Washington University School of Medicine in St. Louis, St. Louis, MO.
Emergency Services Institute, Respiratory Institute, Cleveland Clinic Foundation, Cleveland, OH.
Crit Care Med. 2018 Mar;46(3):471-479. doi: 10.1097/CCM.0000000000002885.
Emerging data suggest that early deep sedation may negatively impact clinical outcomes. This systematic review and meta-analysis defines and quantifies the impact of deep sedation within 48 hours of initiation of mechanical ventilation, as described in the world's literature. The primary outcome was mortality. Secondary outcomes included hospital and ICU lengths of stay, mechanical ventilation duration, and delirium and tracheostomy frequency.
The following data sources were searched: MEDLINE, EMBASE, Scopus, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews and Effects, Cochrane Database of Systematic Reviews databases, ClinicalTrials.gov, conference proceedings, and reference lists.
Randomized controlled trials and nonrandomized studies were included.
Two reviewers independently screened abstracts of identified studies for eligibility.
Nine studies (n = 4,521 patients) published between 2012 and 2017 were included. A random effects meta-analytic model revealed that early light sedation was associated with lower mortality (9.2%) versus deep sedation (27.6%) (odds ratio, 0.34 [0.21-0.54]). Light sedation was associated with fewer mechanical ventilation (mean difference, -2.1; 95% CI, -3.6 to -0.5) and ICU days (mean difference, -3.0 (95% CI, -5.4 to -0.6). Delirium frequency was 28.7% in the light sedation group and 48.5% in the deep sedation group, odds ratio, 0.50 (0.22-1.16).
Deep sedation in mechanically ventilated patients, as evaluated in a small number of qualifying heterogeneous randomized controlled trials and observational studies, was associated with increased mortality and lengths of stay. Interventions targeting early sedation depth assessment, starting in the emergency department and subsequent ICU admission, deserve further investigation and could improve outcome.
新出现的数据表明，早期深度镇静可能对临床结果产生负面影响。本系统评价和荟萃分析定义并量化了机械通气开始后 48 小时内深度镇静的影响，这是在世界文献中描述的。主要结果是死亡率。次要结果包括住院和 ICU 住院时间、机械通气时间以及谵妄和气管切开术的频率。
检索了以下数据源：MEDLINE、EMBASE、Scopus、Cochrane 对照试验中心注册库、评论摘要和效果数据库、Cochrane 系统评价数据库、ClinicalTrials.gov、会议记录和参考文献。
纳入了随机对照试验和非随机研究。
两名审查员独立筛选了已确定研究的摘要，以确定其是否符合入选标准。
纳入了 2012 年至 2017 年期间发表的 9 项研究（n=4521 名患者）。随机效应荟萃分析模型显示，早期轻度镇静与深度镇静（27.6%）相比，死亡率较低（9.2%）（比值比，0.34[0.21-0.54]）。轻度镇静与较少的机械通气（平均差，-2.1；95%CI，-3.6 至-0.5）和 ICU 天数（平均差，-3.0；95%CI，-5.4 至-0.6）有关。轻度镇静组的谵妄发生率为 28.7%，深度镇静组为 48.5%，比值比为 0.50（0.22-1.16）。
在为数不多的符合条件的异质随机对照试验和观察性研究中评估的机械通气患者中，深度镇静与死亡率和住院时间延长有关。针对早期镇静深度评估的干预措施，从急诊科开始，并随后进入 ICU 病房，值得进一步研究，可能会改善结果。
