右美托咪定与咪达唑仑对脓毒性休克患者血浆儿茶酚胺水平及血流动力学影响的对比研究  

Comparative study of dexmedetomidine vs. midazolam on plasma catecholamine levels and hemodynamics in patients with septic shock

作　　者：姚玲 刘博 何天慧 沈锋 Yao Ling;Liu Bo;He Tianhui;Shen Feng(Department of Critical Care Medicine,the Affiliated Hospital of Guizhou Medical University,Guiyang 550004,Guizhou,China)

机构地区：[1]贵州医科大学附属医院重症医学科,贵阳550004

出　　处：《中华危重病急救医学》2021年第10期1193-1197,共5页Chinese Critical Care Medicine

基　　金：贵州省科技支撑计划项目(2017-2876);贵州省教育厅创新群体重大研究项目(2016-034);贵州省留学人员择优资助科技创新项目(2016-19)。

摘　　要：目的比较右美托咪定(DEX)与咪达唑仑对脓毒性休克患者内源性血浆儿茶酚胺水平以及维持血压的外源性去甲肾上腺素(NE)用量的影响。方法纳入2018年1月至2019年12月贵州医科大学附属医院重症医学科收治的需要有创机械通气且重症监护病房(ICU)住院时间≥48 h的接受DEX或咪达唑仑镇静的脓毒性休克患者。动态记录患者入ICU 0、12、24、48、72 h血流动力学数据、动脉血乳酸(Lac)水平、动脉血气分析及血管活性药物用量;记录入ICU 0、24、48 h血浆儿茶酚胺水平,入ICU时急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)和序贯器官衰竭评分(SOFA),以及预后指标。结果共纳入24例患者,DEX组及咪达唑仑组各12例。两组心率(HR)、中心静脉压(CVP)、静脉-动脉血二氧化碳分压差(Pv-aCO_(2))、氧合指数(PaO_(2)/FiO_(2))、Lac水平均存在相似的动态变化趋势,DEX组12 h时CVP和72 h时Pv-aCO_(2)明显高于咪达唑仑组〔CVP(mmHg,1 mmHg=0.133 kPa):13±3比10±3,Pv-aCO_(2)(mmHg):9.4±5.2比4.8±2.2,均P<0.05〕,且DEX组患者48 h和72 h时平均动脉压(MAP)明显高于咪达唑仑组(mmHg:95±10比86±10,96±9比88±7,均P<0.05)。DEX组与咪达唑仑组机械通气时间、ICU病死率及住院病死率差异均无统计学意义〔机械通气时间(d):5.6(3.8,9.5)比10.5(5.9,15.0),ICU病死率:16.7%比33.3%,住院病死率:25.0%比41.7%,均P>0.05〕。DEX组与咪达唑仑组患者丙泊酚和舒芬太尼用量差异均无统计学意义〔丙泊酚(mg/kg):0(0,9.35)比4.07(0,13.75),舒芬太尼(μg/kg):6.26(4.90,9.80)比8.32(3.52,9.34),均P>0.05〕。DEX组48 h时血浆NE、多巴胺和多巴酚丁胺水平均明显低于咪达唑仑组〔NE(ng/L):1850.12(342.16,2938.05)比4596.60(3310.56,5546.84),多巴胺(ng/L):119.10(60.47,200.71)比275.40(214.61,418.88),多巴酚丁胺(ng/L):51.20(36.85,75.59)比98.97(85.65,107.10),均P<0.05〕,但DEX组与咪达唑仑组维持MAP在65~75 mmHg所需NE用量相似〔μg/kg:1922(1170,4887)比246Objective To compare the effects of dexmedetomidine(DEX)and midazolam on the endogenous plasma catecholamine levels and the dosage of exogenous norepinephrine(NE)to maintain blood pressure in patients with septic shock.Methods From January 2018 to December 2019,patients admitted to the department of critical care medicine of the Affiliated Hospital of Guizhou Medical University who needed invasive mechanical ventilation and had a stay of more than 48 hours in the intensive care unit(ICU)for septic shock and received DEX or midazolam for sedation were enrolled in this study.The hemodynamic data,arterial blood lactic acid(Lac)level,arterial blood gas analysis and vasoactive drug dose at 0,12,24,48,72 hours after entering the ICU were dynamically recorded,and the plasma catecholamine levels at 0,24,48 hours after entering the ICU were recorded.The acute physiology and chronic health evaluationⅡ(APACHEⅡ)score and sequential organ failure assessment(SOFA)score on ICU-admission were calculated.The parameters of prognosis were collected.Results A total of 24 patients were enrolled,12 in the DEX group and 12 in the midazolam group.There were similar dynamic trends in heart rate(HR),central venous pressure(CVP),venous-arterial carbon dioxide pressure difference(Pv-aCO_(2)),oxygenation index(PaO_(2)/FiO_(2)),and Lac level of patients between the two groups.Only the 12-hour CVP and 72-hour Pv-aCO_(2) in the DEX group were significantly higher than those in the midazolam group[CVP(mmHg,1 mmHg=0.133 kPa):13±3 vs.10±3,Pv-aCO_(2)(mmHg):9.4±5.2 vs.4.8±2.2,both P<0.05],and the mean arterial pressure(MAP)of patients in the DEX group at 48 hours and 72 hours was significantly higher than that in the midazolam group(mmHg:95±10 vs.86±10,96±9 vs.88±7,both P<0.05).There was no statistically significant difference in the duration of mechanical ventilation,ICU mortality or in-hospital mortality between the DEX group and the midazolam group[duration of mechanical ventilation(days):5.6(3.8,9.5)vs.10.5(5.9,15.0),ICU mortality:16

关 键 词：右美托咪定 咪达唑仑 儿茶酚胺 脓毒性休克 镇静 血流动力学 

分 类 号：R459.7[医药卫生—急诊医学]