The effect of dexmedetomidine on agitation during weaning of mechanical ventilation in critically ill patients Y. Shehabi*, H. Nakae, N. Hammond, F. Bass , L. Nicholson, J. Chen Summary
Ventilated patients receiving opioids and/or benzodiazepines are at high risk of developing agitation, particularly upon weaning towards extubation. This is often associated with an increased intubation time and length of stay in the intensive care unit and may cause long-term morbidity. Anxiety, fear and agitation are amongst the most common non-pulmonary causes of failure to liberate from mechanical ventilation. This prospective, open-label observational study examined 28 ventilated adult patients in the intensive care unit (30 episodes) requiring opioids and/or sedatives for >24 hours, who developed agitation and/or delirium upon weaning from sedation and failed to achieve successful extubation with conventional management. Patients were ventilated for a median (interquartile range) of 115 [87 to 263] hours prior to enrolment. Dexmedetomidine infusion was commenced at 0.4 μg/kg/hour for two hours, after which concurrent sedative therapy was preferentially weaned and titrated to obtain target Motor Activity Assessment Score score of 2 to 4. The median (range) maximum dose and infusion time of dexmedetomidine was 0.7 μg/kg/hour (0.4 to 1.0) and 62 hours (24 to 252) respectively. The number of episodes at target Motor Activity Assessment Score score at zero, six and 12 hours after commencement of dexmedetomidine were 7/30 (23.3%), 28/30 (93.3%) and 26/30 (86.7%), respectively (P <0.001 for 6 and 12 vs 0 hours). Excluding unrelated clinical deterioration, 22 episodes (73.3%) achieved successful weaning from ventilation with a median (interquartile range) ventilation time of 70 (28 to 96) hours after dexmedetomidine infusion. Dexmedetomidine achieved rapid resolution of agitation and facilitated ventilatory weaning after failure
of conventional therapy. Its role as first-line therapy in ventilated, agitated patients warrants further investigation.
Key Words: dexmedetomidine, agitation, ventilation weaning, sedation, critical care
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Delirium duration and mortality in lightly sedated, mechanicallyventilated intensive care patients
Yahya Shehabi, FCICM, EMBA; Richard R. Riker, MD; Paula M. Bokesch, MD; Wayne Wisemandle, MA;Ayumi Shintani, PhD, MPH; E. Wesley Ely, MD, MPH
Objectives: To determine the relationship between the number of delirium days experienced by intensive care patients and
mortality, ventilation time, and intensive care unit stay.
Design: Prospective cohort analysis.
Setting: Patients from 68 intensive care units in five countries.
Patients: Three hundred fifty-four medical and surgical intensive care patients enrolled in the SEDCOM (Safety and Efficacy of Dexmedetomidine
Compared with Midazolam) trial received a sedative study drug and completed at least one delirium assessment.
Interventions: Sedative drug interruption and/or titration to maintain light sedation with daily arousal and delirium assessments
up to 30 days of mechanical ventilation.
Measurements and Main Results: The primary outcome was all-cause 30-day mortality. Multivariable analysis using Cox regression incorporating delirium duration as a time-dependent variable and adjusting for eight relevant baseline covariates was conducted to quantify the relationship between number of delirium days and the three main outcomes. Overall, delirium was diagnosed in 228 of 354 patients (64.4%). Mortality was significantly lower in patients without delirium compared to those with
delirium (15 of 126 [11.9%] vs. 69 of 228 [30.3%]; p < .001).Similarly, the median time to extubation and intensive care unit discharge were significantly shorter among nondelirious patients (3.6 vs. 10.7 days [p < .001] and 4 vs. 16 days [p < .001],respectively). In multivariable analysis, the duration of delirium exhibited a nonlinear relationship with mortality (p < .02), with the strongest association observed in the early days of delirium.In comparison to 0 days of delirium, an independent dose-response increase in mortality was observed, which increased from 1 day of delirium (hazard ratio, 1.70; 95% confidence interval,1.27–2.29; p < .001), 2 days of delirium (hazard ratio, 2.69; confidence interval, 1.58–4.57; p < .001), and >3 days of delirium (hazard ratio, 3.37; confidence interval, 1.92–7.23; p < .001). Similar independent relationships were observed between delirium duration and ventilation time and intensive care length of stay.
