咪达唑仑联合声门下吸痰对呼吸机相关性肺炎的临床价值

目的探讨静脉持续泵入咪达唑仑状态下经声门下吸痰在呼吸机相关性肺炎(ventilation-associated pneumonia,VAP)患者治疗中的临床应用价值。方法以2011年1月—2012年12月收治的共60例VAP患者为研究对象,按随机数字表法分为A组、B组、C组各20例。A组给予ICU常规物理治疗,包括翻身、叩背及常规吸痰(患者自主咳嗽基础上经口腔、鼻腔、人工气道声门上),B组给予ICU常规物理治疗包括翻身、叩背及经声门下吸痰,C组给予咪达唑仑持续静脉泵入下施予同B组相同的处理方法。计量资料采用单因素方差分析,多个实验组与一个对照组比较采用最小显著差法,多个实验组之间采用q检验,P0.05为差异有统计学意义。结果三组患者在治疗后第7天WBC、CRP、PaO2[A组(14.68±5.81)×10~9/L、(68.64±10.68)mg/L、(62.64±8.42)mm Hg(1 mm Hg=0.133 kPa),B组(13.78±4.54)×10~9/L、(72.48±12.13)mg/L、(64.80±8.85)mm Hg,C组(9.86±3.49)×10~9/L、(45.67±9.08)mg/L、(70.98±8.75)mm Hg]测定差异均有统计学意义(均P0.05),而PaCO2测定差异均无统计学意义(P0.05)。C组连续1周内吸痰时不良事件发生次数、机械通气天数[(28.38±2.57)次/周、(9.24±2.18)d]均明显低于A组[(38.68±4.87)次/周、(14.56±3.32)d]、B组[(35.45±3.36)次/周、(13.48±2.98)d],差异均有统计学意义(均P0.05)。结论静脉持续泵入适量咪达唑仑状态下未加重二氧化碳潴留,可增加患者对声门下吸痰的耐受性,二者配合作用下有助于肺内分泌物的排出,有利于VAP患者炎症指标的控制并可缩短机械通气治疗时间。     

A comparison of the antifibrillatory effect of midazolam and flunitrazepam in acute myocardial ischaemia in the dog

Summary

A study was carried out using a model of myocardial ischaemia in the dog after ligation of the left coronary artery to determine the effects of the benzodiazepines, flunitrazepam and midazolam, on the ventricular fibrillation threshold. The fibrillation threshold was measured twice within 15?min and 8?min after ligation. Fifteen minutes after the onset ofischaemic heart attack, 1.2?mg midazolam/kg or 0.25?mg flunitrazepam and midazolam, on the ventricular fibrillation threshold. The fibrillation threshold was measured twice within 15?min and 8?min after ligation. Fifteen minutes after the onset ofischaemic heart attack, 1.2?mg midazolam/kg or 0.25?mg of ischaemia. Their effects on haemodynamics were negligible. It is suggested that both benzodiazepines can be used for increasing electrical stability of the heart in patients with acute myocardial infarction and to inhibit the psychic stress response. Because of its short biological half-life and water solubility, allowing painless intravenous administration, midazolam offers a more flexible approach to pharmacotherapy immediately after acute heart attack according to the patient's current clinical status.     

Efficacy and Safety of Orally Administered Intravenous Midazolam Versus a Commercially Prepared Syrup

Background:

Among different categories of sedative agents, benzodiazepines have been prescribed for more than three decades to patients of all ages. The effective and predictable sedative and amnestic effects of benzodiazepines support their use in pediatric patients. Midazolam is one of the most extensively used benzodiazepines in this age group. Oral form of drug is the best accepted route of administration in children.

Objectives:

The purpose of this study was to compare the efficacy and safety of a commercially midazolam syrup versus orally administered IV midazolam in uncooperative dental patients. Second objective was to determine whether differences concerning sedation success can be explained by child‘s behavioral problems and dental fear.

