汪颖,王迪芬,刘旭,付江泉,陈先俊
WANG Ying,WANG Difen,LIU Xu,FU Jiangquan,CHEN Xianjun

• 1:贵州医科大学附院重症医学科

摘要(Abstract)：

目的:比较咪达唑仑或丙泊酚分别联合瑞芬太尼对重症医学科(ICU)住院患者的镇静镇痛效果及呼吸、循环、消化系统的影响。方法:72例经口气管插管并行机械通气> 24 h的ICU住院患者,根据镇静镇痛方案分为瑞芬太尼+咪达唑仑组(RM组,n=42)及瑞芬太尼+丙泊酚组(RP组,n=30);采用疼痛行为量表(BPS)评估镇痛效果,RASS镇静评分评估镇静效果;分别记录2组患者用药前(T0),用药10 min(T1)、30 min(T2)、1 h(T3)、6 h(T4)、12 h(T5)及用药24 h(T6)时患者心率(HR)、呼吸频率(RR)、平均动脉压(MAP)、脉搏氧饱和度(SPO2)、中心静脉压(CVP)、BPS评分及RASS评分;记录达到相同镇痛镇静状态下,瑞芬太尼用量;记录2组患者的机械通气时间及从停用呼吸机至拔管时间(拔管时间),比较2组患者用药期间发生低血压、心动过速、心动过缓、呼吸抑制、呕吐、胃肠道返流及便秘的发生率。结果:在用药过程中,RP组MAP在T1时点下降较RM组明显(P <0. 01),2组患者T1时点RASS评分,比较差异有统计学意义(P <0. 01),RP组在T1时点就能达到满意镇静效果,RM组在T2时点才达到满意镇静效果,2组患者均在T1时点就能达到满意镇痛效果,在达到相同镇静、镇痛状态下,RM组单位时间内瑞芬太尼使用量较RP组少(P <0. 01); RM组拔管时间长于RP组(P <0. 05),其余指标比较,差异无统计学意义(P> 0. 05);用药期间,2组患者出现血压下降、呼吸抑制发生率比较,差异无统计学意义(P> 0. 05); RP组患者出现胃返流增多及便秘的比例大于RM组(P <0. 05)。结论:咪达唑仑和丙泊酚分别联合瑞芬太尼均可取得较好的镇痛镇静效果;在相同镇痛镇静效果下,咪达唑仑较丙泊酚单位时间内需要联合瑞芬太尼的用量较少,对消化系统影响小;而丙泊酚的拔管时间较短。
Objective: To compare the dosage of remifentanil combined with midazolam and propofol on sedation and analgesia and their effects on respiration,circulation and digestive system of patients in ICU. Methods: Retrospective analysis of 72 cases of endotracheal intubation and mechanical ventilation for more than 24 hours in ICU. The patients were divided into remifentanil combined with the midazolam(RM) group and the remifentanil combined with propofol(RP) group according to the sedative and analgesic program. The level of analgesia was assessed according to pain behavior scale(BPS),while the level of sedation was assessed according to Richmond Agitation Sedation Scale(RASS). The vital signs,sedative and analgesic effects,the dose of remifentanil,the duration of mechanical ventilation and extubation were recorded. Furthermore,the incidence of adverse reactions was documented.Results: Both groups could reach the satisfactory analgesic level within 10 min(T0),there was no statistic difference(P > 0. 05). Compared with RM group,RP group reached the satisfactory sedative level quickly(P < 0. 01),while to the same analgesic and sedative effect,the dose of remifentanil of RM group was lower than that of RP group in unit time(P < 0. 01). During the therapy,the mean arterial pressure of RP group in 10 minutes(T1) was initially lower than that of RM group(P < 0. 01),while there was no significant difference in vital signs between the two groups in the rest of time(P >0. 05). There was no significant difference between the two groups during mechanical ventilation,adverse reaction on respiratory and circulatory systems. But the duration of extubation in RP group was shorter than that in RM group(P < 0. 05). RP group showed more patients attacked by gastric regurgitation and constipation than RM group(P < 0. 05). Conclusion: Both groups achieved the expected sedative and analgetic effects in the treatment with remifentanil in combination with either midazolam or propofol. Remifentanil combined with midazolam can reduce the dosage of remifentanil,and has less negative influence on digestive system,while remifentanil combined with propofol shows shorter time of extubation than that of midazolam.