Conclusions: In ventilated and lightly sedated intensive care unit patients, the duration of delirium was the strongest independent predictor of death, ventilation time, and intensive care unit stay after adjusting for relevant covariates. (Crit Care Med 2010; 38:2311–2318)
KEY WORDS: delirium; mortality; mechanical ventilation; delirium duration; sedation; critically ill 下载pdf全文 Dexmedetomidine and the Reduction of Postoperative Delirium after Cardiac Surgery Jose´ R. Maldonado, M.D.
Ashley Wysong, M.S.
Pieter J.A. van der Starre, M.D.
Thaddeus Block, M.D.
Craig Miller, M.D.
Bruce A. Reitz, M.D. Background: Delirium is a neurobehavioral syndrome caused by the transient disruption of normal neuronal activity secondary to systemic disturbances. Objective: The authors investigated the effects of postoperative sedation on the development of delirium in patients undergoing cardiacvalve procedures.
Methods: Patients underwent elective cardiac surgery with a standardized intraoperative anesthesia protocol, followed by random assignment to one of three postoperative sedation protocols: dexmedetomidine, propofol, or midazolam.
Results: The incidence of delirium for patients receiving dexmedetomidine was 3%, for those receiving propofol was 50%,and for patients receiving midazolam, 50%. Patients who developed postoperative delirium experienced significantly longer intensive-care stays and longer total hospitalization.
Conclusion:The findings of this open-label, randomized clinical investigation suggest that postoperative sedation with dexmedetomidine was associated with significantly lower rates of postoperative deliriumand lower care costs. (Psychosomatics 2009; 50:206 –217)
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Prevalence of Delirium with Dexmedetomidine Compared with Morphine Based Therapy after Cardiac Surgery
A Randomized Controlled Trial (DEXmedetomidine COmpared to Morphine-DEXCOM Study)
Yahya Shehabi, F.J.F.I.C.M., Peter Grant, F.R.A.C.S.,Hugh Wolfenden, F.R.A.C.S.,Naomi Hammond, M.N.,Frances Bass, B.N., Michelle Campbell, B.N., Jack Chen, Ph.D. Background: Commonly used sedatives/analgesics can increase the risk of postoperative complications, including delirium.This double-blinded study assessed the neurobehavioral,hemodynamic, and sedative characteristics of dexmedetomidine compared with morphine-based regimen after cardiac surgery at equivalent levels of sedation and analgesia.
Methods: A total of 306 patients at least 60 yr old were randomized to receive dexmedetomidine (0.1– 0.7 g · kg1 ·h1) or morphine (10-70 g · kg1 · h1) with open-label propofol titrated to a target Motor Activity Assessment Scale of 2–4.Primary outcome was the prevalence of delirium measured daily via Confusion Assessment Method for intensive care. Secondary outcomes included ventilation time, additional sedation/analgesia, and hemodynamic and adverse effects.
Results: Of all sedation assessments, 75.2% of dexmedetomidine and 79.6% (P 0.516) of morphine treatment were in the target range. Delirium incidence was comparable between dexmedetomidine 13 (8.6%) and morphine 22 (15.0%) (relative risk 0.571, 95% confidence interval [CI] 0.256–1.099, P 0.088),however, dexmedetomidine-managed patients spent 3 fewer days (2 [1–7] versus 5 [2–12]) in delirium (95% CI 1.09–6.67, P 0.0317). The incidence of delirium was significantly less in a small subgroup requiring intraaortic balloon pump and treated with dexmedetomidine (3 of 20 [15%] versus 9 of 25 [36%])(relative risk 0.416, 95% CI 0.152–0.637, P 0.001). Dexmedetomidine-treated patients were more likely to be extubated earlier(relative risk 1.27, 95% CI 1.01–1.60, P 0.040, log-rank P 0.036), experienced less systolic hypotension (23% versus 38.1%, P 0.006), required less norepinephrine (P < 0.001),but had more bradycardia (16.45% versus 6.12%, P 0.006)than morphine treatment.
