山东省多中心儿童重症监护室镇静镇痛治疗及管理状况调查

目的了解山东省三级甲等医院儿童重症监护室(PICU)镇静镇痛治疗及管理状况,为镇静镇痛治疗方案的改进提供依据。方法本研究为一项多中心回顾性研究,山东省6家三级甲等医院的PICU参与了本研究。收集2016年1月至2018年12月入住这6家PICU的1340例患儿,调阅病历资料,统计患儿的年龄、性别、入院24 h小儿死亡风险评分Ⅲ、是否接受机械通气、是否接受镇静和(或)镇痛治疗、是否监测镇静和(或)镇痛情况、住院病死率等。依据是否接受镇静治疗和(或)镇痛治疗,将患儿分为单纯镇静组(798例)、镇静+镇痛组(120例)及非镇静镇痛组(422例),比较各组的病种、机械通气比例、低血压发生率、平均住PICU天数及院内病死率。结果1340例患儿的平均年龄为(13.3±6.4)个月,其中男786例(58.7%)。6家PICU均已开展镇静治疗,其中5家PICU进行常规镇静评估;已开展镇痛治疗的PICU有4家,其中仅有2家进行常规疼痛评估。共有918例(68.5%)患儿接受了镇静治疗和(或)镇痛治疗,咪达唑仑是最常用的镇静药物,其次是右美托咪定。526例(57.3%)患儿进行了镇静评估监测,最常用的评估方法是Richmond躁动镇静量表。120例(9.0%)患儿接受了镇静联合镇痛治疗,芬太尼是最常用的镇痛药物,38例(31.7%)患儿接受了常规疼痛评估。3组患儿年龄和性别差异无统计学意义。镇静+镇痛组外科疾病的比例最高,该组机械通气患儿的比例也最高(100.0%,120/120),非镇静镇痛组机械通气患儿的比例最低(11.4%,48/422),两组比较差异有统计学意义(P<0.01)。镇静+镇痛组的平均机械通气时间略短于单纯镇静组,但组间比较差异无统计学意义(P>0.05)。镇静+镇痛组低血压发生率最高,非镇静镇痛组低血压发生率最低[21.7%(26/120)比2.1%(9/422),P<0.01]。院内病死率和平均住PICU天数3组间比较差异无统计学意义。结论苯二氮类药物仍是目前山东省PICU中主要使用的镇静药物,右美托咪定的应用逐渐增加,但镇痛剂应用的比例很低。目前镇痛镇静治疗主要用于外科术后及接受机械通气治疗的患儿,镇痛镇静治疗虽未增加患儿的院内病死率及平均住PICU天数,但增加了低血压的发生率。山东省PICU的镇静镇痛治疗和监测仍欠规范,主要体现在镇痛治疗以及对镇静和疼痛水平的评估未受到重视。

Multicenter investigation on sedative and analgesic treatment and management of pediatric intensive care unit in Shandong province

Objective To understand the status of sedation and analgesia treatment and management in pediatric intensive care unit(PICU)in Shandong Province,and to provide the basis for the improvement of sedation and analgesia treatment plan.Methods This study was a multi-center retrospective study.The PICUs of 6 tertiary hospitals in Shandong Province participated in this study.The data of 1340 children admitted to these 6 PICUs from January 2016 to December 2018 were collected.The age,gender,the pediatric risk of mortality scoreⅢat 24 hours after admission,whether they received mechanical ventilation,whether they received sedation and(or)analgesia,whether they were monitored sedation and(or)analgesia,and in-hospital mortality were analyzed.The children were divided into the simple sedation group(n=798),the sedation+analgesia group(n=120)and the non-sedation analgesia group(n=422)according to whether they received sedation and(or)analgesia.The diseases,proportion of mechanical ventilation,incidence of hypotension,average length of stay in PICU and in-hospital mortality were compared among the three groups.Results The median age of the 1340 children was(13.3±6.4)months,including 786 males(58.7%).Sedation therapy had been carried out in 6 PICUs,of which 5 PICUs had routine sedation assessment;4 PICUs had carried out analgesic therapy,of which only 2 had routine pain assessment.A total of 918 children(68.5%)received sedation and(or)analgesia,midazolam was the most commonly used sedative drug,followed by dexmedetomidine,and 526 children(57.3%)were monitored for sedation assessment,the most commonly used assessment method was the Richmond agitation sedation score.One hundred and twenty(9.0%)cases received sedation combined with analgesia,fentanyl was the most commonly used analgesic,and 38 children(31.7%)underwent routine pain assessment.There was no significant difference in age and sex among the three groups.The proportion of surgical diseases and patients received mechanical ventilation(100.0%,120/120)were the highest in the sedation+analgesia group.The proportion of mechanically ventilated patients was the lowest in the non-sedation analgesia group(11.4%,48/422).The mean duration of mechanical ventilation in the sedation+analgesia group was slightly shorter than that in the simple sedation group(P>0.05).The incidence of hypotension was highest in the sedation+analgesia group,and lowest in the non-sedation analgesia group[21.7%(26/120)vs.2.1%(9/422),P<0.01].There was no significant difference in in-hospital mortality and mean PICU stay among three groups.Conclusion Benzodiazepines are still the main sedative drugs used in PICUs in Shandong Province.In recent years,the usage of dexmedetomidine has gradually increased,but the proportion of analgesic use is very low.At present,analgesic and sedative therapy is mainly used for children after surgery and receiving mechanical ventilation.Although analgesic and sedative therapy does not increase the in-hospital mortality and average length of stay in PICU,it increases the incidence of hypotension.The sedative and analgesic treatment and assessment in the PICU of Shandong Province are still not standardized,mainly reflected in infrequently analgesic treatment and the assessment of sedation and pain,which need to be further improved.