脑电双频指数与镇静-躁动评分指导短期机械通气患者镇静治疗的随机对照研究

目的 比较脑电双频指数(BIS)实时监测和镇静-躁动评分(SAS)在重症监护病房(ICU)短期机械通气患者镇静治疗实施过程中的可行性.方法 选择ICU中18～60岁外科手术后需持续机械通气(＞12 h)患者105例,按信封法随机分为BIS组(42例)和SAS组(63例),分别依据BIS和SAS评估镇静深度.两组均给予芬太尼镇痛,丙泊酚和咪唑安定联合镇静,每小时根据镇静深度评估调节镇静药物泵入剂量(BIS组目标值为50～70,SAS组目标为3～4级).入ICU后次日晨6时停用镇静及镇痛药物,每小时记录镇静深度(BIS值或SAS分级)、镇静持续时间、觉醒时间、机械通气时间、单位时间内咪唑安定和丙泊酚用量及累计总量,以及吸痰后躁动发生率、镇静期间气管导管耐受率和疼痛耐受率、拔管后谵妄发生率.结果 BIS组单位时间内眯唑安定和丙泊酚用量均高于SAS组[咪唑安定(mg·kg-1·h-1):0.10±0.02比0.09±0.02,丙泊酚(mg·kg-1·h-1):0.95±0.23比0.86±0.20,均P＜0.05],总体镇静达标时段(Dt,以1 h为1个时段)以及前3个时段(D1、D2、D3)的镇静达标率均明显高于SAS组[Dt:75.2%(507)比52.8%(421),D1:78.6%(33)比22.2%(14),D2:88.1%(37)比20.6%(13),D3:81.0%(34)比31.7%(20),均P＜0.01],觉醒时间(min)明显短于SAS组[0(0,20)比15(0,47),P＜0.05];BIS组和SAS组患者急性生理学与慢性健康状况评分系统Ⅱ(APACHE Ⅱ)评分(分:3.57±2.60比4.19±2.30)、机械通气时间[h:16.5(14.5,19.0)比17.0(15.0,19.0)]、镇静持续时间[h:14.0(12.9,17.1)比16.0(13.0,18.0)]及吸痰后躁动发生率(81.0%比79.4%)、镇静期间气管导管耐受率(71.4%比74.6%)和疼痛耐受率(92.8%比93.6%)、拔管后谵妄发生率(4.8%比1.6%)等差异均无统计学意义(均P＞0.05).结论 与SAS比较,BIS在指导ICU短期机械通气患者的镇静治疗中,对镇静深度调控具有更好的可操作性.

Abstract：

Objective To compare the value of bispectral index (BIS) monitoring and sedationagitation scale (SAS) in guiding intensive care unit (ICU) sedation therapy for the patients undergoing shortterm mechanical ventilation. Methods One hundred and five patients aged 18 - 60 years after operation receiving mechanical ventilation for longer than 12 hours in ICU were enrolled in this study. The patients were randomly divided into two groups: BIS-guided group (n=42) and SAS-guided group (n=63). All of them received protocolized continuous sedation and analgesia by using fentanyl for analgesia and propofol plus midazolam to sedate intravenously. The effect of sedation was assessed every hour till BIS reaching 50 - 70 or SAS reaching grade 3 - 4. Sedatives and analgesics were suspended st 6: 00 am on next day after ICU admission, and BIS and the SAS were recorded every hour, sedation time, time to wake up, duration of mechanical ventilation, daily dosage of midazolam and propoful, and the incidence of adverse events including restlessness after suction, endotracheal tube resistance, pain tolerance during sedation, and delirium after extubation were all recorded accordingly. Results Dosages of midazolam and propofol were found higher in BIS-guided group than the SAS-guided group [midazolam (mg · kg-1 · h-1) : 0. 10±0. 02 vs. 0. 09±0. 02,propofol (mg · kg-1 · h-1): 0. 95±0. 23 vs. 0. 86±0. 20, both P＜0.05＝. The total time (Dt) of patients under sedative control was significantly longer in BIS-guided group compared with SAS-guided group, and also in first three hours [D1, D2, D3, D,: 75.2% (507) vs. 52.8% (421), D1: 78.6% (33) vs. 22.2%(14), D2: 88. 1% (37) vs. 20. 6% (13), D3: 81.0% (34) vs. 31.7% (20), all P＜0. 01＝. The time to wake up (minutes) was significantly shorter in BIS-guided group compared with SAS-guided group [0 (0, 20) vs.15 (0, 47), P＜0.05＝. No significant difference in acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ ) score (3. 57± 2. 60 vs. 4. 19 ± 2. 30), duration of mechanical ventilation [hours: 16. 5 (14.5, 19.0) vs. 17.0 (15.0, 19.0)], sedation time [hours: 14.0 (12.9, 17.1) vs. 16.0 (13.0, 18.0)]and incidence of adverse events including restlessness after suction (81.0% vs. 79. 4%), endotracheal tube resistance (71.4% vs. 74.6%), pain tolerance during sedation (92.8% vs. 93.6%) and delirium after extubation (4. 8% vs. 1.6%) was found between BIS-guided group and SAS-guided group (all P＞0. 05).Conclusion BIS monitoring is better in sedative control than SAS assessment for ICU patients undergoing short-term mechanical ventilation.

