右美托咪定在急性呼吸衰竭危重患儿中的应用
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Dexmedetomidine Use in Critically Ill Children With Acute Respiratory Failure
背景
危重患儿的管理包括镇静，而遗憾的是，目前的治疗管理并不完美。本研究旨在观察右美托咪定在机械通气治疗急性呼吸衰竭患儿中的应用。
方 法
设计:对右美托咪定滴定法镇静用于呼吸衰竭临床试验的随机评价数据作二次分析。实施地:31个PICUs（儿科重症监护病房）。患者:2周至17岁的2449名儿童。干预措施：病人被分为4个右美托咪定组，右美托咪定组，右美托咪定次要用药组，拔管前用药组，右美托咪定用药不定组，并对右美托咪定的使用量、镇静情况和临床资料进行描述。
测量指标和结果
1224例需要常规管理的病人中，596（49%）例使用了右美托咪啶。右美托咪定作为主要的镇静病人（n＝138，11%）危重程度较轻（儿科死亡率风险评估量表III- 12分，中位数值6分[四分位间距，3-11]）当和其他组相比时，经历更多的短暂的波动。在干预组，以右美托咪定作为主要镇静药的患儿1天内镇静时间由28%提高到50%。右美托咪定作为次要镇静药物的常规管理患儿（n = 280， 23%）中，有更多的小儿患有严重的急性呼吸窘迫综合征或器官衰竭。右美托咪定作为作为次要镇静药物的患儿经历更多的疼痛（22%vs 11%）和镇静事件（镇静不足）（31%vs 16%）。右美托咪定用于已知不能耐受带管状态下清醒患儿的拔管前用药（n = 178；15%）能更短时间的撤机（2.1 vs 2.3 d）。
结 论
我们的数据支持使用右美托咪定作为低危险患儿的主要药物，有利于患儿获得快速达到有针对性的镇静水平带来的益处。右美托咪定作为次要镇静用药副作用似乎没有带来更多的益处。右美托咪啶促进清醒状态下不能耐受带管患儿的拔管，缩短呼吸机撤离时间，这些数据为PICU镇静更广泛的用药提供参考。
原始文献摘要:
OBJECTIVE:
Care of critically ill children includes sedation but current therapies are suboptimal. To describe dexmedetomidine use inchildren supported on mechanical ventilation for acute respiratory failure.
DESIGN:
Secondary analysis of data from the Randomized Evaluation of Sedation Titration for Respiratory Failure clinical trial.
SETTING:
Thirty-one PICUs.
PATIENTS:
Data from 2,449 children; 2 weeks to 17 years old.
INTERVENTIONS:
Sedation practices were unrestrained in the usual care arm. Patients were categorized as receivingdexmedetomidine as a primary sedative, secondary sedative, periextubation agent, or never prescribed. Dexmedetomidine exposure and sedation and clinical profiles are described.
MEASUREMENTS AND MAIN RESULTS:
Of 1,224 usual care patients, 596 (49%) received dexmedetomidine. Dexmedetomidine as a primary sedative patients (n = 138; 11%) were less critically ill (Pediatric Risk of Mortality III-12 score median, 6 [interquartile range, 3-11]) and when compared with all other cohorts, experienced more episodic agitation. In the intervention group, time in sedation target improved from 28% to 50% within 1 day of initiating dexmedetomidine as a primary sedative. Dexmedetomidine as a secondary sedative usual care patients (n = 280; 23%) included more children with severe pediatric acute respiratory distress syndrome or organfailure. Dexmedetomidine as a secondary sedative patients experienced more inadequate pain (22% vs 11%) and sedation (31% vs 16%) events. Dexmedetomidine as a periextubation agent patients (n = 178; 15%) were those known to not tolerate an awake, intubated state and experienced a shorter ventilator weaning process (2.1 vs 2.3 d).
CONCLUSIONS:
Our data support the use of dexmedetomidine as a primary agent in low criticality patients offering the benefit of rapid achievement of targeted sedation levels. Dexmedetomidine as a secondary agent does not appear to add benefit. The use ofdexmedetomidine to facilitate extubation in children intolerant of an awake, intubated state may abbreviate ventilator weaning. These data support a broader armamentarium of pediatric critical care sedation.
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