The remifentanil+midazolam group had a significantly higher percentage of patients with grade 3-4 on the Ramsay Scale and a significantly lower dose of midazolam than the midazolam group (P<0.05). Both groups showed decreases in heart rate (HR), mean arterial pressure (MAP), and spontaneous breathing frequency (RRs) after treatment. However, the remifentanil+midazolam group had significantly greater decreases in HR at 3-24 hours after treatment and MAP and RRs at 3-12 hours after treatment than the midazolam group (P<0.05). Compared with the midazolam group, the remifentanil+midazolam group had significantly higher ventilator tidal volume and transcutaneous oxygen saturation at 6 and 12 hours after treatment and significantly lower end-tidal carbon dioxide partial pressure at 6 and 12 hours after treatment (P<0.05). The remifentanil+midazolam group had significantly shorter time to awake, extubation time, duration of mechanical ventilation, and length of PICU stay than the midazolam group (P<0.05). There were no significant differences in PICU cost, incidence of adverse events, and hepatic and renal functions before and after treatment between the two groups (P>0.05). Both groups showed a significant decrease in fasting blood glucose level after treatment (P<0.05).
For children with mechanical ventilation in the PICU, remifentanil+midazolam treatment can rapidly achieve analgesia and sedation, improve the effect of mechanical ventilation, and reduce the dose of sedative compared with midazolam alone, and is well tolerated.
比较小儿重症监护病房（PICU）中不同镇痛和镇静治疗方法对机械通气患儿的疗效及安全性。
将80例PICU中需要进行镇痛和镇静治疗的机械通气患儿平均随机分为咪达唑仑组和瑞芬太尼+咪达唑仑组。采用Ramsay评分量表和面部、腿部、活动、哭闹及安慰（FLACC）评分量表评估镇静和镇痛效果。记录两组患儿的以下指标：生命体征、呼吸机参数、器官功能、瑞芬太尼和咪达唑仑的总剂量、机械通气时间、PICU住院时间、PICU费用及不良事件发生率。
两组均达到满意的镇静效果，但瑞芬太尼+咪达唑仑组的镇痛和镇静起效时间明显短于咪达唑仑组。瑞芬太尼+咪达唑仑组Ramsay评分3-4级的患者比例明显高于咪达唑仑组，且咪达唑仑剂量明显低于咪达唑仑组（P<0.05）。两组治疗后心率（HR）、平均动脉压（MAP）和自主呼吸频率（RRs）均下降。然而，瑞芬太尼+咪达唑仑组治疗后3-24小时的HR下降幅度以及治疗后3-12小时的MAP和RRs下降幅度均明显大于咪达唑仑组（P<0.05）。与咪达唑仑组相比，瑞芬太尼+咪达唑仑组治疗后6小时和12小时的呼吸机潮气量和经皮血氧饱和度明显更高，治疗后6小时和12小时的呼气末二氧化碳分压明显更低（P<0.05）。瑞芬太尼+咪达唑仑组的清醒时间、拔管时间、机械通气时间和PICU住院时间明显短于咪达唑仑组（P<0.05）。两组在PICU费用、不良事件发生率以及治疗前后的肝肾功能方面均无显著差异（P>0.05）。两组治疗后空腹血糖水平均显著下降（P<0.05）。
对于PICU中机械通气的患儿，与单独使用咪达唑仑相比，瑞芬太尼+咪达唑仑治疗可快速实现镇痛和镇静，改善机械通气效果，减少镇静剂剂量，且耐受性良好。
