Marx C M, Rosenberg D I, Ambuel B, Hamlett K W, Blumer J L
Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH.
Pediatrics. 1993 Feb;91(2):369-78.
Children hospitalized in a pediatric intensive care unit are frequently distressed. The purpose of this study was to identify the patterns of use of sedative agents in pediatric critical care patients. A questionnaire survey was mailed to 45 directors of Pediatric Critical Care Fellowship Training Programs listed in Critical Care Medicine, January 1989. The response rate was 75.6% (34 questionnaires). The most commonly identified goals of sedation were reduced patient discomfort or distress and fewer unplanned extubations. The agents most frequently employed for this purpose were opioids (morphine or fentanyl), chloral hydrate, or benzodiazepines. Although conventional doses are used, opioids and benzodiazepines are often given hourly or by continuous infusion. Satisfaction with the efficacy and safety of commonly used opioids was greater (most common response "very satisfied") than for the benzodiazepines ("somewhat satisfied"). The physician's or nurse's clinical impression was reported to be the "most important" criterion for deciding when a patient required a dose of sedative; objective criteria were selected as less important. The majority of patients (65.7%) in the surveyed units were ideally "sedated to the point of no distress with as-needed medication." The majority of respondents (76.4%) identified efficacy as the major problem with sedation. Drug withdrawal was considered to be the major problem with sedative use by only a minority of respondents (6.9%). Although withdrawal is seen in 61.8% of units, it is generally treated when recognized, rather than prevented by routine tapering of sedation. Optimal sedation of pediatric intensive care unit patients is considered problematic, despite the use of frequent doses of many sedatives. Systematic investigation of pharmacodynamic response to these agents in the pediatric critical care population is indicated.
入住儿科重症监护病房的儿童经常会感到痛苦。本研究的目的是确定儿科重症监护患者中镇静剂的使用模式。向1989年1月《危重病医学》中列出的45个儿科重症监护专科培训项目主任邮寄了一份问卷调查。回复率为75.6%（34份问卷）。最常确定的镇静目标是减轻患者不适或痛苦以及减少意外拔管。为此最常使用的药物是阿片类药物（吗啡或芬太尼）、水合氯醛或苯二氮䓬类药物。尽管使用的是常规剂量，但阿片类药物和苯二氮䓬类药物通常每小时给药或持续输注。对常用阿片类药物疗效和安全性的满意度更高（最常见的回答是“非常满意”），高于苯二氮䓬类药物（“有些满意”）。据报告，医生或护士的临床印象是决定患者何时需要一剂镇静剂的“最重要”标准；客观标准被认为不太重要。接受调查的单位中，大多数患者（65.7%）理想情况下是“根据需要用药镇静至无痛苦状态”。大多数受访者（76.4%）认为疗效是镇静的主要问题。只有少数受访者（6.9%）认为药物戒断是使用镇静剂的主要问题。尽管在61.8%的单位中可见戒断情况，但通常在识别后进行治疗，而不是通过常规逐渐减少镇静剂量来预防。尽管使用了多种镇静剂的频繁剂量，但儿科重症监护病房患者的最佳镇静仍被认为存在问题。有必要对儿科重症监护人群中这些药物的药效学反应进行系统研究。
