Department of Anesthesia and Critical Care, Hôpital Guillaume et René Laennec, University Hospital of Nantes, Boulevard Jacques Monod, Saint-Herblain 44800, France.
Medical Intensive Care Unit, Hôpital Lapeyronie, Montpellier University and MontpellierTeaching Hospital, 191, Avenue du Doyen Gaston Giraud, MontpellierCedex 5, Montpellier, 34295, France.
Burns. 2020 Sep;46(6):1310-1317. doi: 10.1016/j.burns.2020.02.009. Epub 2020 Mar 8.
Severe burn patients undergo prolonged administration of sedatives and analgesics for burn care. There are currently no guidelines for the dose adaptation of sedation-analgesia in severe burn patients.
We performed a before-after 2-center study to demonstrate the feasibility and efficacy of a sedation-analgesia scale-based protocol in severely burned patients receiving ≥24h of invasive mechanical ventilation. Before the intervention, continuous infusion of hypnotic and morphine derivatives was continued. During the Intervention phase, general anesthesia was relayed from day 1 by RASS/BPS-titrated continuous infusion of hypnotic and morphine derivatives and with short half-life drugs adminstered for daily burn dressings. The primary outcome was the duration of invasive mechanical ventilation in the ICU.
Eighty-seven (46.2%) patients were included in the Control phase and 101 (53.7%) in the Intervention phase. The median burned cutaneous surface was 20% [11%-38%] and median ABSI was 7 [5-9]. The durations of hypnotic and opioid infusions were not statistically different between the 2 phases (8 days [2-24] vs. 6 days [2-17] (P=0.3) and 17 days [4-32] vs. 8 days [3-23] (P=0.06), respectively). The duration of mechanical ventilation was 14 days [3-29] in the Control phase and 7 days [2-24] in the Intervention phase (P=0.7). When taking into account the competition between mortality and weaning from mechanical ventilation, we found no significant difference between the 2 phases (Gray test, P=0.4). The time-series analysis showed no difference for the duration of mechanical ventilation in the Intervention phase (P=0.6). Eighteen (20.7%) patients died in the Control phase, and 18 (18%) in the Intervention phase (P=0.6).
Scale-based lightening of continuous sedation-analgesia with repeated short general anesthesia for dressing is feasible in severe burn patients but failed to demonstrate a decrease in the duration of invasive mechanical ventilation.
严重烧伤患者在烧伤护理过程中需要长时间使用镇静剂和镇痛药。目前，尚无严重烧伤患者镇静-镇痛剂量调整的指南。
我们进行了一项前后 2 中心研究，以证明在接受≥24 小时有创机械通气的严重烧伤患者中，基于镇静-镇痛量表的方案的可行性和疗效。在干预前，继续持续输注催眠药和吗啡衍生物。在干预阶段，从第 1 天开始通过 RASS/BPS 滴定的催眠药和吗啡衍生物持续输注，并给予半衰期短的药物进行每日烧伤换药，从而实现从全身麻醉的转换。主要结局是 ICU 中有创机械通气的持续时间。
共有 87 例（46.2%）患者纳入对照组，101 例（53.7%）患者纳入干预组。中位烧伤皮肤面积为 20%[11%-38%]，中位 ABSI 为 7[5-9]。2 个阶段之间催眠药和阿片类药物输注的持续时间无统计学差异（8 天[2-24]与 6 天[2-17]（P=0.3）和 17 天[4-32]与 8 天[3-23]（P=0.06））。对照组机械通气时间为 14 天[3-29]，干预组为 7 天[2-24]（P=0.7）。考虑到死亡率和机械通气撤机之间的竞争，我们发现 2 个阶段之间无显著差异（Gray 检验，P=0.4）。时间序列分析显示干预组机械通气持续时间无差异（P=0.6）。对照组 18 例（20.7%）患者死亡，干预组 18 例（18%）患者死亡（P=0.6）。
在严重烧伤患者中，重复短暂全身麻醉减轻持续镇静-镇痛并进行重复每日烧伤换药是可行的，但未能证明有创机械通气持续时间缩短。