A comparison of bispectral index and sedation-agitation scale in guiding sedation therapy: a randomized controlled study in patients undergoing short-term mechanical ventilation

Objective To compare the value of bispectral index (BIS) monitoring and sedationagitation scale (SAS) in guiding intensive care unit (ICU) sedation therapy for the patients undergoing shortterm mechanical ventilation. Methods One hundred and five patients aged 18 - 60 years after operation receiving mechanical ventilation for longer than 12 hours in ICU were enrolled in this study. The patients were randomly divided into two groups: BIS-guided group (n=42) and SAS-guided group (n=63). All of them received protocolized continuous sedation and analgesia by using fentanyl for analgesia and propofol plus midazolam to sedate intravenously. The effect of sedation was assessed every hour till BIS reaching 50 - 70 or SAS reaching grade 3 - 4. Sedatives and analgesics were suspended st 6: 00 am on next day after ICU admission, and BIS and the SAS were recorded every hour, sedation time, time to wake up, duration of mechanical ventilation, daily dosage of midazolam and propoful, and the incidence of adverse events including restlessness after suction, endotracheal tube resistance, pain tolerance during sedation, and delirium after extubation were all recorded accordingly. Results Dosages of midazolam and propofol were found higher in BIS-guided group than the SAS-guided group [midazolam (mg · kg-1 · h-1) : 0. 10±0. 02 vs. 0. 09±0. 02,propofol (mg · kg-1 · h-1): 0. 95±0. 23 vs. 0. 86±0. 20, both P＜0.05＝. The total time (Dt) of patients under sedative control was significantly longer in BIS-guided group compared with SAS-guided group, and also in first three hours [D1, D2, D3, D,: 75.2% (507) vs. 52.8% (421), D1: 78.6% (33) vs. 22.2%(14), D2: 88. 1% (37) vs. 20. 6% (13), D3: 81.0% (34) vs. 31.7% (20), all P＜0. 01＝. The time to wake up (minutes) was significantly shorter in BIS-guided group compared with SAS-guided group [0 (0, 20) vs.15 (0, 47), P＜0.05＝. No significant difference in acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ ) score (3. 57± 2. 60 vs. 4. 19 ± 2. 30), duration of mechanical ventilation [hours: 16. 5 (14.5, 19.0) vs. 17.0 (15.0, 19.0)], sedation time [hours: 14.0 (12.9, 17.1) vs. 16.0 (13.0, 18.0)]and incidence of adverse events including restlessness after suction (81.0% vs. 79. 4%), endotracheal tube resistance (71.4% vs. 74.6%), pain tolerance during sedation (92.8% vs. 93.6%) and delirium after extubation (4. 8% vs. 1.6%) was found between BIS-guided group and SAS-guided group (all P＞0. 05).Conclusion BIS monitoring is better in sedative control than SAS assessment for ICU patients undergoing short-term mechanical ventilation.