Prolonged sedation of critically ill patients with midazolam or propofol: Impact on weaning and costs
Prolonged sedation of critically ill patients with midazolam or propofol: Impact on weaning and costs
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DOI：
10.1097/00003246-199701000-00009
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发表时间：
1997-01-01
影响因子：
8.8
通讯作者：
AyensaRincon, A
中科院分区：
文献类型：
--
作者：
BarrientosVega, R;SanchezSoria, MM;AyensaRincon, A
目的：比较咪达唑仑与异丙酚对危重机械通气患者的镇静效果、脱机时间及延长镇静时间的成本。设计：开放标签，随机，前瞻性，IV期临床试验。环境：社区医院内科和外科重症监护病房（ICU）。患者：所有ICU住院患者（内科、外科和外伤）需要机械通气24小时。研究共纳入108例患者。干预措施：患者随机接受咪达唑仑或异丙酚。每种药物允许的剂量范围为咪达唑仑为0.1至0.5毫克/公斤/小时，异丙酚为1至6毫克/公斤/小时。达到充分的患者-呼吸机同步的最低剂量是输注。所有患者均给予0.5 mg/kg/24小时的氯吗啡。测量结果及主要结果：每2 h用Ramsay评分法定量镇静水平，直至开始脱离机械通气。如果注射最高剂量的咪达唑仑或异丙酚仍不能达到镇静效果，则记录为治疗失败。异丙酚组每72小时检测一次血清甘油三酯。浓度为bb0 ~ 500mg /dL也被记录为治疗失败。当患者根据规定的标准准备脱机时，突然中断镇静，并测量从镇静中断到第一次t桥试验和拔管的时间。成本分析是根据我们单位的重症监护费用（54美元/小时）进行的。咪达唑仑组（n=54），死亡15例（27.8%）；治疗失败11例（20.4%）；28例（51.8%）患者接受t桥治疗。在异丙酚组（n=54）中，这些比例分别为11例（20.4%）、18例（33.4%[其中7例因镇静不足，11例因高甘油三酯血症]）和25例（46.2%）。这些数值在两组之间没有显著差异。镇静持续时间为141.7 +/- 89.4 （SD）小时和139.7 +/- 84.7小时（p = NS），镇静成本（美元）咪达唑仑组和异丙酚组分别为378 +/- 342美元和1047 +/- 794美元（p = 0.0001）。咪达唑仑组停药至拔管时间为97.9 +/- 54.6小时（首次断药时间为45.9 +/- 4.2小时，拔管时间为49.0 +/- 23.7小时）。异丙酚组停药至拔管时间为34.8 +/- 29.4小时（首次断药时间为4.0 +/- 3.9小时，拔管时间为30.8 +/- 29.2小时）。两组断奶时间差异为63.1±12.5 (SEM) hrs （p < 0.001）。咪达唑仑组每位患者的费用（包括ICU治疗和咪达唑仑镇静）为10,828美元+/- 5,820美元，比咪达唑仑组少1,362美元。结论：在长期使用咪达唑仑或异丙酚镇静的危重患者人群中，咪达唑仑和异丙酚作为镇静剂同样有效。然而，尽管这两种药物在镇静成本上存在显著差异，但由于异丙酚给药的脱机时间较短，因此经济状况比咪达唑仑更有利。
Objective: To compare the effectiveness of sedation, the time required for weaning, and the costs of prolonged sedation of critically ill mechanically ventilated patients with midazolam and propofol.Design: Open-label, randomized, prospective, phase IV clinical trial.Setting: Medical and surgical intensive care unit (ICU) in a community hospital.Patients: All ICU admissions (medical, surgical and trauma) requiring mechanical ventilation for >24 hrs. A total of 108 patients were included in the study.Interventions: Patients were randomized to receive midazolam or propofol. The dose range allowed for each drug was 0.1 to 0.5 mg/kg/hr for midazolam and 1 to 6 mg/kg/hr for propofol. The lowest dose that achieved an adequate patient-ventilator synchrony was infused. All patients received 0.5 mg/kg/24 hrs of morphine chloride.Measurements and Main Results: The level of sedation was quantified by the Ramsay scale every 2 hrs until weaning from mechanical ventilation was started. If sedation could not be achieved by infusing the highest dose of midazolam or propofol, the case was recorded as a therapeutic failure. In the propofol group, serum triglycerides were determined every 72 hrs. concentrations of >500 mg/dL were also recorded as a therapeutic failure. When the patient was ready for weaning according to defined criteria, sedation was interrupted abruptly and the time from interruption of sedation to the first T-bridge trial and to extubation was measured. cost analysis was performed based on the cost of intensive care in our unit ($54/hr).In the midazolam group (n=54), 15 (27.8%) patients died; 11 (20.4%) patients had therapeutic failure; and 28 (51.8%) patients were subjected to a T-bridge trial. In the propofol group (n=54), these proportions were 11 (20.4%), 18 (33.4% [including seven due to inadequate sedation, and 11 due to hypertriglyceridemia]), and 25 (46.2%), respectively. None of these values was significantly different between the two groups.Duration of sedation was 141.7 +/- 89.4 (SD) hrs and 139.7 +/- 84.7 hrs (p = NS), and cost (US dollars) attributed to sedation was $378 +/- 342 and $1,047 +/- 794 (p = .0001) for the midazolam and propofol groups, respectively.In the midazolam group, time from discontinuation of the drug infusion to extubation was 97.9 +/- 54.6 hrs (45.9 +/- 4.2 hrs to the first disconnection, and 49.0 +/- 23.7 hrs to extubation). In the propofol group, time from discontinuation of the drug infusion to extubation was 34.8 +/- 29.4 hrs (4.0 +/- 3.9 hrs to the first disconnection, and 30.8 +/- 29.2 hrs to extubation). The difference between the two groups in the weaning time was 63.1 +/- 12.5 (SEM) hrs (p < .001).Cost per patient in the midazolam group (including ICU therapy and sedation with midazolam) was $10,828 +/- 5,820, $1,362 less than in the midazolam group.Conclusions: In our population of critically ill patients sedated with midazolam or propofol over prolonged periods, midazolam and propofol were equally effective as sedative agents. However, despite remarkable differences in the cost of sedation with these two agents, the economic profile is more favorable for propofol than for midazolam due to a shorter weaning time associated with propofol administration.