镇痛镇静策略在PICU机械通气患儿中的应用

Efficacy of analgesic and sedative treatments in children with mechanical ventilation in the pediatric intensive care unit

摘要:

目的 探讨不同镇静、镇痛策略对机械通气患儿的辅助治疗效果及不良反应。方法 将80例进行机械通气且需镇静镇痛治疗的危重患儿随机分为咪达唑仑组（40例）和瑞芬太尼+咪达唑仑组（40例），采用Ramsay及FLACC量表评估镇静、镇痛效果，记录治疗期间生命体征、呼吸机参数动态变化、脏器功能指标、瑞芬太尼及咪达唑仑应用总量、机械通气时间、PICU住院时间及费用、不良反应发生情况等。结果 2组患儿均能达到满意镇痛镇静效果。与咪达唑仑组比较，瑞芬太尼+咪达唑仑组达到镇静镇痛效果所需时间更短，Ramsay评估3~4级所占百分比增高，咪达唑仑用量降低，差异均有统计学意义（P < 0.05）。2组患儿治疗后心率、平均动脉压及自主呼吸频率均降低，但瑞芬太尼+咪达唑仑组在用药后3~24 h的心率、3~12 h的平均动脉压和自主呼吸频率下降更明显（P < 0.05）。与咪达唑仑组比较，瑞芬太尼+咪达唑仑组患儿用药后的6 h和12 h呼吸机潮气量及经皮氧饱和度均明显增高，呼气末二氧化碳水平明显降低，差异有统计学意义（P < 0.05）。瑞芬太尼+咪达唑仑组停药至苏醒的时间、拔管时间、机械通气以及PICU住院时间均明显低于咪达唑仑组（P < 0.05）。2组患儿PICU住院费用、不良反应发生率以及用药前后肝肾功能差异均无统计学意义（P > 0.05），但空腹血糖比镇静前明显降低（P < 0.05）。结论 PICU机械通气患儿采用瑞芬太尼+咪达唑仑治疗方案能迅速达到镇痛、镇静目标，改善通气效果，减少镇静剂用量，耐受性良好。

Abstract:

Objective To compare the efficacy and safety of different analgesic and sedative treatments in children with mechanical ventilation in the pediatric intensive care unit (PICU). Methods Eighty children with mechanical ventilation in the PICU who needed analgesic and sedative treatments were equally and randomly divided into midazolam group and remifentanil+midazolam group. The sedative and analgesic effects were assessed using the Ramsay Scale and the Face, Legs, Activity, Cry and Consolability (FLACC) Scale. The following indices were recorded for the two groups:vital signs, ventilator parameters, organ function, total doses of remifentanil and midazolam, duration of mechanical ventilation, length of PICU stay, PICU cost, and incidence of adverse events. Results Satisfactory sedation was achieved in the two groups, but the remifentanil+midazolam group had a significantly shorter time to analgesia and sedation than the midazolam group. The remifentanil+midazolam group had a significantly higher percentage of patients with grade 3-4 on the Ramsay Scale and a significantly lower dose of midazolam than the midazolam group (P < 0.05). Both groups showed decreases in heart rate (HR), mean arterial pressure (MAP), and spontaneous breathing frequency (RRs) after treatment. However, the remifentanil+midazolam group had significantly greater decreases in HR at 3-24 hours after treatment and MAP and RRs at 3-12 hours after treatment than the midazolam group (P < 0.05). Compared with the midazolam group, the remifentanil+midazolam group had significantly higher ventilator tidal volume and transcutaneous oxygen saturation at 6 and 12 hours after treatment and significantly lower end-tidal carbon dioxide partial pressure at 6 and 12 hours after treatment (P < 0.05). The remifentanil+midazolam group had significantly shorter time to awake, extubation time, duration of mechanical ventilation, and length of PICU stay than the midazolam group (P < 0.05). There were no significant differences in PICU cost, incidence of adverse events, and hepatic and renal functions before and after treatment between the two groups (P > 0.05). Both groups showed a significant decrease in fasting blood glucose level after treatment (P < 0.05). Conclusions For children with mechanical ventilation in the PICU, remifentanil+midazolam treatment can rapidly achieve analgesia and sedation, improve the effect of mechanical ventilation, and reduce the dose of sedative compared with midazolam alone, and is well tolerated.