Patients and Methods:

Eighty eight uncooperative dental patients (Frankl Scales 1,2) aged 3 to 6 years, and ASA I participated in this double blind, parallel randomized, controlled clinical trial. Midazolam was administered in a dose of 0.5 mg/kg for children under the age 5 and 0.2 mg/kg in patients over 5 years of age. Physiologic parameters including heart rate, respiratory rate, oxygen saturation and blood pressure were recorded. Behavior assessment was conducted throughout the course of treatment using Houpt Sedation Rating Scale and at critical moments of treatment (injection and cavity preparation) by North Carolina Scale. Dental fear and behavioral problems were evaluated using Child Fear Schedule Survey-Dental Subscale (CFSS-DS), and Strength and Difficulties Questionnaire (SDQ). Independent t-test, Chi-Square, and Pearson correlation were used for statistical analysis.

Results:

Acceptable overall sedation ratings were observed in 90% and 86% of syrup and IV/Oral group respectively; Chi-Square P = 0.5. Other domains of Houpt Scale including: sleep, crying and movement were also not significantly different between groups. Physiological parameters remained in normal limits during study without significant difference between groups.

Conclusions:

“Orally administered IV midazolam” preparation can be used as an alternative for commercially midazolam syrup.     

丙泊酚与咪达唑仑对治疗难治性癫痫持续状态的临床观察研究

目的：探讨单用丙泊酚、单用咪达唑仑和2者联用在难治性癫痫持续状态治疗中的疗效、不良反应等,以寻找较好的抗癫痫治疗方案。方法回顾性分析难治性癫痫持续患者75例。使用丙泊酚治疗的患者25例,使用咪达唑仑的患者25例,2药联合使用的患者25例。记录用药前、控制癫痫发作后、停药时这3个时点的心率（HR）、自主呼吸频率（RR）、收缩压（SBP）、舒张压（DBP）、血氧饱和度（SpO 2）以及治疗后镇静评级分数,癫痫控制起效时间以及不良反应的发生情况。结果联合用药组总体有效率为92.0%,显著高于丙泊酚组和咪达唑仑组的80.0%和84.0%（P<0.05）。3组患者用药前HR、RR、SBP、DBP、SpO 2与控制癫痫发作后、停药时所测得值相比,差异有统计学意义（P<0.05）;联合用药后,药物使用总量分别低于单独使用的组别,癫痫控制时间缩短,镇静分数提高（P<0.05）。结论丙泊酚及咪达唑仑2者联合抗癫痫的疗效优于单独使用。     

靶控输注不同镇静药物用于围术期自控镇静技术中的比较

目的探讨围术期自控镇静技术中靶控输注不同镇静药物的临床镇静效果。方法对在该院接受手术的80例患者入院资料进行分析,随机分为丙泊酚组和咪达唑仑组。本研究中二组患者在围术期靶控输注不同镇静药物,咪达唑仑组靶控输注咪达唑仑镇静剂,丙泊酚组靶控输注丙泊酚镇静,注射完后记录患者平卧10min、注射镇静药后2min、5min、10min以及手术结束前10min、手术结束时等6个时间点的OAA/S镇静评分值,并密切观察患者的镇静效果和呼吸情况。结果丙泊酚组T1时刻镇静评分为(5.0±0.0),镇静评分值在注射药物2min到5min后都明显下降,T2时刻镇静评分为(3.6±0.2)、T3时刻镇静评分为(2.5±0.4)与咪达唑仑组差异有统计学意义(P<0.05);T4、T5、T6时刻镇静评分二组患者差异无统计学意义(P>0.05);镇静后二组患者的MAP,HR均明显下降,丙泊酚组患者在镇静后2min,5min时的MAP、HR均低于咪达唑仑组(P<0.05),其他时间二组差异无统计学意义;丙泊酚组中有5例患者呼吸抑制,咪达唑仑组有3例(P>0.05)。结论围术期自控镇静技术中靶控输注丙泊酚镇静效果较好,患者麻醉后对其生命体征影响比较小,值得推广使用。     

