Cognitive improvement during continuous sedation in critically ill, awake and responsive patients: the Acute Neurological ICU Sedation Trial (ANIST)
Cognitive improvement during continuous sedation in critically ill, awake and responsive patients: the Acute Neurological ICU Sedation Trial (ANIST)
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DOI：
10.1007/s00134-010-1874-9
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发表时间：
2010-09-01
影响因子：
38.9
通讯作者：
Griswold, Michael
中科院分区：
文献类型：
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作者：
Mirski, Marek A.;Lewin, John J., III;Griswold, Michael
重症监护病房(ICU)中的大多数抗焦虑药物和镇静方案损害了智能功能，降低了患者的自主性，并经常增加患者的发病率。使用ICU验证的认知评估工具适配认知检查(ACE)，我们对右美托咪定(DEX)和异丙酚(PRO)进行了比较，以评估哪种镇静方案对智力的影响最小。这是一项前瞻性、随机、双盲研究，对象为30名清醒和插管性脑损伤(BI，n=18)和非BI(12例)ICU患者。每个患者都接受了芬太尼/PRO和芬太尼/地塞米松的交叉设计，滴定到平静的清醒状态。在每一个研究阶段，使用经过验证的霍普金斯大学ACE认知测验进行认知测试。使用PRO使调整后的ACE分数(100分考试)平均减少-12.4(95%CI-8.3to-16.5p<；0.001)，而使用DEX则提高ACE分数(6.8，95%CI1.2-12.4，p<；0.018)。DEX和PRO之间血管紧张素转换酶评分变化的差异为19.2(95%可信区间为12.3-26.1p<；0.001)，支持改善血管紧张素转换酶评分。BI患者需要较少的镇静剂，但PRO和DEX对认知的影响没有改变。未发生严重不良事件。DEX治疗后出现中度心动过缓(-7.7次/分，P<；0.01)。ICU患者可以在不影响觉醒或认知的情况下给予镇静。如果避免明显的前脑功能障碍，缓解焦虑和焦虑可以单独有效地改善精神投入和表现。血管紧张素转换酶在DEX中的较高得分可能是这种药物的智力节约和镇静作用的结果。
Most anxiolytics and sedative regimens in the intensive care unit (ICU) impair intellectual function, reducing patient autonomy, and often add to patient morbidity. Using an ICU-validated cognitive assessment tool Adapted Cognitive Exam (ACE), we performed a comparison between dexmedetomidine (DEX) and propofol (PRO) to evaluate which sedative regimen offered the least decrement in intellectual capacity.This was a prospective, randomized, double-blinded study of 30 awake and intubated brain-injured (BI, n = 18) and non-BI (12) ICU patients. Each patient received fentanyl/PRO and fentanyl/DEX titrated to a calm, awake state using a crossover design. Cognitive testing was performed at each study period using the validated 100-point Hopkins ACE cognitive battery.Sedation with PRO diminished adjusted ACE scores (100-point exam) by a mean of -12.4 (95% CI -8.3 to -16.5, p < 0.001) while DEX, in contrast, improved ACE scores (6.8, 95% CI 1.2-12.4, p < 0.018). The difference in the change of ACE score between DEX versus PRO, our primary endpoint, was 19.2 (95% CI 12.3-26.1 p < 0.001) in favor of an improved ACE score on DEX. Patients with BI required less sedative, but effects of PRO and DEX on cognition were not changed. No serious adverse events occurred. Modest bradycardia was noted post hoc with DEX (-7.7 bpm, p < 0.01).ICU patients may be offered sedation without necessarily compromising arousal or cognition. Alleviation of anxiety and agitation can singly and effectively improve mental engagement and performance if overt forebrain dysfunction is avoided. Higher ACE scores with DEX may be a consequence of the intellect-sparing yet calming effect of this drug.