刘 骥,李正明,卜向飞,金孝东,蒋 健,丁涟沭
·临床研究·
右美托咪定在脑出血患者中的应用效果观察
刘 骥,李正明,卜向飞,金孝东,蒋 健,丁涟沭
目的观察右美托咪定在脑出血患者中的应用效果。方法选取2014年6月—2015年5月南京医科大学附属淮安第一医院收治的脑出血患者100例,随机分为对照组和观察组,每组50例。对照组患者给予咪达唑仑,观察组患者给予盐酸右美托咪定;两组患者均持续用药24 h。比较两组患者镇静效果〔心率(HR)、平均动脉压(MAP)、脉搏血氧饱和度(SpO2)、呼吸频率(RR)〕、镇静满意时间、调整用药次数、停药后唤醒时间及不良反应发生情况。结果用药前两组患者HR、MAP、SpO2、RR比较,差异无统计学意义(P>0.05)。用药后两组患者HR、MAP、SpO2比较,差异无统计学意义(P>0.05);而观察组患者RR高于对照组(P<0.05)。用药后观察组患者HR、MAP低于用药前,SpO2、RR高于用药前(P<0.05)。用药后对照组患者HR、MAP低于用药前,SpO2高于用药前(P<0.05);而RR与用药前比较,差异无统计学意义(P>0.05)。两组患者镇静满意时间比较,差异无统计学意义(P>0.05);观察组患者调整用药次数少于对照组,停药后唤醒时间短于对照组(P<0.05)。两组患者不良反应发生率比较,差异无统计学意义(P>0.05);观察组患者呼吸抑制率低于对照组(P<0.05)。结论右美托咪定在脑出血患者中的应用效果较好,起效较快,可安全、稳定地发挥镇静作用,且不影响患者意识。
脑出血;右美托咪定;催眠药和镇静药
刘骥,李正明,卜向飞,等.右美托咪定在脑出血患者中的应用效果观察[J].实用心脑肺血管病杂志,2016,24(9):150-152.[www.syxnf.net]
LIU J,LI Z M,BU X F,et al.Application effect of dexmedetomidine in patients with cerebral hemorrhage[J].Practical Journal of Cardiac Cerebral Pneumal and Vascular Disease,2016,24(9):150-152.
脑出血患者易产生焦躁情绪,进而导致呼吸、循环系统不稳定,增加机体耗氧量,诱发心律失常,影响疾病康复,严重时还会造成昏迷、脑瘫,甚至危及患者生命安全[1],因此,脑出血患者的镇定治疗十分必要。目前,临床上应用较为广泛的镇静药为苯二氮卓类药物,其中以咪达唑仑为代表,但其具有呼吸抑制作用,会影响对患者意识的判断,因此临床应用受限[2]。右美托咪定属α2-肾上腺素受体激动剂,具有镇静、抗焦虑等作用,同时还具有良好的抗交感神经活性,且对呼吸系统无抑制作用,不影响患者意识,临床可控性较好[3]。目前,右美托咪定已广泛应用于围术期患者的镇静麻醉[3],但关于其在脑出血患者中应用效果的研究报道较少。本研究以咪达唑仑为对照,旨在观察右美托咪定在脑出血患者中的应用效果,现报道如下。
1.1一般资料选取2014年6月—2015年5月南京医科大学附属淮安第一医院收治的脑出血患者100例。纳入标准:(1)经颅脑CT检查确诊为脑出血患者,且颅内无迟发性脑血肿形成;(2)行药物保守治疗,未行手术。排除标准:(1)对右美托咪定或咪达唑仑过敏者;(2)伴有严重中枢神经系统疾病者;(3)伴有严重心、肺、肝、肾功能不全者;(4)存在精神障碍者;(5)合并糖尿病或血糖控制不佳者;(6)妊娠期妇女。将所有患者随机分为对照组和观察组,每组50例。对照组中男31例、女19例,年龄40~80岁;观察组中男38例、女12例,年龄36~78岁。两组患者性别、年龄间具有均衡性。
1.2用药方法对照组患者给予咪达唑仑注射液0.05 mg/kg静脉泵注,泵注速度为0.03~0.20 mg·kg-1·h-1,调整咪达唑仑注射液泵注速度以使Ramsay评分控制在2~4分。观察组患者就要盐酸右美托咪定1 μg/kg,前10 min静脉推注,之后以微量注射泵持续泵注,泵注速度为0.20~0.70 μg·kg-1·h-1,调整盐酸右美托咪定剂量以使Ramsay评分控制在2~4分。用药过程中严密监测两组患者生命体征并及时调整药物泵注速度,两组患者均持续用药24 h。