咪唑安定联合芬太尼在无痛胃镜检查中的应用

目的探讨咪唑安定联合芬太尼在胃镜检查中的应用效果及安全性。方法随机选择在惠州市中心人民医院胃镜室接受胃镜检查的400例患者，将其分为对照组（m=200）和麻醉组（m=200）。对照组患者咽部经喷雾利多卡因局麻后，常规进行胃镜检查；麻醉组患者咽部局麻后，静脉注射咪唑安定（0．05mg/kg）和芬太尼（0．5mg），使患者进入睡眠状态后立即行胃镜检查。两组患者在胃镜检查中均监测血压、心率、指脉搏血氧饱和度，观察检查中患者的反应以及操作时间和成功率，并在检查后询问患者的感受。结果在胃镜检查中，麻醉组患者心率和收缩压均较对照组低（P〈0．05），两组指脉搏血氧饱和度差异无显著性（P〉0．05），麻醉组不良反应发生率明显低于对照组，感觉难受和不适患者所占的比例较小（2％），感觉尚可和舒适的比例较大（98％），对照组则相反，而麻醉组检查成功率、操作时间与对照组比较差异无统计学意义。结论咪唑安定联合芬太尼进行胃镜检查安全、舒适、有效。     

咪达唑仑联用地西泮控制复发性热性惊厥及再发预防的研究

目的研究咪达唑仑联用地西泮治疗对热性惊厥患儿惊厥复发预防的作用、药物不良反应,以及对语言发育、智力发育、运动功能发育的影响。 方法选择潮州市人民医院普通儿科与梅州市人民医院儿童内科自2017年1月至12月收治84例热性惊厥患儿作为研究对象,根据随机数字表法分为观察组和对照组,每组42例,并根据患儿的年龄组内分为6个月~2岁年龄段和2岁以上~6岁年龄段。观察组采用咪达唑仑联合地西泮进行治疗,对照组采用地西泮进行治疗。比较不同年龄段2组患儿在2年随访期内热性惊厥复发率、药物不良反应,以及入组治疗后第24个月时语言发育商（DQ）、贝利婴幼儿发展量表中智力发育指数（MDI）和运动发育指数（PDI）差异。 结果6个月~2岁年龄段,观察组患儿的热性惊厥复发率低于对照组,差异有统计学意义（χ²=4.251,P=0.039）,2岁以上~6岁年龄段,2组患儿的热性惊厥复发率差异无统计学意义（χ²=0.555,P=0.458）,观察组总的热性惊厥复发率低于对照组,差异有统计学意义（χ²=4.141,P=0.042）。2组患儿在不同年龄段以及总体不良反应发生率差异均无统计学意义（P>0.05）。所有患儿入组时的DQ、MDI、PDI差异均无统计学意义（P>0.05）。治疗后,观察组6个月~2岁年龄段的患儿在DQ、MDI评分上优于对照组,差异有统计学意义（P<0.05）,但PDI差异无统计学意义（P>0.05）;2组在2岁以上~6岁年龄段患儿治疗后DQ、MDI、PDI差异均无统计学意义（P>0.05）。 结论咪达唑仑联用地西泮治疗可以降低6个月~2岁年龄段热性惊厥患儿的惊厥复发率,不增加药物不良反应发生率,并且使患儿的语言发育和智力发育得到有效改善,但是对2岁以上~6岁年龄段热性惊厥患儿无明显临床效益。     

Pre- and post-intervention study to assess the impact of a sedation protocol in critically ill surgical patients

Introduction

Sedation and pain management for mechanically ventilated critically ill surgical patients pose many challenges for the intensivist. Even though daily interruption of sedatives and opioids is appropriate in medical intensive care unit (ICU) patients, it may not be feasible in the surgical patients with pain from surgical incision or trauma. Therefore we developed an analgesia/sedation based protocol for the surgical ICU population.

Methods

We performed a two-phase prospective observational control study. We evaluated a prescriber driven analgesia/sedation protocol (ASP) in a 12-bed surgical ICU. The pre-ASP group was sedated as usual (n = 100) and the post-ASP group was managed with the new ASP (n = 100). Each phase of the study lasted for 5 mo. Comparisons between the two groups were performed by χ² or Fisher’s exact test for categorical variables and the Mann-Whitney test for nonparametric variables. A P value <0.05 was statistically significant.

