早期目标导向型镇静策略对术后机械通气患者的临床效果观察

目的：探讨早期目标导向型镇静策略（EGDS）治疗用于重症监护病房（ICU）机械通气患者的临床效果观察。方法：选取2016年1月—2021年6月我院收治的84例术后带气管插管需继续行机械通气(MV)治疗的非昏迷ICU患者,按照随机数字表法分为治疗组(n=42)和对照组(n=42)。治疗组以右美托咪定作为主要镇静剂,丙泊酚辅助微调镇静的EGDS对ICU机械通气患者进行治疗;对照组以咪达唑仑作为镇静剂进行治疗。结果：与对照组相比,EGDS可提高48 h内达到浅镇静目标（RASS评分-2～+1）的比例、24 h自主呼吸试验（SBT）通过率,减少患者MV时间、ICU入住时间、住院时间及谵妄的发生率（P<0.05）。结论：在早期镇痛基础上应用以右美托咪定为主导、丙泊酚为辅助微调的EGDS方案具有较好的安全性和有效性。     

eCASH理念结合早期活动在ICU机械通气患者的应用研究

目的探讨eCASH理念结合早期活动在ICU机械通气患者中的应用效果。方法将96例ICU机械通气患者按入院时间分为对照组和观察组各48例,对照组给予常规镇痛镇静及护理,观察组实施基于eCASH理念的舒适化浅镇静管理结合早期活动。结果观察组谵妄发生率和ICU获得性衰弱发生率显著低于对照组,MRC肌力评分显著高于对照组,机械通气时间和ICU住院天数显著短于对照组(P0.05,P0.01)。结论 eCASH理念结合早期活动应用于ICU机械通气患者,可降低患者谵妄和ICU获得性衰弱,缩短机械通气和ICU入住时间,促进患者康复。     

eCASH策略预防ICU机械通气患者谵妄效果评价

目的降低ICU机械通气患者谵妄发生率,优化患者临床转归。方法将100例ICU机械通气患者按入院先后分为两组各50例,在常规治疗的基础上对照组按常规防范患者发生IUC谵妄,观察组实施早期以患者为中心的舒适化浅镇静(eCASH)策略防范。结果观察组谵妄发生率、谵妄持续时间、机械通气时间、ICU停留时间均显著低于对照组,临床转归好于对照组(P0.05,P0.01)。结论 eCASH策略应用于ICU机械通气患者谵妄预防管理,可有效降低谵妄发生率,改善患者临床结局。     

ESCAPE策略在机械通气患者谵妄管理的应用

目的评价ESCAPE策略用于机械通气患者谵妄管理的效果。方法将165例机械通气患者采用随机数字软件分为干预组(n=86)、对照组(n=79)。对照组采用ICU常规护理,包括观察患者生命体征、呼吸机及循环监测、常规镇痛镇静护理、药物不良反应及脏器功能监测。干预组采用ICU常规护理的同时应用ESCAPE策略,包括早期活动、睡眠管理、每日唤醒及自主呼吸试验、精神状态评估、情感支持、镇痛镇静管理。比较两组患者谵妄发生率、谵妄持续时间、镇痛镇静药物使用量、机械通气时间、ICU住院时间。结果干预组患者谵妄发生率、谵妄持续时间、镇痛镇静药物使用量、机械通气时间、ICU住院时间显著低于/短于对照组(P0.05,P0.01)。结论实施ESCAPE策略可有效降低ICU机械通气患者谵妄发生率,缩短谵妄持续时间,提高临床护理质量。     

