使⽤丙泊酚和右美托咪定镇静对感染性休克患者去甲肾上腺素需要 量的影响：交叉研究
本公众号每天分享一篇最新一期Anesthesia & Analgesia等SCI杂志的摘要翻译，敬请关注并提出宝贵意见
The Effect of Propofol and Dexmedetomidine Sedation on Norepinephrine Requirements in Septic Shock Patients: A Crossover Trial
背景与目的
丙泊酚镇静可使⾎管张⼒和回⼼⾎量降低从⽽引起⾎流动⼒学紊乱。增加外源性⼉茶酚胺可对抗交感神经过度刺激产⽣的不利影响。据报道，α-2肾上腺素受体激动剂可降低实验性脓毒性休克受试者对去甲肾上腺素的需要量。本研究旨在探究由丙泊酚镇静转为α-2激动剂右美托咪啶是否可降低脓毒性休克患者去甲肾上腺素的需要量。
方 法
本前瞻性开放式交叉研究共纳⼊附属医院重症监护病房需要去甲肾上腺素维持⾜够的平均动脉压（MAP），同时需要异丙酚和瑞芬太尼进⾏深度镇静以维持Richmond 躁动镇静评分在-3⾄-4之间的脓毒性休克患者38例。第⼀组数据包括⾎流动⼒学、去甲肾上腺素需要剂量和使⽤丙泊酚时的镇静深度。然后⽤右美托咪定代替丙泊酚后4⼩时获得第⼆组数据。将镇静剂再次更换为异丙酚后8h进⾏最后⼀组数据测量。在研究期间，始终维持Richmond 躁动镇静评分在-3⾄-4之间。
结 果
去甲肾上腺素需要量从注射右美托咪啶前的0.69±0.72μg/kg/min降⾄给药后4h的0.30±0.2 5μg/kg/min，停药后8h升⾄0.42±0.36μg/kg/min(p<0.005)。右美托咪定的使⽤剂量为0.7 ± 0.2μg/kg/hr 。在右美托咪定输注前后镇静剂量不变(分别为丙泊酚2.6±1.2vs2.6 ±1.2mg/kg/hr;p=0.23和瑞芬太尼1.27±0.17vs1.27±0.16μg/kg/hr;p=0.52)Richmond 躁动镇静评分为-4(-4~-3)分，-4(-4~-3)分，-4(-4~-4)分和(-4~-4)分(p=0.07)。
结 论
当镇静程度相当时，将丙泊酚更换为右美托咪定可使感染性休克患者⼉茶酚胺的需要量减少。
原始文献摘要
Morelli A, Sanfilippo F, Arnemann P, et al. T he Effect of Propofol and Dexmedetomidine Sedat ion on Norepinephrine Requirement s in Septic Shock Pat ient s: A Crossover Trial[J]. Crit . Care Med. 2018 Oct 31;DOI：10.1097/CCM.000000000000352
Objectives: Propofol-based sedation may increase hemodynamic instability by decreasing vascular tone and venous return. Incremental exogenous catecholamines doses may be required to counteract such eff ects, aggravating the deleterious effects of sympathetic overstimulation. α-2 adrenergic agonists have been reported to decrease norepinephrine requirements in experimental septic shock. The aim of the present study is to test the hypothesis that switching from sedation with propofol to the α-2 agonist dexmedetomidine may decrease norepinephrine doses in septic shock
METHODS: Design: Prospective open-label crossover study.Settings: University hospital, ICU.Patients: Thirty-eight septic shock patients requiring norepinephrine to maintain adequate mean arterial pressure and needing deep sedation with propof ol and remifentanil to maintain a Richmond Agitation-Sedation Scale score between –3 and –4.
Interventions: An initial set of measurements including hemodynamics, norepinephrine doses, and depth of sedation were obtained during sedation with propof ol. Propof ol was then replaced by dexmedetomidine and a second set of data was obtained after 4 hours of dexmedetomidine inf usion. Sedation was switched back to propofol, and a final set of measurements was obtained after 8 hours. A Richmond Agitation-Sedation Scale score between –3 and –4 was maintained during the study period.
Measurements and Main Results: Norepinephrine requirements decreased from 0.69±0.72 μg/kg/min bef ore dexmedetomidine to 0.30±0.25 μg/kg/min 4 hours af ter dexmedetomidine inf usion, increasing again to 0.42±0.36 μg/kg/min while on propofol 8 hours after stopping dexmedetomidine (p < 0.005). Dexmedetomidine dosage was 0.7±0.2 μg/kg/hr. Bef ore and af ter dexmedetomidine infusion, sedative doses remained unchanged (propof ol 2.6±1.2 vs2.6±1.2mg/kg/hr; p = 0.23 and remifentanil 1.27±0.17 vs 1.27±0.16 μg/kg/hr; p = 0.52, respectively). Richmond Agitation Sedation Scale was –4 (–4 to –3) bef ore, –4 (–4 to –3) during, and –4 (–4 to –4) after dexmedetomidine (p = 0.07).
CONCLUSION: For a comparable level of sedation, switching from propofol to dexmedetomidine resulted in a reduction of catecholamine requirements in septic shock patients. (Crit Care Med 2018; XX:00–00)
麻醉学文献进展分享
贵州医科大学高鸿教授课题组
编辑：李华宇 审校：代东君