Cammarano W B, Pittet J F, Weitz S, Schlobohm R M, Marks J D
Department of Anesthesia, University of California, San Francisco at San Francisco General Hospital, 94110, USA.
Crit Care Med. 1998 Apr;26(4):676-84. doi: 10.1097/00003246-199804000-00015.
To estimate the frequency of acute withdrawal syndrome related to the administration of analgesic and sedative medications in mechanically ventilated adult intensive care unit (ICU) patients; to identify associated clinical factors.
Retrospective review of medical records.
An adult trauma/surgical ICU in an urban Level I trauma center.
Twenty-eight mechanically ventilated adult trauma/ surgical ICU patients requiring >7 days of ICU care.
None.
Daily doses of all opioid, sedative, hypnotic, and major tranquilizer drugs administered to each patient were measured, as was duration of ICU stay, duration of mechanical ventilation, and duration of the administration of analgesic, sedative, and neuromuscular blocking agents (NMBAs) for each patient. All opioids and benzodiazepines were converted to their respective fentanyl and lorazepam equivalent units based on potency and bioavailability. Calculation of the weaning rate for each patient during tapering from opioid and benzodiazepine medications was performed. The presence or absence of acute withdrawal syndrome was identified for each patient. Nine (32.1%) patients developed acute withdrawal syndrome potentially related to the administration of analgesic or sedative medications. Patients in the withdrawal group received significantly higher mean daily (p = .049) and peak (p = .032) doses of fentanyl equivalents, as well as higher mean daily lorazepam equivalents (p = .049) compared with patients not experiencing withdrawal. Patients in the withdrawal group were also significantly more likely to have received neuromuscular blocking agents (p = .004) or propofol (p =.026) for >1 day during ICU admission compared with patients not experiencing withdrawal. Duration of mechanical ventilation (p = .049), benzodiazepine therapy (p = .048), and propofol therapy (p = .049) was also significantly longer in the group experiencing withdrawal. Withdrawal patients received a significantly lower mean daily dose of haloperidol (p = .026). There was a significant association between the development of withdrawal syndrome and the presence of ARDS (p = .017). Finally, the slopes of the lines representing opioid and benzodiazepine drug weaning were more steep for the withdrawal group, although these results did not achieve statistical significance.
These results suggest that mechanically ventilated adult patients with extended ICU care (> or =7 days) who receive large doses of analgesic and sedative medications are at risk for acute withdrawal syndromes during drug weaning. The association between ARDS and withdrawal syndrome, combined with the observation that withdrawal syndromes were also associated with the use of neuromuscular blocking agents and prolonged mechanical ventilation, suggests that patients with ARDS may be more likely to receive high doses of analgesic and sedative medications, and are therefore at increased risk for withdrawal syndrome.
评估在接受机械通气的成年重症监护病房（ICU）患者中，与镇痛和镇静药物使用相关的急性戒断综合征的发生率；确定相关的临床因素。
病历回顾性研究。
城市一级创伤中心的成人创伤/外科ICU。
28名接受机械通气的成年创伤/外科ICU患者，需要在ICU接受超过7天的治疗。
无。
记录每位患者使用的所有阿片类、镇静、催眠和主要安定类药物的每日剂量，以及每位患者的ICU住院时间、机械通气时间、镇痛、镇静和神经肌肉阻滞剂（NMBA）的使用时间。根据效价和生物利用度，将所有阿片类药物和苯二氮䓬类药物换算为各自的芬太尼和劳拉西泮等效单位。计算每位患者在阿片类和苯二氮䓬类药物减量过程中的撤药率。确定每位患者是否出现急性戒断综合征。9名（32.1%）患者出现了可能与镇痛或镇静药物使用相关的急性戒断综合征。与未出现戒断症状的患者相比，戒断组患者接受的芬太尼等效物的平均每日剂量（p = 0.049）和峰值剂量（p = 0.032）显著更高，劳拉西泮等效物的平均每日剂量也更高（p = 0.049）。与未出现戒断症状的患者相比，戒断组患者在ICU住院期间接受神经肌肉阻滞剂（p = 0.004）或丙泊酚（p = 0.026）超过1天的可能性也显著更高。戒断组的机械通气时间（p = 0.049）、苯二氮䓬类药物治疗时间（p = 0.048）和丙泊酚治疗时间（p = 0.049）也显著更长。戒断患者接受的氟哌啶醇平均每日剂量显著更低（p = 0.026）。戒断综合征的发生与急性呼吸窘迫综合征（ARDS）的存在之间存在显著关联（p = 0.017）。最后，尽管这些结果未达到统计学显著性，但代表阿片类和苯二氮䓬类药物撤药过程的直线斜率在戒断组中更陡。
这些结果表明，接受大剂量镇痛和镇静药物治疗且ICU治疗时间延长（≥7天）的接受机械通气的成年患者在药物撤减过程中存在急性戒断综合征的风险。ARDS与戒断综合征之间的关联，以及戒断综合征也与神经肌肉阻滞剂的使用和机械通气时间延长相关的观察结果，表明ARDS患者可能更有可能接受高剂量的镇痛和镇静药物，因此发生戒断综合征的风险增加。