模拟人体生物钟镇静用于ICU机械通气患者的临床研究

目的探讨模拟人体生物钟镇静方案对ICU机械通气患者谵妄及其他临床结局的影响。方法将110例ICU有创机械通气≥12h患者根据是否应用模拟人体生物钟镇静方案分为模拟人体生物钟组(研究组,55例)与非模拟人体生物钟组(对照组,55例),两组再根据使用镇静药物的不同分为右美托咪定组(各15例)、丙泊酚组(各20例)、右美托咪定+丙泊酚组(联合镇静组,各20例)。应用重症监护疼痛观察工具(CPOT)及Richmond躁动-镇静评分(RASS)对镇痛镇静深度进行量化控制,使研究组RASS评分白天维持在0~1分、夜间维持在-1~-2分;对照组昼夜均维持在-1~-2分。记录患者谵妄、呼吸机相关性肺炎等并发症或不良事件发生率,以及机械通气时间、住ICU时间、拔管时间、镇痛镇静药物用量。结果研究组谵妄、呼吸机相关性肺炎、严重低血压及心动过缓发生率显著低于对照组(P0.05,P0.01);与同种镇静药的对照组比较,研究组机械通气时间、拔管时间、住ICU时间显著缩短,镇痛镇静药物剂量显著减少(均P0.05)。结论模拟人体生物钟镇静有助于降低ICU机械通气患者不良反应发生率,缩短机械通气时间、拔管时间及住ICU时间,减少镇静镇痛药物用量,可提高临床疗效。     

标准化镇静护理给药方案的制订及在ICU患者镇静治疗中的应用

目的 探讨标准化镇静护理给药方案在ICU机械通气患者镇静治疗中的应用效果.方法 将综合性ICU接受机械通气及镇静治疗的患者74例,按入住ICU时间分为干预组和对照组各37例.对照组采用现有给药护理措施,医生在开具镇静处方时给出初始泵速,护士使用Ramsay镇静评分表每4小时对患者进行镇静评估,并根据评估结果及患者表现进行泵速调整.干预组采取标准化镇静护理给药方案,即包括人员培训、标准化表单设计、动态镇静目标设置、规范评估并记录等.比较干预前后两组镇静治疗效果及不良事件发生情况.结果 干预后两组镇静评分、住院时间比较,差异有统计学意义(均P＜0.05);两组ICU留观时间、置管期间镇静药物使用情况、与镇静有关不良事件发生率比较,差异无统计学意义(均P＞0.05).结论 标准化镇静护理给药方案可使患者镇静深度适宜并缩短患者住院时间,对镇静治疗的过程指标及结局指标均有良好改善.     

降低ICU机械通气患者约束率的课题达成型品管圈实践

目的探讨课题达成型品管圈活动在降低ICU机械通气患者约束率中的效果。方法按时间段将118例ICU行机械通气患者分为对照组57例,研究组61例。对照组实施约束常规护理;研究组针对降低约束率开展课题达成型品管圈活动,即制定有效对策群组并组织实施,进行标准化管理。结果开展品管圈活动后,研究组患者身体约束率、镇静镇痛合格率、谵妄发生率显著下降(均P0.05)。品管圈活动目标达成率110.8%,进步率33.24%。结论开展课题达成型品管圈活动,有效降低了ICU机械通气患者约束率、谵妄发生率,同时圈员的品管手法、专业知识、沟通协调能力得到有效提高。     

ICU机械通气患者早期四级康复训练效果

目的探讨ICU机械通气患者早期四级康复训练的实施效果。方法将100例入住综合ICU的重症患者随机分为干预组和对照组各50例,对照组按ICU护理常规给予四肢被动活动和功能锻炼,干预组在机械通气24h内开始实施早期四级康复训练。干预后对两组肌力变化、Barthel指数、机械通气时间、ICU住院时间、总住院时间、ICU获得性肌无力发生率、呼吸机相关性肺炎发生率、深静脉血栓发生率、压疮发生率进行评估。结果干预组出院前1天肌力、Barthel指数评分显著高于对照组,机械通气时间、ICU住院时间、总住院时间显著短于对照组,ICU获得性肌无力、呼吸机相关性肺炎发生率显著低于对照组(P0.05,P0.01)。结论早期四级康复训练可提高ICU机械通气患者的肌力和自理能力,预防患者获得性肌无力的发生,缩短住院时间,利于患者早日康复。     

