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右美托咪定或异丙酚用于机械通气成人败血症患者镇静后临床结局无差异
作者:小柯机器人 发布时间:2021/2/4 16:48:52

美国纳什维尔危重症、脑功能障碍和生存中心Christopher G. Hughes团队比较了右美托咪定或异丙酚用于机械通气成人败血症患者镇静对预后的影响。2021年2月2日,该研究发表在《新英格兰医学杂志》上。

目前的指南建议成人接受机械通气时使用右美托咪定或异丙酚靶向轻度镇静。这些镇静剂在唤醒能力、免疫力和炎症方面存在差异。对于接受轻度镇静的机械通气成人败血症患者,这些镇静剂是否对预后有不同的影响尚不清楚。

研究组进行了一项多中心双盲试验,招募患有败血症、接受机械通气的成人患者,将其随机分组,分别接受右美托咪定或异丙酚镇定,由床边护士调整剂量,以达到临床医生根据里士满躁动一镇静评分(RASS)设定的镇静目标。主要终点为在14天的干预期内无谵妄或昏迷的存活天数。次要终点为第28天的无呼吸机天数、第90天的死亡以及6个月时电话采访认知状况问卷(TICS-T)的年龄校正评分。

在接受随机分组的432名患者中,422名被分配接受试验药物并被纳入分析,其中214名患者接受右美托咪定,中位剂量为0.27μg/kg/h,208名患者接受异丙酚,中位剂量为10.21μg/kg/min。接受试验药物的中位持续时间为3.0天,RASS中位得分为−2.0分。右美托咪定组和异丙酚组患者在无谵妄或昏迷的存活天数、无呼吸机天数、90天死亡、以及6个月时的TICS-T评分方面均无显著差异。两组的安全终点相似。

研究结果表明,对于使用推荐轻度镇静方法治疗的机械通气成人败血症患者,采用右美托咪定或异丙酚镇定对患者临床结局没有明显差异。

附:英文原文

Title: Dexmedetomidine or Propofol for Sedation in Mechanically Ventilated Adults with Sepsis | NEJM

Author: Christopher G. Hughes, M.D., M.S.C.R.,, Patrick T. Mailloux, D.O.,, John W. Devlin, Pharm.D.,, Joshua T. Swan, Pharm.D., M.P.H.,, Robert D. Sanders, M.D.,, Antonio Anzueto, M.D.,, James C. Jackson, Psy.D.,, Aimee S. Hoskins, B.S.N., R.N.,, Brenda T. Pun, D.N.P., R.N.,, Onur M. Orun, M.S.,, Rameela Raman, Ph.D.,, Joanna L. Stollings, Pharm.D.,, Amy L. Kiehl, M.A.,, Matthew S. Duprey, Pharm.D., Ph.D.,, Lan N. Bui, Pharm.D., M.P.H.,, Hollis R. O’Neal, Jr., M.D.,, Allison Snyder, M.S.N., A.P.R.N.,, Michael A. Gropper, M.D., Ph.D.,, Kalpalatha K. Guntupalli, M.D.,, Gregg J. Stashenko, M.D.,, Mayur B. Patel, M.D., M.P.H.,, Nathan E. Brummel, M.D., M.S.C.I.,, Timothy D. Girard, M.D., M.S.C.I.,, Robert S. Dittus, M.D., M.P.H.,, Gordon R. Bernard, M.D.,, E. Wesley Ely, M.D., M.P.H.,, and Pratik P. Pandharipande, M.D., M.S.C.I.

Issue&Volume: 2021-02-02

Abstract:

Background

Guidelines currently recommend targeting light sedation with dexmedetomidine or propofol for adults receiving mechanical ventilation. Differences exist between these sedatives in arousability, immunity, and inflammation. Whether they affect outcomes differentially in mechanically ventilated adults with sepsis undergoing light sedation is unknown.

Methods

In a multicenter, double-blind trial, we randomly assigned mechanically ventilated adults with sepsis to receive dexmedetomidine (0.2 to 1.5 μg per kilogram of body weight per hour) or propofol (5 to 50 μg per kilogram per minute), with doses adjusted by bedside nurses to achieve target sedation goals set by clinicians according to the Richmond Agitation–Sedation Scale (RASS, on which scores range from 5 [unresponsive] to +4 [combative]). The primary end point was days alive without delirium or coma during the 14-day intervention period. Secondary end points were ventilator-free days at 28 days, death at 90 days, and age-adjusted total score on the Telephone Interview for Cognitive Status questionnaire (TICS-T; scores range from 0 to 100, with a mean of 50±10 and lower scores indicating worse cognition) at 6 months.

Results

Of 432 patients who underwent randomization, 422 were assigned to receive a trial drug and were included in the analyses — 214 patients received dexmedetomidine at a median dose of 0.27 μg per kilogram per hour, and 208 received propofol at a median dose of 10.21 μg per kilogram per minute. The median duration of receipt of the trial drugs was 3.0 days (interquartile range, 2.0 to 6.0), and the median RASS score was 2.0 (interquartile range, 3.0 to 1.0). We found no difference between dexmedetomidine and propofol in the number of days alive without delirium or coma (adjusted median, 10.7 vs. 10.8 days; odds ratio, 0.96; 95% confidence interval [CI], 0.74 to 1.26), ventilator-free days (adjusted median, 23.7 vs. 24.0 days; odds ratio, 0.98; 95% CI, 0.63 to 1.51), death at 90 days (38% vs. 39%; hazard ratio, 1.06; 95% CI, 0.74 to 1.52), or TICS-T score at 6 months (adjusted median score, 40.9 vs. 41.4; odds ratio, 0.94; 95% CI, 0.66 to 1.33). Safety end points were similar in the two groups.

Conclusions

Among mechanically ventilated adults with sepsis who were being treated with recommended light-sedation approaches, outcomes in patients who received dexmedetomidine did not differ from outcomes in those who received propofol.

DOI: 10.1056/NEJMoa2024922

Source: https://www.nejm.org/doi/full/10.1056/NEJMoa2024922

 

期刊信息

The New England Journal of Medicine:《新英格兰医学杂志》,创刊于1812年。隶属于美国麻省医学协会,最新IF:70.67
官方网址:http://www.nejm.org/
投稿链接:http://www.nejm.org/page/author-center/home