模拟人体生物钟镇静在重症加强治疗病房机械通气谵妄防控中的研究  

Study of prevention and control of delirium in ventilated patients by simulating blockage of circadian rhythm with sedative in intensive care unit

作　　者：李俊艳[1] 董晨明[1] 张虹[1] 张红松[1] 宋瑞霞[1] 杨朝辉[1] 冯芳[1] 齐艳[1] 杨静[1] 

机构地区：[1]兰州大学第二医院重症医学一科,甘肃兰州730030

出　　处：《中华危重病急救医学》2016年第1期50-56,共7页Chinese Critical Care Medicine

基　　金：甘肃省卫生行业科研计划项目（QSWSKY-2014-32）

摘　　要：目的探讨模拟人体生物钟镇静防控对重症加强治疗病房（ICU）机械通气患者谵妄的发生及预后的作用。方法采用前瞻性双盲随机对照试验（RCT）。选取2014年7月至2015年2月入住兰州大学第二医院重症医学科接受机械通气治疗≥12h的患者，所有患者常规应用芬太尼镇痛治疗，按计算机生成的随机数字表将患者分为模拟生物钟组（研究组，35例）与非模拟生物钟组（对照组，35例），两组再依据使用镇静药物的不同分为右美托咪定组（各8例）、丙泊酚组（各14例）、右美托咪定＋丙泊酚组（联合镇静组，各13例）3个亚组。应用疼痛视觉模拟评分（VAS）、Richmond躁动-镇静评分（RASS）标准对镇痛镇静的深度进行量化控制，滴定式调节镇静药物剂量，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RASS评分昼夜均维持在-1—-2分。采用酶联免疫吸附试验（ELISA）检测患者第一个昼夜节律不同时间点（06：00、12：00、18：00、24：00）尿液中6-羟基硫酸褪黑素（aMT6s）水平；记录患者谵妄、严重低血压、严重心动过缓等不良反应的发生率以及机械通气时间、拔管时间、ICU住院时间、镇静镇痛药物用量；采用Spearman相关分析患者谵妄发生与其他指标间的相关性。结果①各组患者性别、年龄、急性生理学与慢性健康状态评分系统Ⅱ（APACHEⅡ）评分等基线资料差异均无统计学意义，具有可比性。②两组患者尿液中aMT6s水平均无昼夜节律性，研究组06：00的aMT6s水平较对照组有增高趋势，但差异无统计学意义。③研究组患者谵妄发生率较对照组明显降低（14．3％比37．1％，P=0．029），严重低血压、心动过缓的发生率差异无统计学意义（20．0％比25．7％，11．4％比20．0％，均P〉0．05）。在模拟人体生物钟的研究组患者中，右美托咪定亚组谵妄发�Objective To explore the effect of giving sedatives according to the circadian rhythm in prevention of occurrence of delirium and the prognosis of patients undergoing mechanical ventilation in intensive care unit （ICU）. Methods A prospective double-blinded randomized controlled trial （RCT） was conducted. The patients admitted to Department of Critical Care Medicine of the Second Hospital of Lanzhou University from July 2014 to February 2015, undergoing invasive mechanical ventilation over 12 hours were enrolled. All the patients were given fentanyl for analgesia, and they were randomly divided into simulated circadian clock group （study group, n = 35） and non-simulated circadian clock group （control group, n = 35）. The patients in each group were subdivided into three subgroups according to the kinds of sedative drugs, namely dexmedetomidine group （n = 8）, propofol group （n = 14）, and dexmedetomidine combined with propofol group （combination group, n = 13）. Visual analogue scale （VAS） standard and Richmond agitation-sedation scale （RASS） were used to control the analgesic and to quantify the depth of sedation by titrating the dose of sedative drugs, the simulated circadian clock was set to control the RASS score at 0-1 during the day, and -1 to -2 at night in study group. The RASS score in the control group was set at -1 to -2 day and night. The urine 6-hydroxy acid melatonin （aMT6s） levels at different time points in the first diurnal rhythm （06：00, 12：00, 18：00, 24：00） were determined by enzyme linked immunosorbent assay （ELISA）. The incidence of delirium, severe hypotension, severe bradycardia and other adverse reactions, duration of mechanical ventilation and the time of extubation, length of ICU stay, amount of sedative and analgesic drugs used were recorded. The correlation between delirium and other indexes was analyzed by using Spearman correlation analysis. Results （1） There were no significant differences in gender, age, acute physiology and ch

关 键 词：模拟人体生物钟 谵妄 右美托咪定 6-羟基硫酸褪黑素 

分 类 号：R614[医药卫生—麻醉学]