右美托咪啶作为单次连续镇静药物用于无创通气：经典用法、血流动力学影响及戒断反应
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
Dexmedetomidine as Single Continuous Sedative During Noninvasive Ventilation: Typical Usage, Hemodynamic Effects, and Withdrawal.
背景与目的
右美托咪定儿科重症监护中的应用正在增加，作为单一镇静药物连续用药其长期作用并没有得到很好描述。本研究的目的是在不存在其他持续镇静情况下，描述长期应用右美托咪定治疗下的血流动力学效应，停用策略，以及戒断的危险因素。
方 法
数据来源于未满18岁被PICU 收入的382名儿童，在不存在其他持续镇静情况下接受右美托咪定镇静无创正压通气超过24小时。本研究中采用右美托咪啶的常用使用方法。中止策略被定义为突然中止右美托咪啶注射液及可乐定直肠用药过渡。
结 果
中位峰值和累积值在四分位数范围内分别为1 µg/kg/h（0.6-1.2 µg/kg/hr）和30 µg/kg (20-50 µg/kg)，持续时间中位数为45h（34-66 h）。在达到剂量峰值4小时后，我们观察到心率下降(p<0.01)且心动过缓发生率为28%；收缩压升高(p<0.01)，且高血压发生率为33%，低血压发生率2%。在剂量增加阶段，心动过缓和低血压的患病率分别为75%和30%。有336例（88%）患者发生突然用药中断，37(10%)逐渐过渡，9例(2%例)转为可乐定。19例(5%)患者发生戒断反应。戒断的独立危险因素与持续时间相关最大：每12小时的比值比为1.5（1.3-1.7），P值小于0.01。通过包括年龄、中断组、右美托咪定累计量、最大剂量在内的多变量分析，只有累积剂量与10 µg/kg下比值比1.3(1.1-1.5) 保持显着相关性，p值小于0.01。
结 论
右美托咪定在儿童重症监护中用于无创正压通气镇静具有可预见的血流动力学效应，包括心动过缓和高血压。虽然戒断与更高的累积剂量有关，短期直肠可乐定用药可有效地控制治疗这些症状。
原始文献摘要
Brittany L. Shutes, ; Samantha W. Gee, ;Dexmedetomidine as Single Continuous Sedative During Noninvasive Ventilation: Typical Usage, Hemodynamic Effects, and Withdrawal；Pediatr Crit Care Med. 2018 Jan 16. doi: 10.1097/PCC.0000000000001451.
Background:Dexmedetomidine use in pediatric critical care is increasing. Its prolonged effects as a single continuous agent for sedation are not well described. The aim of the current study was to describe prolonged dexmedetomidine therapy without other continuous sedation, specifically the hemodynamic effects, discontinuation strategies, and risk factors for withdrawal.
Methods: Data from 382 children, less than 18 years old admitted to the PICU who received dexmedetomidine for more than 24 hours without other infusions for sedation during noninvasive positive pressure ventilation.Usual care practices for dexmedetomidine use were described. Discontinuation strategies were categorized as abrupt discontinuation, wean from dexmedetomidine infusion, and transition to enteral clonidine.
Results: Median peak and cumulative doses with interquartile range were 1 µg/kg/hr (0.6-1.2 µg/kg/hr) and 30 µg/kg (20-50 µg/kg), respectively, and median duration was 45 hours (34-66 hr). Four hours after reaching peak dose, we observed a decrease in heart rate (p < 0.01) with 28% prevalence of bradycardia and an increase in systolic blood pressure (p < 0.01) with 33% prevalence of hypertension and 2% hypotension. During the escalation phase, the prevalence of bradycardia and hypotension were 75% and a 30%, respectively. Three-hundred thirty-six patients (88%) had abrupt discontinuation, 37 (10%) were weaned, and nine (2%) were transitioned to clonidine. Nineteen patients (5%) experienced withdrawal. Univariate risk of withdrawal was most associated with duration: odds ratio equals to 1.5 (1.3-1.7) for each 12-hour period, p value of less than 0.01. By multivariate analysis including age, discontinuation group, dexmedetomidine cumulative dose, and peak dose, only cumulative dose remained significant with an odds ratio equals to 1.3 (1.1-1.5) for each 10 µg/kg, p value of less than 0.01.
Conclusions:Dexmedetomidine use for noninvasive positive pressure ventilation sedation in pediatric critical care has predictable hemodynamic effects including bradycardia and hypertension. Although withdrawal was associated with higher cumulative dose, these symptoms were effectively managed with short-term enteral clonidine.
麻醉学文献进展分享
联系我们