艾贝宁促进拔管研究

Feasibility of dexmedetomidine in facilitating extubation in the  intensive care unit

P. A. Arpino*PharmD BCPS, K. Kalafatas* PharmD and  B. T. Thompsont MD

SUMMARY

Background: Spontaneous  breathing  trials (SBT) and  intermittent mandatory ventilation (IMV) are common techniques utilized to expedite the  ven- tilator weaning process. These techniques often require the  reduction and ⁄ or  discontinuation of sedatives and  analgesics. Reducing these medi- cations can  lead  to agitation and  the  inability to conduct SBTs  or  weaning by  IMV.  Adding dex- medetomidine (dex),  a potent alpha-2-adrenergic receptor agonist  that   possesses  sedative,  anxio- lytic and  analgesic effects without causing sig- nificant respiratory depression, may  facilitate extubation in these patients.
Objective: To assess the  feasibility of adding dex to facilitate extubation in  a group of difficult-to- extubate patients secondary to agitation.
Methods:  Mechanically ventilated patients who  were  deemed difficult to wean and  extubate secondary to agitation were  evaluated for dex therapy. Inclusion criteria were  location in an intensive care unit, intubated and  mechanically ventilated, required IV sedation, deemed suitable by   unit  criteria  for   weaning  and    extubation within 24 h of dex initiation, previous attempts at weaning sedation  and ⁄ or  analgesia resulted in agitation causing either severe patient ventilator dyssynchrony, prolong need for intubation, or an inability to conduct a successful SBT. Additional inclusion criteria were  unsuccessful use  of tradi- tional  intravenous  agents  to   control  agitation.Recommended dex dosing was a bolus of 1ug⁄ kg followed by an infusion of 0.2–0.7 ug ⁄ kg ⁄ h.

Results: Twenty-five patients  were  evaluated for dex  therapy with 20 meeting the  criteria to treat. All  had  failed prior attempts at  weaning.  Four- teen  of the  20 patients were  successfully weaned and  extubated and  one patient was  reintubated within 48 h, giving a 65% success rate.  Heart rate trended down after  dex initiation in most  patients but  did  not result in the discontinuation of dex in any  patient. The  addition of  dex  was  associated with minimal changes in mean arterial pressure. Conclusions: Dexmedetomidine  was  initiated in a group of mechanically ventilated patients who failed previous attempts at weaning and  extuba- tion  secondary to  agitation. After  dex  initiation,
65% of the patients was successfully extubated. Dexmedetomidine was  associated with a  reduc- tion   in  concomitant sedative and   analgesic use with minimal adverse effect.

Keywords: agitation, dexmedetomidine, extuba- tion,  intensive care unit
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Use of Dexmedetomidine to Facilitate Extubation in Surgical Intensive-Care-Unit Patients Who Failed Previous Weaning Attempts Following Prolonged Mechanical Ventilation: A Pilot Study

Mark S Siobal RRT, Richard H Kallet MSc RRT FAARC, Valerie A Kivett, and
Julin F Tang MD MSc

INTRODUCTION: Dexmedetomidine is a selective alpha-2 adrenergic receptor agonist that exhib- its sedative, analgesic, anxiolytic, and sympatholytic effects without respiratory-drive depression. We prospectively evaluated the use of dexmedetomidine to facilitate the withdrawal of mechanical ventilation and extubation in 5 trauma/surgical intensive-care-unit patients who had failed previous weaning attempts due to agitation and hyperdynamic cardiopulmonary response. METHODS: Intravenous infusion of dexmedetomidine commenced at 0.5 or 0.7 μg/kg/h without a loading dose. Background sedation and analgesia with propofol, benzodiazepines, and opiates was discontinued or reduced as tolerated. Dexmedetomidine infusion was titrated between 0.2 and 0.7 μg/kg/h to maintain a stable cardiopulmonary response and modified Ramsay Sedation Score between 2 and 4. RESULTS: Following dexmedetomidine administration, propofol infusion was weaned and dis- continued in 4 patients. In the fifth patient, benzodiazepine and opiate infusions were reduced. Ventilatory support in all patients could be weaned to continuous positive airway pressure of 5 cm H2O without agitation, hemodynamic instability, or respiratory decompensation. All patients were extubated while receiving dexmedetomidine infusion (mean dose of 0.32 :t 0.08 μg/kg/h).  One patient required reintubation for upper-airway obstruction. CONCLUSION: Dexmedetomidine appears to maintain adequate sedation without hemodynamic instability or respiratory-drive de- pression, and thus may facilitate extubation in agitated difficult-to-wean patients; it therefore deserves further investigation toward this novel use. Key words: dexmedetomidine, ventilator weaning, extubation, sedation, agitation.   [Respir Care 2006;51(5):492– 496. © 2006 Daedalus Enterprises]

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