1 Department of Medicine, McGill University, Montreal, Quebec, Canada.
2 Regroupement de Soins Critiques Respiratoires, Réseau de Santé Respiratoire, Fonds de Recherche du Québec-Santé, Montréal, Québec, Canada.
Am J Respir Crit Care Med. 2018 May 1;197(9):1147-1156. doi: 10.1164/rccm.201710-1995OC.
Dexmedetomidine is associated with less delirium than benzodiazepines and better sleep architecture than either benzodiazepines or propofol; its effect on delirium and sleep when administered at night to patients requiring sedation remains unclear.
To determine if nocturnal dexmedetomidine prevents delirium and improves sleep in critically ill adults.
This two-center, double-blind, placebo-controlled trial randomized 100 delirium-free critically ill adults receiving sedatives to receive nocturnal (9:30 p.m. to 6:15 a.m.) intravenous dexmedetomidine (0.2 μg/kg/h, titrated by 0.1 μg /kg/h every 15 min until a goal Richmond Agitation and Sedation Scale score of -1 or maximum rate of 0.7 μg/kg/h was reached) or placebo until ICU discharge. During study infusions, all sedatives were halved; opioids were unchanged. Delirium was assessed using the Intensive Care Delirium Screening Checklist every 12 hours throughout the ICU admission. Sleep was evaluated each morning by the Leeds Sleep Evaluation Questionnaire.
Nocturnal dexmedetomidine (vs. placebo) was associated with a greater proportion of patients who remained delirium-free during the ICU stay (dexmedetomidine [40 (80%) of 50 patients] vs. placebo [27 (54%) of 50 patients]; relative risk, 0.44; 95% confidence interval, 0.23-0.82; P = 0.006). The average Leeds Sleep Evaluation Questionnaire score was similar (mean difference, 0.02; 95% confidence interval, 0.42-1.92) between the 34 dexmedetomidine (average seven assessments per patient) and 30 placebo (six per patient) group patients able to provide one or more assessments. Incidence of hypotension, bradycardia, or both did not differ significantly between groups.
Nocturnal administration of low-dose dexmedetomidine in critically ill adults reduces the incidence of delirium during the ICU stay; patient-reported sleep quality appears unchanged. Clinical trial registered with www.clinicaltrials.gov (NCT01791296).
右美托咪定与苯二氮䓬类药物相比，致谵妄发生率更低，与苯二氮䓬类药物或丙泊酚相比，睡眠结构更佳；但其在需要镇静的患者夜间给药时对谵妄和睡眠的影响尚不清楚。
确定夜间给予右美托咪定是否可预防危重症成人患者发生谵妄并改善睡眠。
这项双中心、双盲、安慰剂对照试验将 100 例无谵妄的危重症患者随机分为两组，镇静组患者在夜间（9:30 至 6:15）接受静脉内右美托咪定（0.2μg/kg/h，每 15 分钟滴定 0.1μg/kg/h，直至达到目标 Richmond 躁动镇静量表评分-1 或最大速率 0.7μg/kg/h）或安慰剂，直至 ICU 出院。在研究输注期间，所有镇静药物均减半；阿片类药物不变。在 ICU 住院期间，每 12 小时使用 ICU 谵妄筛查检查表评估谵妄。每天早上使用利兹睡眠评估问卷评估睡眠。
与安慰剂相比，夜间右美托咪定（右美托咪定[50 例患者中的 40 例（80%）] vs. 安慰剂[50 例患者中的 27 例（54%）]）更能使患者在 ICU 住院期间保持无谵妄状态（相对风险，0.44；95%置信区间，0.23-0.82；P=0.006）。利兹睡眠评估问卷的平均评分相似（平均差异，0.02；95%置信区间，0.42-1.92），34 例接受右美托咪定（每名患者平均七次评估）和 30 例接受安慰剂（每名患者六次评估）的患者中有一人或多人能够提供一次或多次评估。低血压、心动过缓或两者均无显著差异。
在危重症成人中夜间给予低剂量右美托咪定可降低 ICU 住院期间谵妄的发生率；患者报告的睡眠质量似乎没有改变。临床试验已在 www.clinicaltrials.gov（NCT01791296）注册。
