Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee.
Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee.
Pharmacotherapy. 2019 Mar;39(3):271-279. doi: 10.1002/phar.2225. Epub 2019 Feb 27.
The appropriate level of sedation in patients with an open abdomen following damage control laparotomy (DCL) is debated. Chemical paralysis with neuromuscular blocking agents (NMBAs) has been used to decrease time to abdominal closure. We sought to evaluate the effect of NMBA use on sedation requirements in patients with an open abdomen and to determine the effect of sedation on patient outcomes. A retrospective cohort study was conducted at an American College of Surgeons' verified level 1 trauma center. Adult trauma patients who underwent DCL between 2009 and 2015 were included. Patients with an intensive care unit length of stay of less than 48 hours and those who died before abdominal closure were excluded. The NMBA+ group received continuous NMBA within 24 hours of DCL; the NMBA- group did not. The primary outcome was cumulative sedation dose during the 7 days following DCL. Secondary outcomes included Richmond Agitation-Sedation Scale (RASS) score, mechanical ventilation-free days, and delirium-coma-free days. Delirium-coma-free days were analyzed with linear regression. A total of 222 patients were included (NMBA+ 125; NMBA- 97). Demographics were similar between groups including age, Injury Severity Score, and mechanism of injury. The median time to closure in the overall cohort was 2 days (interquartile range [IQR] 1-2 days). Propofol and fentanyl were the primary sedatives used. The NMBA+ group received higher cumulative doses of propofol (NMBA+ 5405 mg, IQR 3103-10,573 mg; NMBA- 3601 mg, IQR 1605-6887 mg; p=0.007), but not of fentanyl. Time to abdominal closure, but not NMBA use, was associated with a higher cumulative propofol dose on multivariate analysis. The NMBA+ group had significantly lower RASS scores on the first 3 days following DCL. Mechanical ventilation-free days (NMBA+ 20 days vs NMBA- 18 days, p=0.960) and delirium-coma-free days (NMBA+ 18 days vs NMBA- 18 days, p=0.610) were similar between the groups. On linear regression, cumulative propofol dose was associated with fewer delirium-coma-free days (β-coefficient -0.007, 95% confidence interval -0.015 to -0.003). In trauma patients managed with DCL, higher cumulative sedative doses were administered in patients who received adjunctive NMBA, although NMBA therapy was not associated with a higher cumulative propofol dose on multivariate analysis. Consideration must be given to the potential effect of sedation on delirium and awakening following DCL.
在接受损伤控制性剖腹术（DCL）后的开放性腹部患者中，镇静的适当水平存在争议。使用神经肌肉阻滞剂（NMBA）进行化学麻痹已被用于减少腹部闭合的时间。我们旨在评估 NMBA 在开放性腹部患者中的镇静需求中的作用，并确定镇静对患者结局的影响。一项在美国外科医师学会认证的 1 级创伤中心进行的回顾性队列研究。纳入了 2009 年至 2015 年间接受 DCL 的成年创伤患者。排除了 ICU 住院时间少于 48 小时和在腹部闭合前死亡的患者。NMBA+组在 DCL 后 24 小时内持续接受 NMBA；NMBA-组未接受 NMBA。主要结局是 DCL 后 7 天内的累积镇静剂量。次要结局包括 Richmond 躁动-镇静量表（RASS）评分、无机械通气天数和无谵妄-昏迷天数。使用线性回归分析无谵妄-昏迷天数。共纳入 222 例患者（NMBA+125 例；NMBA-97 例）。两组之间的人口统计学特征相似，包括年龄、损伤严重程度评分和损伤机制。总体队列中关闭的中位数时间为 2 天（四分位距[IQR]1-2 天）。丙泊酚和芬太尼是主要的镇静剂。NMBA+组接受了更高剂量的丙泊酚（NMBA+5405mg，IQR 3103-10573mg；NMBA-3601mg，IQR 1605-6887mg；p=0.007），但芬太尼剂量没有增加。多变量分析表明，腹部闭合时间而不是 NMBA 的使用与更高的累积丙泊酚剂量相关。NMBA+组在 DCL 后第 1-3 天的 RASS 评分明显更低。无机械通气天数（NMBA+20 天 vs NMBA-18 天，p=0.960）和无谵妄-昏迷天数（NMBA+18 天 vs NMBA-18 天，p=0.610）两组之间相似。在线性回归中，累积丙泊酚剂量与无谵妄-昏迷天数减少相关（β系数-0.007，95%置信区间-0.015 至-0.003）。在接受 DCL 治疗的创伤患者中，接受辅助 NMBA 的患者接受了更高剂量的累积镇静剂，尽管 NMBA 治疗与多变量分析中更高的累积丙泊酚剂量无关。必须考虑镇静对 DCL 后谵妄和觉醒的潜在影响。