关键词(KeyWords)： 瑞芬太尼;丙泊酚;咪达唑仑;镇静;镇痛;重症监护;机械通气
remifentanil;propofol;midazolam;sedation;analgesia;intensive care unit;mechanical ventilation

Abstract:

Keywords:

基金项目(Foundation): 国家自然科学基金项目(81701958);; 贵州省高层次人才科研项目(TZJF-2011-25);; 贵州省临床重点学科建设项目(2011-52)

作者(Author): 汪颖,王迪芬,刘旭,付江泉,陈先俊
WANG Ying,WANG Difen,LIU Xu,FU Jiangquan,CHEN Xianjun

DOI: 10.19367/j.cnki.1000-2707.2018.11.011

参考文献(References)：

• [1]DEVABHAKTHUNI S,ARMAHIZER M J,DASTA J F,et al. Analgosedation:a paradigm shift in intensive care unit sedation practice[J]. Annals of Pharmacotherapy,2012,46(4):530-540.
• [2]李炬带,刘力新.重症加强治疗病房无创正压通气患者应用镇静治疗的安全性探讨[J].中国呼吸与危重监护杂志,2014,(6):593-594.
• [3]杨波,赵玉良,周文博,等.右美托咪定与咪达唑仑在ICU长期机械通气患者中镇静效果及安全性对照研究[J].中国药物警戒,2018,(3):140-143.
• [4]吴新民,叶铁虎,岳云,等.国产注射用盐酸瑞芬太尼有效性和安全性的评价[J].中华麻醉学杂志,2003,23(4):245-248.
• [5]郑增旺,王克杰.咪达唑仑和丙泊酚用于全身麻醉效果的比较[J].首都医科大学学报,2006,27(3):110
• [6]Sessler C N,Gosnell M S,Grap M J,et al. The Richmond Agitation-Sedation Scale:validity and reliability in adult intensive care unit patients[J]. Am J Respir Crit Care Med,2002,166(10):1338-1344.
• [7]佘守章,忽新刚.疼痛评估在ICU危重症患者中的应用近况[J].实用疼痛学杂志,2010,6(3):203-212.
• [8]马朋林,王宇,席修明,等.重症加强治疗病房清醒患者不良住院经历调查分析[J].中华危重病急救医学,2008,20(9):553-557.
• [9]PATEL S B,KRESS J P. Sedation and analgesia in the mechanically ventilated patient[J]. Clinics in Chest Medicine,2009,30(1):486-497.
• [10]JAKOB S M,LUBSZKY S,FRIOLET R,et al. Sedation and weaning from mechanical ventilation:effects of process optimization outside a clinical trial[J]. Journal of Critical Care,2007,22(3):219.
• [11]BRNER R,MOORMANN J,WANG M. Survival of propofol infusion syndrome in a head[J]. Critical Care Medicine,2006,34(9):2479-2483.
• [12]赵帅,李娟,季清娜,等.右美托咪定和咪达唑仑复合芬太尼对ICU术后机械通气患者的镇静效果观察[J].中国医药导报,2012,9(31):95-96,114.
• [13]张宝成,钟志越,李宏治,等.右美托咪定与咪达唑仑对危重病患者镇静效果的比较[J].中国临床医学,2012,19(3):290-292.
• [14]田悦,郭善斌.咪达唑仑与芬太尼联合用于ICU机械通气患者镇静的临床观察[J].实用药物与临床,2010,13(2):107-108.
• [15]DEVLIN J W,ROBERTS R J. Pharmacology of commonly used analgesics and sedatives in the ICU:benzodiazepines,propofol,and opioids[J]. Anesthesiology Clinics,2011,25(3):431-449.
• [16]陈伯銮.临床麻醉药理学[M].北京:人民卫生出版社,2000:184.
• [17]王伟,杨万杰.瑞芬太尼在ICU中的研究进展[J].临床麻醉学杂志,2015,31(9):926-928.
• [18]KATO T,KOITABASHI T,OUCHI T,et al. The utility of bispectral index monitoring for sedated patients treated with low-dose remifentanil.[J]. Journal of Clinical Monitoring&Computing,2012,26(6):459-463.
• [19]乔淼,杜立宏,王志玮,等.丙泊酚复合瑞芬太尼靶控输注在胃肠镜检查中的应用[J].中国全科医学,2006,9(19):1625-1626.
• [20]刘艳秋,高鸿,安丽,等.瑞芬太尼对家兔离体心室肌动作电位时程及跨室壁复极不均一性的影响[J].贵阳医学院学报,2015,40(9):935-938.
• [21]何国栋,徐旭仲,蔡楠,等.瑞芬太尼对小白鼠胃肠道蠕动功能的影响[J].浙江实用医学,2010,15(3):172-172.
• [22]BOER F,ROS P,BOVILL J G,et al. Effect of propofol on peripheral vascular resistance during cardiopulmonary bypass[J]. British Journal of Anaesthesia,1990,65(2):184-189.
• [23]CULLEN P M,TURTLE M,PRYS-ROBERTS C,et al.Effect of propofol anesthesia on baroreflex activity in humans[J]. Anesthesia&Analgesia,1987,66(11):1115.
• [24]刘坤彬,王东浩,马赟,等.瑞芬太尼在重症监护病房机械通气患者镇痛镇静中的应用研究[J].中华危重病急救医学,2013,25(3):167-170.
• [25]高尚兰,付云,郭世勋.异丙酚和咪唑安定对机械通气患者镇静效果的对比观察[J].中国现代医药杂志,2010,12(1):67-69.
• [26]曾军,钟维农,何卫国,等.丙泊酚和咪唑安定用于ICU机械通气镇静效果的比较[J].临床麻醉学杂志,2004,20(11):684-685.

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