Conclusion: Dexmedetomidine reduced the duration but not the incidence of delirium after cardiac surgery with effective analgesia/sedation, less hypotension, less vasopressor requirement,and more bradycardia versus morphine regimen.
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右美托咪定用于术后兴奋型谵妄患者的临床研究
李金玉,刘海林,张志杰,李广明,唐江华
摘 要: 目的 探讨右美托咪定在术后兴奋型谵妄患者中的作用。 方法 13例术后兴奋型谵妄患者,随机分为2组: A组(n=7)使用右美托咪定维持治疗24 h; B组(n=6)使用右美托咪定维持治疗36 h。观察2组患者治疗期间及停药后的平均动脉压、心率、呼吸频率、氧分压、Ramsay评分、Riker评分、精神状态及停药后复发状态。 结果 停药后12 h, A组MAP、Ramsay评分明显低于B组,P<0.01;幻觉发生比率明显高于B组,P<0.05。停药后24 h, A组HR明显高于B组,P<0.01;幻觉发生比率明显高于B组,P<0.05。A组患者停药后12 h 1例患者出现谵妄,但症状较轻,B组患者停药后未出现谵妄患者。 结论 右美托咪定用于术后兴奋型谵妄效果明显。 关键词:右美托咪定;谵妄;临床研究
澹妄与脑葡萄糖代谢的相关性及右美托咪咤对脑葡萄糖代谢的影响
马昊 欧阳文 莫逸 黎祖荣 王越春
目的:利用PET-CT脑葡萄糖代谢显像了解全麻术后老年患者脑葡萄糖代谢的改变与术后澹妄的相关性，并观察澹妄病人用右美托咪陡干预治疗后脑葡萄糖代谢的变化。
方法:选择择期行腹部手术的老年病人，年龄在65一85岁，术后均入住ICU24一48小时。将澹妄病人随机分为未干预组(A组n一13)和干预组(B组n=16)，A组在澹妄发生后未给予镇静药干预，B组在澹妄发生后给予右旋美托咪吮镇静;另选同期术后没有发生澹妄的条件相仿者为对照组(C组n=13)。所有病人，在术后24一8小时内(瞻妄病人在澹妄发生后)采用18氟一脱氧葡萄糖(18F一FDG)行PET脑葡萄糖代谢显像。通过视觉分析法和计算葡萄糖标准摄取值(SLJV值)的半定量分析法，对脑葡萄糖代谢状况进行评价。 结果:术后澹妄病人脑葡萄糖代谢降低所累及的常见部位主要集中大脑皮层顶叶、颖叶、额叶等脑区。PET图像视觉分析显示:术后澹妄病人(A组和B组)各脑区葡萄糖代谢明显低于无澹妄病人(C组)的相同脑区。葡萄糖标准摄取值(SUV值)半定量分析:术后澹妄病人(A组和B组)各脑区SUv值明显小于无澹妄的病人(C组)(P<0.05)，而两组澹妄病人(A组和B组)相比，用了右旋美托咪睫的B组st〕v值明显高于未用右旋美托咪睫的A组伊<0.05)。
结论:1术后发生澹妄的老年患者其脑葡萄糖代谢明显低于未发生澹妄的术后同龄患者，澹妄发作可能与脑葡萄糖代谢显著减低有关。2右美托咪睫不仅能够控制澹妄的症状，还可能在一定程度上减少澹妄发作引起的脑葡萄糖代谢的进一步降低。 |
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