Daily Sedation Interruption in Mechanically Ventilated Critically Ill Patients Cared for With a Sedation Protocol A Randomized Controlled Trial
Daily Sedation Interruption in Mechanically Ventilated Critically Ill Patients Cared for With a Sedation Protocol A Randomized Controlled Trial
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DOI：
10.1001/jama.2012.13872
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发表时间：
2012-11-21
影响因子：
120.7
通讯作者：
Meade, Maureen
中科院分区：
文献类型：
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作者：
Mehta, Sangeeta;Burry, Lisa;Meade, Maureen
研究背景协议镇静和每日镇静中断是最大限度地减少镇静和减少机械通气和重症监护室（ICU）停留时间的2种策略。目的比较危重病患者常规镇静与常规镇静加每日镇静中断的效果。设计、设置和患者随机对照试验，共纳入430例危重病患者，2008年1月至2009年7月期间，在加拿大和美国的16个三级医疗和外科ICU中进行的机械通气成人研究2011.干预连续阿片类药物和/或苯二氮卓类药物输注，并随机分配至协议镇静（n=209）（对照）或协议镇静加每日镇静中断（n=214）。使用经验证的量表，护士滴定输液，以达到轻度镇静。对于接受每日中断的患者，护士恢复输注（如有指征），剂量为先前剂量的一半。评估患者是否出现谵妄和是否准备好进行无辅助呼吸。主要观察指标成功拔管时间。次要结局包括住院时间、镇静剂和阿片类药物剂量、意外器械取出、谵妄以及护士和呼吸治疗师的临床工作量结果中断组和对照组成功拔管的中位时间均为7天（中位数[IQR]，7 [4-13] vs 7 [3-12];中断组风险比，1.08; 95% CI，0.86-1.35; P= 0.52）。ICU住院时间（中位数[IQR]，10 [5-17]天vs 10 [6-20]天; P= 0.36）和住院时间（中位数[IQR]，20 [10-36]天vs 20 [10-48]天; P= 0.42）在每日中断组和对照组之间分别没有差异。每日中断与咪达唑仑（102 mg/d vs 82 mg/d; P= 0.04）和芬太尼（中位数[IQR]，550 [50-1850] vs 260 [0-1400]; P
Context Protocolized sedation and daily sedation interruption are 2 strategies to minimize sedation and reduce the duration of mechanical ventilation and intensive care unit (ICU) stay. Wehypothesized that combining these strategies would augment the benefits.Objective To compare protocolized sedation with protocolized sedation plus daily sedation interruption in critically ill patients.Design, Setting, and Patients Randomized controlled trial of 430 critically ill, mechanically ventilated adults conducted in 16 tertiary care medical and surgical ICUs in Canada and the United States between January 2008 and July 2011.Intervention Continuous opioid and/or benzodiazepine infusions and random allocation to protocolized sedation (n=209) (control) or to protocolized sedation plus daily sedation interruption (n=214). Using validated scales, nurses titrated infusions to achieve light sedation. For patients receiving daily interruption, nurses resumed infusions, if indicated, at half of previous doses. Patients were assessed for delirium and for readiness for unassisted breathing.Main Outcome Measure Time to successful extubation. Secondary outcomes included duration of stay, doses of sedatives and opioids, unintentional device removal, delirium, and nurse and respiratory therapist clinical workload (on a 10-point visual analog scale [VAS]).Results Median time to successful extubation was 7 days in both the interruption and control groups (median [IQR], 7 [4-13] vs 7 [3-12]; interruption group hazard ratio, 1.08; 95% CI, 0.86-1.35; P=.52). Duration of ICU stay (median [IQR], 10 [5-17] days vs 10 [6-20] days; P=.36) and hospital stay (median [IQR], 20 [10-36] days vs 20 [10-48] days; P=.42) did not differ between the daily interruption and control groups, respectively. Daily interruption was associated with higher mean daily doses of midazolam (102 mg/d vs 82 mg/d; P=.04) and fentanyl (median [IQR], 550 [50-1850] vs 260 [0-1400]; P