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以驱动压为导向的镇静策略对机械通气患者预后影响的研究

Study on the effect of sedation strategy guided by driving pressure on prognosis of patients with mechanical ventilation

摘要:

目的:评估以气道驱动压(ΔP)为导向的镇静策略对机械通气患者预后的影响。方法:选择2017年1月至2018年12月在江西省人民医院重症监护病房(ICU)住院需有创机械通气的患者,经患者或家属知情同意后,按随机数字表法分为研究组和对照组。两组患者均接受ICU常规治疗。对照组采用浅镇静策略,每4 h进行1次Richmond躁动-镇静评分(RASS),镇静目标为RASS>-3分;研究组每日测定1次ΔP,低驱动压者(ΔP≤14 cmH 2O,1 cmH 2O=0.098 kPa)镇静目标为RASS>-3分,高驱动压者(ΔP>14 cmH 2O)镇静目标为RASS≤-3分。入住ICU 28 d时进行评价,并随访至60 d。主要观察指标为28 d无机械通气日;次要观察指标为气管插管拔管成功率、出院转归、呼吸机相关性肺炎(VAP)和谵妄发生率以及60 d生存率。 结果:共入选60例因各种原因导致呼吸衰竭行有创机械通气的患者,对照组和观察组各30例。两组患者性别、年龄、原发病、病情严重程度及ΔP等一般情况差异无统计学意义。研究组28 d无机械通气日较对照组显著增多〔d:20(0,23)比12(0,16), P=0.018〕,并且VAP发生率(3.3%比16.7%, P=0.045)和谵妄发生率(0%比10.0%, P=0.038)较对照组显著降低。研究组与对照组拔管成功率(73.3%比66.7%, P=0.273)、出院转归〔好转(例):24比21,未愈(例):2比5,死亡(例):4比4, P=0.506〕以及60 d生存率(83.3%比76.7%, P=0.519)差异均无统计学意义。 结论:与浅镇静策略相比,以ΔP为导向的镇静策略能有效地缩短ICU患者机械通气时间,减少VAP及谵妄的发生。

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abstracts:

Objective:To evaluate the effect of airway driving pressure (ΔP) guided sedation strategy on the prognosis of patients with mechanical ventilation.Methods:Patients who needed invasive mechanical ventilation and admitted to the department of intensive care unit (ICU) of Jiangxi Provincial People's Hospital from January 2017 to December 2018 were enrolled. The patients were divided into study group and control group according to the random number table. After informed consent of patients or their families, both groups received routine treatment in ICU. The control group was treated with light sedation strategy, the Richmond agitation sedation score (RASS) was performed every 4 hours, and the target was RASS > -3. ΔP in the study group was measured once a day, and the sedative target of patients with low driving pressure (ΔP ≤ 14 cmH 2O, 1 cmH 2O = 0.098 kPa) was RASS > -3, while the patients with high driving pressure (ΔP > 14 cmH 2O) was RASS ≤ -3. The evaluation was conducted at 28 days after admission to ICU, and the patients were followed up to 60 days. The main outcome was days without mechanical ventilation in 28 days. The secondary outcomes were the rate of extubation, discharge outcome, incidence of ventilator associated pneumonia (VAP) and delirium, and 60-day survival rate. Results:A total of 60 patients with respiratory failure due to various reasons were recruited, 30 in each group. There was no significant difference in gender, age, primary disease, severity of disease or ΔP between the two groups. The days without mechanical ventilation within 28 days in the study group were significantly more than that in the control group [days: 20 (0, 23) vs. 12 (0, 16), P = 0.018], and the incidences of VAP (3.3% vs. 16.7%, P = 0.045) and delirium (0% vs. 10.0%, P = 0.038) were significantly lower than that in the control group. There were no significant differences in the rate of extubation (73.3% vs. 66.7%, P = 0.273), discharge outcome [improvement (cases): 24 vs. 21, unhealed (cases): 2 vs. 5, deaths (cases): 4 vs. 4, P = 0.506] and 60-day survival rate (83.3% vs. 76.7%, P = 0.519) between the study group and control group. Conclusion:Compared with light sedation strategy, ΔP directed sedation strategy can effectively shorten the duration of mechanical ventilation and reduce the incidence of VAP and delirium in the ICU patients.

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作者: 贺慧为 [1] 杨春丽 [1] 陈志 [1] 楼丽琼 [1] 夏文翰 [1]
期刊: 《中华危重病急救医学》2020年32卷10期 1217-1220页 MEDLINEISTICPKUCSCD
栏目名称: 论著·重症呼吸与机械通气
DOI: 10.3760/cma.j.cn121430-20200514-00385
发布时间: 2021-01-11
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