George Brendan P, Vakkalanka J Priyanka, Harland Karisa K, Faine Brett, Rewitzer Stacey, Zepeski Anne, Fuller Brian M, Mohr Nicholas M, Ahmed Azeemuddin
Prehosp Emerg Care. 2020 Nov-Dec;24(6):783-792. doi: 10.1080/10903127.2019.1705948. Epub 2020 Jan 23.
: Analgesics, sedatives, and neuromuscular blockers are commonly used medications for mechanically ventilated air medical transport patients. Prior research in the emergency department (ED) and intensive care unit (ICU) has demonstrated that depth of sedation is associated with increased mechanical ventilation duration, delirium, increased hospital length-of-stay (LOS), and decreased survival. The objectives of this study were to evaluate current sedation practices in the prehospital setting and to determine the impact on clinical outcomes. : A retrospective cohort study of mechanically ventilated patients transferred by air ambulance to a single 812-bed Midwestern academic medical center from July 2013 to May 2018 was conducted. Prehospital sedation medications and depth of sedation [Richmond Agitation-Sedation Scale score (RASS)] were measured. Primary outcome was hospital LOS. Secondary outcomes were delirium, length of mechanical ventilation, in-hospital mortality, and need for neurosurgical procedures. Univariate analyses were used to measure the association between sedatives, sedation depth, and clinical outcomes. Multivariable models adjusted for potentially confounding covariates to measure the impact of predictors on clinical outcomes. : Three hundred twenty-seven patients were included. Among those patients, 79.2% of patients received sedatives, with 41% of these patients achieving deep sedation (RASS = -4). Among patients receiving sedation, 58.3% received at least one dose of benzodiazepines. Moderate and deep sedation was associated with an increase in LOS of 59% (aRR: 1.59; 95% CI: 1.40-1.81) and 24% (aRR: 1.24; 95% CI: 1.10-1.40), respectively. Benzodiazepines were associated with a mean increase of 2.9 days in the hospital (95% CI, 0.7-5.1). No association existed between either specific medications or depth of sedation and the development of delirium. : Prehospital moderate and deep sedation, as well as benzodiazepine administration, is associated with increased hospital LOS. Our findings point toward sedation being a modifiable risk factor and suggest an important need for further research of sedation practices in the prehospital setting.
镇痛药、镇静剂和神经肌肉阻滞剂是机械通气的空中医疗转运患者常用的药物。先前在急诊科（ED）和重症监护病房（ICU）的研究表明，镇静深度与机械通气时间延长、谵妄、住院时间（LOS）延长及生存率降低有关。本研究的目的是评估院前环境下当前的镇静实践，并确定其对临床结局的影响。
对2013年7月至2018年5月通过空中救护车转运至一家拥有812张床位的中西部学术医疗中心的机械通气患者进行了一项回顾性队列研究。测量了院前镇静药物和镇静深度[里士满躁动 - 镇静量表评分（RASS）]。主要结局是住院LOS。次要结局是谵妄、机械通气时间、院内死亡率以及神经外科手术需求。采用单因素分析来衡量镇静剂、镇静深度与临床结局之间的关联。多变量模型对潜在的混杂协变量进行了调整，以衡量预测因素对临床结局的影响。
纳入了327例患者。在这些患者中，79.2%的患者接受了镇静剂，其中41%的患者达到深度镇静（RASS = -4）。在接受镇静的患者中，58.3%至少接受了一剂苯二氮䓬类药物。中度和深度镇静分别与LOS增加59%（aRR：1.59；95%CI：1.40 - 1.81）和24%（aRR：1.24；95%CI：1.10 - 1.40）相关。苯二氮䓬类药物与住院时间平均增加2.9天相关（95%CI，0.7 - 5.1）。特定药物或镇静深度与谵妄的发生之间均无关联。
院前中度和深度镇静以及苯二氮䓬类药物的使用与住院LOS增加有关。我们的研究结果表明镇静是一个可改变的风险因素，并表明迫切需要进一步研究院前环境下的镇静实践。
