Sedation and analgesia in the pediatric intensive care unit.
Sedation and analgesia in the pediatric intensive care unit.
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儿科重症监护病房的镇静和镇痛。
DOI：
10.3928/0090-4481-20050801-12
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发表时间：
2005
期刊：
影响因子：
1.1
通讯作者：
J. Tobias
中科院分区：
文献类型：
--
作者：
J. Tobias
PICU 中可能会出现各种需要使用镇静剂、镇痛剂或两者同时使用的临床情况。尽管咪达唑仑在 PICU 人群中拥有丰富的临床经验，并且它仍然是这种情况下最常用的苯二氮卓类药物，但劳拉西泮可能提供有效的替代品，具有更长的半衰期和更可预测的药代动力学，且无需担心活性代谢物。然而，有关其在 PICU 人群中使用的报道有限，并且对其稀释剂丙二醇相关的潜在毒性存在担忧。尽管合成阿片类药物芬太尼因其血流动力学稳定性而经常被选择用于 PICU，但初步数据表明吗啡的耐受性发展可能较芬太尼较慢，并且可能比芬太尼引起更少的戒断症状。吗啡的安全性包括长期随访研究，这些研究表明，在新生儿和婴儿中使用吗啡不会对中枢神经系统发育产生不良影响。对于先天性心脏病手术后面临危险的危重婴儿，临床经验支持使用合成阿片类药物，因为它们能够调节 PVR 和预防肺动脉高压危象。苯二氮卓类药物和阿片类药物的替代品包括氯胺酮、戊巴比妥或右美托咪定。氯胺酮可能对血流动力学不稳定或气道反应性患者有用。关于在儿科重症监护室使用戊巴比妥的报道有限，一项研究提出了与其使用相关的不良反应高发生率的担忧。异丙酚作为一种提供深度镇静同时允许快速苏醒的方法而受到成年人的青睐。然而，不建议常规使用，因为它可能与“异丙酚输注综合征”相关。随着儿科经验的增加，右美托咪定等新型药物似乎将发挥作用。
Various clinical situations may arise in the PICU that necessitate the use of sedation, analgesia, or both. Although there is a large clinical experience with midazolam in the PICU population and it remains the most commonly used benzodiazepine in this setting, lorazepam may provide an effective alternative, with a longer half-life and more predictable pharmacokinetics without the concern of active metabolites. However, there are limited reports regarding its use in the PICU population, and concerns exist regarding the potential for toxicity related to its diluent, propylene glycol. Although the synthetic opioid fentanyl frequently is chosen for use in the PICU setting because of its hemodynamic stability, preliminary data suggest morphine may have a slower development of tolerance and may cause fewer withdrawal symptoms than fentanyl. Morphine's safety profile includes long-term follow-up studies that have demonstrated no adverse central nervous system developmental effects from its use in neonates and infants. In the critically ill infant at risk following surgery for congenital heart disease, clinical experience supports the use of the synthetic opioids, given their ability to modulate PVR and prevent pulmonary hypertensive crisis. Alternatives to the benzodiazepines and opioids include ketamine, pentobarbital, or dexmedetomidine. Ketamine may be useful for patients with hemodynamic instability or airway reactivity. There are limited reports regarding the use of pentobarbital in the PICU, with one study raising concerns of a high incidence of adverse effects associated with its use. Propofol has gained great favor in the adult population as a means of providing deep sedation while allowing for rapid awakening; however, its routine use is not recommended because of its potential association with "propofol infusion syndrome." As the pediatric experience increases, it appears that there will be a role for newer agents such as dexmedetomidine.