右美托咪定用于心外科术后无创通气不耐受患者挽救性镇静治疗的可行性研究  

Salvage treatment for non-invasive ventilation intolerance in cardiac surgical patients with dexmedetomidine： a pilot feasibility trial Ma

作　　者：马国光[1] 郑吉莉 薛燕[2] 郝光伟[1] 杨晓梅[1] 刘岚[1] 刘华[1] 张颖[1] 庄亚敏[1] 屠国伟[1] 罗哲[1] 

机构地区：[1]复旦大学附属中山医院重症医学科,上海200032 [2]复旦大学附属中山医院护理部,上海200032

出　　处：《中华急诊医学杂志》2017年第4期420-425,共6页Chinese Journal of Emergency Medicine

摘　　要：目的观察右美托咪定对心脏外科术后无创通气（NW）不耐受患者的镇静效果以及对呼吸功能、血流动力学及NIV失败率的影响。方法前瞻性收集35例心脏外科术后NIV不耐受合并低氧血症的患者，予右美托咪定镇静，并制定标准化的NIV治疗过程。终点事件以避免气管插管为NIV成功标准，接受气管插管或死亡为NIV失败标准。记录镇静实施前、实施后1h及后续每间隔1h的血压（BP）、心率（HR）、呼吸频率（RR），每4h采集动脉血气分析。观察右美托咪定对成功组和失败组患者呼吸功能和血流动力学的影响。同时对呼吸功能和血流动力学指标进行Logistic回归分析，预测NIV失败的危险因素。结果35例NIV不耐受患者接受右美托咪定镇静治疗后，NIV成功20例（57．14％），失败15例（42．86％）。在右美托咪定镇静下NIV1h和4h后，与基线值相比，成功组和失败组患者RR均明显下降，其中成功组RR更低；两组患者的PaO2／FiO2在NIV后1h和4h也均明显改善，且成功组改善更为明显；HR在NIV后1h和4h与基线值相比均明显下降，但两组问差异无统计学意义。PaCO2和平均动脉压（MAP）在治疗过程中均无显著变化，两组间比较差异无统计学意义。将呼吸功能和血流动力学指标进行Logistic回归分析，结果发现NIV1h后的RR〉23次／min（OR=3．2，95％CI：2．043—4．301，P〈0．01）、NIV4h后RR〉20次/min（OR=2．1，95％CI：1．659～3．231，P=0．025），NIV1h后Pa02／Fi02〈178mmHg（OR=2．4，95％CI：1．892～3．287，P〈0．01）以及NIV4h后PaO2／FiO2〈185mmHg（OR：1．7，95％CI：1．243～2．365，P：0．041）是预测NIV失败的危险因素。结论右美托咪定用于心脏外科术后NIV不耐受患者镇静安全有效。早期识别NIV失败的危险因素可有助于对此类患者的及时干预。Objective To investigate the efficacy of dexmedetomidine on sedation in post-cardiac surgery patients with NIV intolerance. The changes of respiratory function and hemodynamics of the patients as well as non-invasive ventilation （NIV） failure rate were also under evaluation. Methods Thirty-five post-cardiac surgery patients with NIV intolerance and hypoxemia were enrolled in this prospective study. All patients were sedated with dexmedetomidine. NIV was standardized according to the uniform protocol. The main outcome was NIV success （avoiding endotracheal intubation） or NIV failure （requiring endotracheal intubation or die） . The cardiorespiratory parameters （BP, HR and RR） and artery blood gas analysis were prospectively recorded before and after sedation. The respiratory function and hemodynamics changes in both groups （NIV success group and NIV failure group ） were then evaluated. Factors independently associated with NIV failure were identified using a logistic regression model. Results Twenty out of 35 patients （57. 14%） survived while 15 （42. 86%） patients failed NIV. After 1 h and 4 h of NIV with dexmedetomidine sedation, respiratory rate in both groups were decreased compared with baseline, especially in NIV success group. The PaOJFi02 was also improved after lh and 4h of NIV treatment compared with baseline. The improvement was more significantly in NIV success group. The heart rate was decreased compared with baseline with no differences between two groups. There were no significant changes on PaCO2 and mean arterial pressure （MAP） during the treatment. The respiratory and hemodynamics variables identified as predictors of NIV failure were included in a multivariate logistic regression. RR 〉 23 time/min （OR=3.2, 95%CI： 2.043 -4.301, P〈0.01） 1 h after NIV, RR〉20 time/min （OR=2.1, 95% CI： 1. 659 - 3. 231, P = 0. 025） 4 h after NIV, PaO2/FiO2 〈 178 mmHg （OR = 2.4, 95% CI： 1. 892 3.287, P〈0.01） 1 hafterNIVand PaOa/FiO2 〈185 mmHg （OR=1.7, 95%CI�

关 键 词：无创通气 镇静 右美托咪定 心脏手术 

分 类 号：R614[医药卫生—麻醉学]