1.3观察指标比较两组患者镇静效果〔心率(HR)、平均动脉压(MAP)、脉搏血氧饱和度(SpO2)、呼吸频率(RR)〕、镇静满意时间、调整用药次数、停药后唤醒时间及不良反应发生情况。
2.1两组间患者镇静效果比较用药前两组患者HR、MAP、SpO2、RR比较,差异无统计学意义(P>0.05)。用药后两组患者HR、MAP、SpO2比较,差异无统计学意义(P>0.05);而观察组患者RR高于对照组,差异有统计学意义(P<0.05)。用药后观察组患者HR、MAP低于用药前,SpO2、RR高于用药前,差异有统计学意义(P<0.05)。用药后对照组患者HR、MAP低于用药前,SpO2高于用药前,差异有统计学意义(P<0.05);而RR与用药前比较,差异无统计学意义(P>0.05,见表1)。
2.2两组患者镇静满意时间、调整用药次数、停药后唤醒时间比较两组患者镇静满意时间比较,差异无统计学意义(P>0.05);观察组患者调整用药次数少于对照组,停药后唤醒时间短于对照组,差异有统计学意义(P<0.05,见表2)。
Table 2Comparison of time to satisfactory sedative effect,times of adjusting medication,wake-up time after drug withdrawal between the two groups
组别例数镇静满意时间(min)调整用药次数(次)停药后唤醒时间(min)对照组5028.8±3.716.7±4.512.6±3.1观察组5030.6±2.612.1±3.07.2±2.5t值5.177.648.13P值0.120.01<0.01
2.3两组患者不良反应发生率比较对照组患者发生高血压9例,低血压4例,心动过缓4例,心动过速2例,不良反应发生率为38.0%;观察组患者发生高血压8例,低血压3例,心动过缓2例,心动过速3例,不良反应发生率为32.0%。两组患者不良反应发生率比较,差异无统计学意义(χ2=2.13,P>0.05)。对照组患者发生呼吸抑制13例,观察组无一例患者发生呼吸抑制,观察组患者呼吸抑制率低于对照组,差异有统计学意义(χ2=4.31,P<0.05)。
脑出血是指非创伤自发性颅内出血,其病因较多,常见病因为高血压引起小动脉粥样硬化而导致颅内血管破裂,约95%的脑出血是由高血压引起的[1]。据统计,脑出血所致死亡占卒中性死亡患者的20%~30%[3],而若脑出血患者在用药过程中出现焦躁情绪及血压升高,则可引起脑出血进展及血肿进一步增大,导致病情恶化,严重时则导致患者死亡。目前,临床上常用的镇静药为苯二氮卓类药物,但其可能会引发老年患者认知障碍,导致呼吸抑制并影响患者意识,甚至导致短暂性死亡或顺行性记忆缺失[2],因此其临床应用受限。寻找更为安全、有效的镇静药物是临床亟待解决的问题之一。右美托咪定是高度选择性α2-肾上腺素受体激动剂,可作用于蓝斑核内α受体,进而抑制去甲肾上腺素释放,发挥镇静、镇痛、抗焦虑作用,同时还可帮助患者维持意识清醒,且无呼吸抑制作用,可诱导患者自然成眠,但患者在受到刺激时也很容易被唤醒[4]。
本研究结果显示,两组患者镇静满意时间间无明显差异,说明两种药物镇静速度相似,均可在短时间内达到满意的镇静效果;观察组患者用药后RR高于对照组,且无一例出现呼吸抑制,呼吸抑制发生率低于对照组,而对照组患者则普遍出现呼吸抑制反应,这在一定程度上会影响患者预后;观察组患者调整用药次数少于对照组,停药后唤醒时间短于对照组,这有利于减轻医护人员工作量,促使患者平稳康复;两组患者用药过程中均未出现严重不良反应,部分患者出现高血压、低血压、心动过缓、心动过速,经减少用药剂量或停药处理后得以改善。
综上所述,右美托咪定在脑出血患者中的应用效果较好,起效较快,可安全、稳定地发挥镇静作用,有利于降低脑出血患者因躁动所致意外发生率,且不影响患者意识,提高患者临床疗效,与咪达唑仑相比具有较大优势,值得推广应用[5]。
表1 两组患者镇静效果比较±s)
注:HR=心率,MAP=平均动脉压,SpO2=脉搏血氧饱和度,RR=呼吸频率;与用药前比较,aP<0.05;1 mm Hg=0.133 kPa
[1]李超,孟凡民.Narcotrend监测下右美托咪定对冠心病患者麻醉诱导期血流动力学的影响[J].海南医学院学报,2015,21(2):35-38.