Results

We found a significant reduction in the use of fentanyl (P < 0.001) and midazolam (P = 0.001). We achieved sedation goals of 86.8% in the post-ASP group compared to 74.4% in the pre-ASP (P < 0.001). Mean mechanical ventilations days in pre- and post-ASP group were 5.9 versus 3.8 (P = 0.033).

Conclusion

In our cohort of critically ill surgery patients implementation of an ASP resulted in reduced use of continuously infused benzodiazepines and opioids, a decline in cumulative benzodiazepine and analgesic dosages, and a greater percentage of Richmond Agitation Sedation Scale scores at goal. We also showed reduced mechanical ventilation days.     

抗焦虑对胃癌根治术患者七氟烷用量及术后恢复的影响

目的:研究劳拉西泮联合咪达唑仑对择期胃癌根治术患者抗焦虑作用的有效性,及该方法对术中七氟烷用量和术后疼痛的影响.方法:观察组手术前1d服劳拉西泮,术前40min静注咪达唑仑,术中BIS监测控制麻醉深度,观察两组患者术前Spielberge状态—特质焦虑问卷(STAI)评分,术中七氟烷用量,麻醉恢复时间及术后2、6、24h疼痛VAS评分.结果:观察组状态-特质焦虑问卷评分低于对照组(S-AI:53.60±4.45vs62.70±3.98,P<0.05;T-AI:54.78±3.97vs65.65±4.21,P<0.05),七氟烷的使用量少于对照组(34.70±0.46vs36.20±0.44,P<0.05).两组术后苏醒及拔管时间无统计学差异.两组患者术后6、24hVAS评分,观察组低于对照组(6hVAS评分:3.45±1.60vs4.89±1.91,P<0.05;24hVAS评分:3.51±1.76vs5.17±1.71,P<0.05).结论:劳拉西泮联合咪达唑可以减轻术前患者的焦虑状态,减少术中七氟烷的使用,有利于减轻患者术后疼痛.     

小剂量咪达唑仑-芬太尼在支气管镜检查中的作用及其对心、肺功能的影响

目的 探讨在不需要麻醉科医师监护和特殊供氧条件下,小剂量咪达唑仑-芬太尼静脉复合麻醉在支气管镜检查中的作用及其对心、肺功能的影响.方法 选取在我院接受支气管镜检查的患者共47例,分为2组:A组为1％丁卡因喷喉及2％利多卡因环甲膜穿刺法局部黏膜表面麻醉,共20例;B组为上述局部麻醉方式加用小剂量咪达唑仑-芬太尼静脉注射镇静镇痛,共27例.记录对比患者术中镇静分级、不良反应发生情况、术后满意度、遗忘程度,观察其麻醉前、麻醉后术前、术中进声门时及术后生命体征(心率、呼吸频率、血氧饱和度、平均动脉压)和术前、术后10 min、术后4h肺功能指标[用力肺 活量(FVC)、第1秒用力呼气量(FEV1)、FEV1/FVC、最大呼气流量(PEF)]变化情况.结果 A、B两组在患者镇静分级、术中不良反应程度、术后遗忘程度及患者主观满意度四个方面差异具有统计学意义(P＜0.05),B组明显优于A组.两组肺功能指标FVC、FEV1及PEF在术后10 min均较术前下降,其中B组用力肺活量下降程度较A组更显著(P＜0.05);两组术后4h的肺功能可回到基线水平.两组生命体征指标:A组内心率、呼吸频率、平均动脉压在术中进声门时及术后较麻醉前升高,且术中进声门时血氧饱和度较麻醉前下降( P＜0.05);而B组仅心率较麻醉前差异具有统计学意义,且A组术中进声门时心率和平均动脉压的升高程度均大于B组(P＜0.05).结论 小剂量咪达唑仑-芬太尼复合麻醉在支气管镜麻醉效果方面明显优于传统局部麻醉方式,且对心血管系统及氧和方面的影响更小,对于术后4h肺功能各指标无附加影响;由于不需要专职麻醉医师监护管理以及其麻醉的有效性及安全性,更易于被医师及患者所接受,有利于其在临床推广.