Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama.
Department of Nursing Services, Children's of Alabama, Birmingham, Alabama.
Respir Care. 2022 Nov;67(11):1385-1395. doi: 10.4187/respcare.09942. Epub 2022 Jul 12.
Recent studies reported that children on mechanical ventilation who were managed with an analgosedation approach and standardized extubation readiness testing experienced better outcomes, including decreased delirium and invasive mechanical ventilation duration.
This was a quality improvement project in a 24-bed pediatric ICU within a single center, including subjects ≤ 18 years old who required invasive mechanical ventilation via an oral or nasal endotracheal tube. The aim was to decrease the invasive mechanical ventilation duration for all the subjects by 25% within 9 months through the development and implementation of bundled benzodiazepine-sparing analgosedation and extubation readiness testing clinical pathways.
In the pre-implementation cohort, there were 274 encounters, with 253 (92.3%) that met inclusion for ending in an extubation attempt. In the implementation cohort, there were 367 encounters with 332 (90.5%) that ended in an extubation attempt. The mean invasive mechanical ventilation duration decreased by 23% (Pre 3.95 d vs Post 3.1 d; = .039) after the implementation without a change in the mean pediatric ICU length of stay (Pre 7.5 d vs Post 6.5 d; = .42). No difference in unplanned extubation ( > .99) or extubation failure rates ( = .67) were demonstrated. Sedation levels as evaluated by the mean State Behavioral Scale were similar (Pre -1.0 vs Post -1.1; = .09). The median total benzodiazepine dose administered decreased by 75% (Pre 0.4 vs Post 0.1 mg/kg/ventilated day; < .001). No difference in narcotic withdrawal (Pre 17.8% vs Post 16.4%; = .65) or with delirium treatment (Pre 5.5% vs Post 8.7%; = .14) was demonstrated.
A multidisciplinary, bundled benzodiazepine-sparing analgosedation and extubation readiness testing approach resulted in a reduction in mechanical ventilation duration and benzodiazepine exposure without impacting key balancing measures. External validity needs to be evaluated in similar centers and consensus on best practices developed.
最近的研究报告表明，接受镇痛镇静管理和标准化拔管准备测试的机械通气患儿的预后更好，包括降低谵妄和有创机械通气时间。
这是一项在一家单中心的 24 张床位儿科 ICU 中进行的质量改进项目，包括需要通过口腔或鼻腔气管内插管进行有创机械通气的≤18 岁的患者。目的是通过制定和实施包含苯二氮䓬类药物节省的镇痛镇静和拔管准备测试临床路径，在 9 个月内将所有患者的有创机械通气时间减少 25%。
在实施前队列中，有 274 次就诊，其中 253 次（92.3%）以拔管尝试结束。在实施队列中，有 367 次就诊，其中 332 次（90.5%）以拔管尝试结束。实施后，有创机械通气时间平均减少 23%（实施前 3.95 天，实施后 3.1 天；=.039），而儿科 ICU 住院时间的平均时间没有变化（实施前 7.5 天，实施后 6.5 天；=.42）。未计划的拔管（>.99）或拔管失败率（=.67）无差异。镇静水平（评估为平均状态行为量表）相似（实施前-1.0，实施后-1.1；=.09）。给予的总苯二氮䓬类药物剂量中位数减少了 75%（实施前 0.4 毫克/公斤/通气日，实施后 0.1 毫克/公斤/通气日；<.001）。在戒断症状（实施前 17.8%，实施后 16.4%；=.65）或谵妄治疗（实施前 5.5%，实施后 8.7%；=.14）方面无差异。
多学科、包含苯二氮䓬类药物节省的镇痛镇静和拔管准备测试方法可减少机械通气时间和苯二氮䓬类药物暴露，而不会影响关键平衡措施。需要在类似的中心评估外部有效性，并制定最佳实践的共识。