右美托咪定联合咪达唑仑在ICU短时间机械通气患者中的镇静效果和安全性评价

目的探讨右美托咪定联合咪达唑仑在ICU短时间机械通气患者中的镇静效果和安全性。方法回顾性分析2016年12月～2017年6月我科100例全麻手术后机械通气时间48 h患者资料。按镇静方案不同分为4组:右美托咪定联合咪达唑仑组(Dex+Mid组) 30例,右美托咪定组(Dex组) 25例,咪达唑仑组(Mid组) 26例,丙泊酚组(Pro组) 19例。4组性别、年龄、体重指数、急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分无统计学差异(P 0. 05)。比较4组浅镇静水平比例、镇静期间及镇静停止后24 h内谵妄、低血压、心动过缓(60次/min)发生率和机械通气时间。结果 4组间镇静后4～6 h的镇静深度、机械通气时间和低血压发生率有统计学差异(P 0. 05),谵妄和心动过缓发生率差异无显著性(P0. 05)。Dex+Mid组达浅镇静水平患者比例[76. 7%(23/30)]明显高于Mid组[38. 5%(10/26)](P=0. 004); Mid组机械通气时间[(20. 9±5. 6) h]明显长于Dex+Mid组[(17. 3±4. 6) h]、Dex组[(15. 1±5. 5) h]、Pro组[(16. 1±4. 6) h](P=0. 010、0. 000、0. 003); Dex组低血压发生率最高[48. 0%(12/25)]。结论右美托咪定联合咪达唑仑在ICU短时间机械通气患者中具有良好的镇静效果和安全性。     

早期床上脚踏车运动对ICU机械通气患者康复的影响

目的探讨早期床上脚踏车运动对ICU机械通气患者康复的影响。方法将124例机械通气患者随机分为干预组和对照组各62例。对照组行常规床上活动;干预组在此基础上加床上脚踏车运动,每天2次,每次20min。结果两组均60例完成研究。运动第7、14天,干预组肌肉总量、骨骼肌、体脂肪、四肢水分、前白蛋白值及潮气量、呼吸频率、二氧化碳分压与对照组比较,差异有统计学意义(均P0.05);干预组机械通气时间、ICU住院时间、VAP发生率、谵妄发生率显著低于对照组(P0.05,P0.01)。结论床上脚踏车运动实现早期活动,可改善机械通气患者的营养指标和心肺功能,促进患者康复。     

Sedation failures in children undergoing MRI and CT: is temperament a factor?

This study examined the relationship between temperament and sedation failure during magnetic resonance imaging (MRI) and computerized tomography (CT). One hundred and two children (aged 3-7 years) who underwent MRI or CT with or without sedation were studied. Demographics, sedatives administered, efficacy of sedation, and adverse events were recorded. Parents completed the Behavioural Style Questionnaire for 3-7 years olds during their wait. Eight children underwent MRI successfully without sedation, 83 were successfully sedated, and 11 procedures were aborted. Children whose sedation failed were less adaptable than children whose sedation was successful (P =0.04). Children who underwent MRI without sedation were more persistent than children who were sedated (P =0.05), and more persistent and less active than those whose sedation failed (P =0.02 and 0.03, respectively). The child's underlying temperament may contribute to sedation outcomes during MRI and CT. A presedation assessment of the child's temperament may therefore assist in decisions regarding sedation.     

The use of sedatives in dental care: legal aspects in Sweden

The patient's rights and the dentist's obligations within Swedish dental care are groverned by the Dental Care Act. The general dentist Instruction enjoins on every dentist, in accordance with science and tested experience, to advise and, as far as possible, to inform the patient about the treatment the patient's condition requires. Dentists have the right to prescribe sedative drugs. Intravenous injection of sedative agents may not at present be used by dentists. Dentists have the right to use nitrous oxide analgesia after undergoing training approved by the National Board of Health and Welfare. With regard to the nitrous oxide apparatus, it is stipulated that the concentration of oxygen must never fall below 40% volume. There are special directions for ventilation in the treatment room, portable exsuction, and other measures when nitrous oxide analgesia is used. It is specially directed how dentists shall keep case records in general. Stipulations also exist for the keeping of case records on nitrous oxide analgesia. Dentists are bound to report secondary effects of drugs to the National Board of Health and Welfare.     