[2]PENG K,JIN X H,LIU S L,et al.Effect of intraoperative dexmedetomidine on post-craniotomy pain[J].Clinical Therapeutics,2015,37(5):1114-1121.
[3]程华.小骨窗微创手术联合中西医药物治疗脑出血患者的临床疗效观察[J].实用心脑肺血管病杂志,2014,22(6):48-49.
[4]MORACE R,DE ANGELIS M,AGLIALORO E,et al.Sedation with α2agonist dexmedetomidine during unilateral subthalamic nucleus deep brain stimulation:a preliminary report[J].World Neurosurgery,2016,89(5):322-328.
[5]BARR J,FRASER G L,PUNTILLO K,et al.Clinical practice guidelines for the management of pain,agitation,and delirium in adult patients in the intensive care unit[J].Crit Care Med,2013,41(1):263-306.
(本文编辑:王凤微)
Application Effect of Dexmedetomidine in Patients with Cerebral Hemorrhage
LIUJi,LIZheng-ming,BUXiang-fei,JINXiao-dong,JIANGJian,DINGLian-shu.
DepartmentofNeurosurgery,theFirstPeople′sHospitalofHuaian,AffiliatedtoNanjingMedicalUniversity,Huaian223300,China
DINGLian-shu,DepartmentofNeurosurgery,theFirstPeople′sHospitalofHuaian,AffiliatedtoNanjingMedicalUniversity,Huaian223300,China;E-mail:Dlshu@163.com
ObjectiveTo observe the application effect of dexmedetomidine in patients with cerebral hemorrhage.MethodsFrom June 2014 to May 2015,a total of 100 patients with cerebral hemorrhage were selected in the First People′s Hospital of Huaian,Affiliated to Nanjing Medical University,and they were randomly divided into control group and observation group,each of 50 cases.Ptients of control group were given midazolam,while patients of observation group were given dexmedetomidine;both groups continuously treated for 24 hours.The sedative effect(HR,MAP,SpO2,RR),time to satisfactory sedative effect,times of adjusting medication,wake-up time after drug withdrawal,and incidence of adverse reactions were compared between the two groups.ResultsNo statistically significant differences of HR,MAP,SpO2,RR was found between the two groups before medication(P>0.05).After medication,no statistically significant differences of HR,MAP,SpO2was found between the two groups(P>0.05),while RR of observation group was statistically significantly higher than that of control group(P<0.05).After medication,HR and MAP of observation group were statistically significantly lower than those before medication,SpO2and RR were statistically significantly higher than those before medication(P<0.05).After medication,HR and MAP of control group were statistically significantly lower than those before medication,SpO2was statistically significantly higher than that before medication(P<0.05);while no statistically significant differences of RR was found before medication and after medication(P>0.05).No statistically significant differences of time to satisfactory sedative effect was found between the two groups(P>0.05).Times of adjusting medication of observation group was statistically significantly less than that of control group,wake-up time after drug withdrawal of observation group was statistically significantly shorter than that of control group(P<0.05).No statistically significant differences of incidence of adverse reactions was found between the two groups(P>0.05).The incidence of respiration inhibition of observation group was statistically significantly lower than that of control group(P<0.05).Conclusion Dexmedetomidine has better application effect in patients with cerebral hemorrhage,with faster initiating effect,can safely and stably achieve the sedative effect without obvious impact on consciousness.
Cerebral hemorrhage;Dexmedetomidine;Hypnotics and sedatives
223300 江苏省淮安市,南京医科大学附属淮安第一医院神经外科
丁涟沭,223300 江苏省淮安市,南京医科大学附属淮安第一医院神经外科;E-mail:Dlshu@163.com
R 722.151
B
10.3969/j.issn.1008-5971.2016.09.046
2016-05-07;
2016-08-19)