摘要
目的 探讨右美托咪定序贯镇静模式对ICU中深度镇静的机械通气患者预后和谵妄的影响.方法 采用前瞻性随机对照研究,将2021年1月至2022年12月江苏大学附属人民医院ICU机械通气患者中经过筛选实验筛选出有中深度镇静需求的74例患者随机分为右序贯镇静组(38例)和常规镇静组(36例).比较两组患者的机械通气时间、ICU住院时间、总住院时间、28 d病死率、呼吸机相关性肺炎(VAP)和不良反应(患者意外拔管、再次插管、心动过缓)发生率、镇静持续时间、镇静药物使用剂量、谵妄发生率.采用酶联免疫吸附测定(ELLSA)法检测两组谵妄患者入ICU时、诊断谵妄当天及诊断谵妄后48 h血清脑源性神经营养因子(BDNF)、神经元特异性烯醇化酶(NSE)和S100钙结合蛋白B(S100B)的浓度.受试者工作特征(ROC)曲线分析患者入ICU时血清BDNF、NSE和S100B浓度对谵妄发生的预测价值.结果 序贯镇静组患者机械通气时间[(6±3)d vs.(8±4)d,t=2.555,P=0.013]、住 ICU 时间[(12±4)d vs.(17±8)d,t=3.371,P=0.001]、总住院时间[(23±5)d vs.(31±7)d,t=5.680,P＜0.001]、谵妄发生率[34.2％(13/38)vs.58.3％(21/36),x2=4.331,P=0.037]、咪达唑仑使用剂量[(2.7±1.7)mg/kg vs.(4.3± 2.3)mg/kg,t=3.416,P=0.001]、镇静持续时间[(7.3±2.4)d vs.(9.7±3.1)d,t=3.735,P＜0.001]均低于常规镇静组.两组患者28 d病死率、VAP发生率、意外拔管率、再次插管率、心动过缓发生率和芬太尼使用剂量比较,差异均无统计学意义(P均＞0.05).诊断谵妄后48 h,序贯镇静组患者血清BDNF[(0.37±0.12)vs.(0.56±0.27),t=2.385,P=0.023]、NSE[(0.078±0.020)vs.(0.234± 0.079),t=6.598,P＜0.001]、S100B[(0.28±0.16)vs.(0.47±0.24),t=2.521,P=0.017]水平均较常规镇静组显著降低.ROC曲线分析结果显示,入ICU时BDNF预测谵妄发生的曲线下面积(AUC)为 0.744[95％置信区间(CI)(0.627,0.861),P＜0.001],NSE 的 AUC 为 0.711[95％CI(0.593,0.830),P=0.002],S100B 的 AUC 为 0.727[95％CI(0.609,0.845),P=0.001],提示 ICU 中深度镇静的机械通气患者入ICU时血清BDNF、NSE、S100B水平均对谵妄发生具有一定的预测价值.结论 右美托咪定序贯镇静可以减少ICU机械通气患者谵妄发生率,缩短机械通气时间,减少ICU住院时间,且不增加不良反应发生率.入ICU时血清BDNF、NSE和S100B水平对预测谵妄发生具有一定作用.
Abstract
Objective To investigate the effect of sequential sedation mode of dexmedetomidine on prognosis and delirium in mechanically ventilated patients with moderate and deep sedation requirements in the ICU.Methods A prospective randomized controlled study was conducted after screening experiments to divide 74 mechanically ventilated patients with moderate and deep sedation requirements in the ICU of the Affiliated People's Hospital of Jiangsu University from January 2021 to December 2022 into a sequential sedation group(38 cases)and a conventional sedation group(36 cases).The duration of mechanical ventilation,length of ICU stay,total length of hospital stay,28 d mortality,incidence of ventilator associated pneumonia(VAP)and adverse reactions(patients with unplanned extubation,re-intubation,and bradycardia),duration of sedation,dose of sedative drugs,and incidence of delirium were compared between these two groups.Serum concentrations of brain-derived neurotrophic factor(BDNF),neuron-specific enolase(NSE),and S100 calcium-binding protein B(S100B)were measured at ICU admission,on the day of diagnosis of delirium,and 48 h after diagnosis of delirium in both groups by enzyme-linked immunosorbent assay(ELLSA).A receiver operating characteristic(ROC)curve was used to analyze the predictive value of serum concentrations of BDNF,NSE,and S100B on admission to the ICU for delirium occurrence.Results The mechanical ventilation time[(6±3)d vs.(8±4)d,t=2.555,P=0.013],length of ICU stay[(12± 4)d vs.(17±8)d,t=3.371,P=0.001],total length of stay[(23±5)d vs.(31±7)d,t=5.680,P＜0.001],incidence of delirium[34.2％(13/38)vs.58.3％(21/36),x2=4.331,P=0.037],dosage of sedative midazolam[(2.7±1.7)mg/kg vs.(4.3±2.3)mg/kg,t=3.416,P=0.001],and duration of sedation[(7.3±2.4)d vs.(9.7±3.1)d,t=3.735,P＜0.001]in the sequential sedation group were lower than those in the conventional sedation group.There were no significant differences in the 28 d mortality,incidence of VAP,patients with accidental extubation,re-intubation and bradycardia,and dosage of analgesic fentanyl between these two groups(all P＞0.05).The concentrations of BDNF[(0.37±0.12)vs.(0.56±0.27),t=2.385,P=0.023],NSE[(0.078±0.020)vs.(0.234±0.079),t=6.598,P＜0.001],and S100B[(0.28±0.16)vs.(0.47±0.24),t=2.521,P=0.017]were significantly lower in the sequential sedation group than in the conventional sedation group 48 h after diagnosis of delirium.ROC curve analysis showed that BDNF at ICU admission predicted the onset of delirium in mechanically ventilated patients with an area under the curve(AUC)of 0.744[95％confidence interval(C1)(0.627,0.861),P＜0.001],together with the AUC of 0.711[95％CI(0.593,0.830),P=0.002]for NSE and 0.727[95％CI(0.609,0.845),P=0.001]for S100B.Conclusions Sequential sedation with dexmedetomidine can reduce the occurrence of delirium,and shorten the duration of mechanical ventilation and ICU stay without increasing the incidence of adverse reactions for mechanically ventilated patients in the ICU.Serum levels of BDNF,NSE,and S100B at ICU admission can predict the occurrence of delirium.
基金项目
江苏大学临床医学科技发展基金(JLY2021006)
NETL
NSTL
维普
万方数据