Stratification of sedation risk--a challenge to the sedation continuum

We detail the limitations of the current paradigm of the sedation continuum – a tool ubiquitous to all sedation care settings and now a quarter century old. Definitions in this existing taxonomy are based on patient responsiveness to verbal and/or tactile stimuli, and the inherent subjectivity of this focus has both challenged the reliable assessment of adverse event risk and precluded clear delineation of sedation boundaries, e.g., what is the dividing line between moderate and deep sedation? We present the rationale to support a broadening of this sedation continuum precept to include an objective mechanism to predict the ongoing risk of serious adverse events, and then propose sequential steps for the development of such a restructured framework. This process, while ambitious, would yield a clear and consistent language to facilitate quality assurance, provide an objective framework for standardized sedationist training and credentialing, and permit inclusion into computerized decision‐support algorithms to facilitate more precise sedative delivery. It is important to clearly delineate this goal now to permit design and initiation of the requisite research.     

A randomized controlled trial of sedation in the critically ill

A randomized controlled trial comparing: a) a combination of oral chloral hydrate and promethazine to b) a continuous intravenous midazolam infusion, for maintenance sedation in critically ill children, was carried out. The level of sedation was assessed four hourly using a specifically devized sedation scale. Forty-four children entered the study of whom two were subsequently excluded. The number of satisfactory assessments (desired and actual levels of sedation equal) was significantly greater in the chloral hydrate and promethazine group (Chi-squared P <0.01; confidence intervals of the difference 0.06 to 0.20). The number of assessments at level 5 on the sedation scale (patient restless/distressed) was significantly greater in the midazolam group (Chi-squared P <0.05). The total number of satisfactory assessments in the two groups were only 61 and 48% respectively, suggesting that sedation can be considerably improved. Chloral hydrate and promethazine are more effective than midazolam as maintenance sedation in critically ill children. It is possible to prospectively study the efficacy of sedative drugs in critically ill children.     

Changes in respiratory and hemodynamic parameters during low-dose propofol sedation in combination with regional anesthesia for herniorrhaphy and genitourinary surgery in children

BACKGROUND: Spontaneous vs mechanical ventilation during propofol sedation has been a subject of debate. We evaluated the safety of low-dose propofol sedation as an adjunct to regional anesthesia during herniorrhaphy and genitourinary surgery in infants and children. METHODS: The study was conducted in a prospective, nonrandomized manner using a consecutive sample of 62 American Society of Anesthesiologists physical status class I patients between 5 months to 11 years of age in the surgery unit of an urban University Hospital. Propofol sedation (4-8 mg x kg(-1) x h(-1) continuous infusion) was used with regional anesthesia (caudal, ilioinguinal/iliohypogastric nerve or penile block with 0.2-0.375% ropivacaine). All children were spontaneously breathing without an anesthesia circuit. Respiratory and hemodynamic parameters were continuously recorded on all patients. One-way analysis of variance (ANOVA) for repeated measurements was used to analyze changes in respiratory and hemodynamic parameters during the procedure. RESULTS: Spontaneous ventilation was maintained in all patients with minimal changes in hemodynamic parameters. Heart rate, mean arterial pressure, and P(E)CO(2) remained stable throughout the study period: 23/62 (37%) patients exhibited signs of developing intrinsic endexpiratory pressure (PEEPi) or the presence of PEEPi because of progressive reduction of expiratory time. CONCLUSIONS: Low-dose propofol sedation in combination with regional anesthesia for elective herniorrhaphy and genitourinary surgery in children maintains spontaneous ventilation and has minimal effects on hemodynamic parameters for sedation lasting <1 h. The presence of PEEPi is a relative contraindication to the use of this regimen in children with asthma or history of upper airway infections.     

Capnography enhances surveillance of respiratory events during procedural sedation: a meta-analysis

Study Objective

To determine if capnography, in addition to standard monitoring, identified more respiratory complications than standard monitoring alone.

Design

Meta-analysis.

Setting

University medical center.

Measurements

The electronic databases PubMed, CINAHL, and Cochrane Library (Cochrane Reviews, CENTRAL) were searched for studies published between 1995-2009 reporting adverse respiratory events during procedural sedation and analgesia (PSA) with clearly defined end-tidal carbon dioxide threshold, adult population, clear study design, P-value calculation, similar outcome and predictor variable definitions, and binary independent and dependent variable raw data. Five such studies were evaluated independently. A meta-analysis of these studies was performed.

Main Results

During PSA, cases of respiratory depression were 17.6 times more likely to be detected if monitored by capnography than cases not monitored by capnography (95% CI, 2.5-122.1; P < 0.004).

Conclusion

End-tidal carbon dioxide monitoring is an important addition in detecting respiratory depression during PSA.     

右美托咪啶的药理作用及在重症监护病房中的应用

右美托咪啶是高选择性的α2激动剂，具有镇静、镇痛、抗焦虑作用。被右美托咪啶镇静的患者血流动力学和呼吸功能稳定，可随时唤醒，与医护人员交流并配合检查和治疗。右美托咪啶在拔管期间亦可持续使用，有助于脱机困难者脱离呼吸机。可加强阿片类药物和镇静药的作用，显著减少其用量，并可预防和治疗撤药反应。大量临床试验证实其在重症监护病房镇静中具有独特优势，尤其适用于躁动、创伤、高血压、心动过速、缺血性心脏病、心脏移植等患者。     

瑞芬太尼临床作用的研究进展

瑞芬太尼是一种较理想的阿片类药物，虽已在临床上得到广泛应用，但其临床应用研究资料仍在不断丰富，本文简要叙述其在临床相关作用的研究及麻醉、镇痛、镇静方面的进展。     

异丙酚病人自控镇静与靶控镇静的对比研究

目的 比较异丙酚病人自控镇静术（PCS）与靶控镇静术（TCI）在硬膜外麻醉中的应用价值。方法 32例行下肢或下腹部手术的成年患者,硬膜外麻醉满意后,随机分成两组,PCS组行病人自控镇静,单次剂量0.3mg/kg,锁定时间2min;TCI组行靶控输注,术中维持镇静深度于OAA/S镇静评分3分。监测不同时点的镇静评分、双频谱指数（BIS）、边缘频率（95％SEF）、异丙酚靶浓度（CP）及血药浓度（Cm）、术中遗忘及镇静满意程度,并比较BIS、95％SEF及Cm与镇静评分的相关性。结果 所有患者均对镇静效果满意,PCS组镇静深度较浅,异丙酚用药量较TCI组少（分别为 2.5mg·kg-1·h-1与 3.8mg·kg-1·h-1,P<0.01）,且个体差异明显。TCI组血药浓度平稳,并与靶浓度基本相符,术中及术后遗忘率较自控镇静组高（分别为31％与69％,P<0.01）。BIS与镇静评分的相关性（γ=0.73）较95％SEF及Cm高。结论 两种方法镇静效果均满意,但又各具特点。自控镇静体现了个体化给药原则,用药量较少,其合理的设置至关重要。靶控镇静的深度平稳且易于调控,遗忘良好,但由于其治疗窗较窄,需要有良好的监测。BIS是监测硬膜外麻醉中镇静深度的较敏感指标。     

Intranasal flumazenil and naloxone to reverse over-sedation in a child undergoing dental restorations

We describe a 3-year-old child who became over-sedated after receiving intranasal (IN) midazolam (0.53 mg·kg⁻¹) and IN sufentanil (1 mcg·kg⁻¹) for dental restorations in the dental office. Desaturation was attributed to laryngospasm, which was managed with positive pressure ventilation and oxygen. The sedation was reversed with a combination of IN flumazenil and naloxone.