Study on the application of dexmedetomidine combined with remifentanil in dressing change of conscious patients with non-intubation in burn intensive care unit
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摘要: 目的 观察右美托咪定复合瑞芬太尼在烧伤重症监护病房(ICU)中清醒非插管患者换药时的镇痛镇静效果及安全性。 方法 选择2015年4月—2017年4月笔者单位烧伤ICU中收治的符合入选标准的患者40例,采用前瞻性随机双盲法,将患者按随机数字表法分为瑞芬太尼组和右美托咪定+瑞芬太尼组,每组20例。换药时2组患者分别给予相应药物。记录患者的换药次数及换药时间,换药中(给药25 min)及换药后(换药结束20 min)患者的主诉疼痛分级法(VRS)评分,换药中Ramsay镇静评分(RSS),换药后患者及换药医师对麻醉的满意度,瑞芬太尼用量,换药中及换药后的各种不良反应,给药前、给药10 min、给药15 min、给药25 min患者的心率、平均动脉压(MAP)、呼吸频率、脉搏血氧饱和度(SpO2)。对数据行重复测量方差分析、
t 检验、χ 2检验、Fisher确切概率法检验。 结果 (1)共有38例患者完成试验,2组患者性别、美国麻醉医师协会分级、年龄、体质量、烧伤总面积比较,差异均无统计学意义(χ 2=0.230、0.146,t =0.224、0.351、0.367,P >0.05)。(2)2组患者的总换药次数均为48次,换药时间及换药中VRS评分无明显差异(t =0.821、1.522,P >0.05),换药后右美托咪定+瑞芬太尼组患者的VRS评分为(3.1±0.4)分,明显低于瑞芬太尼组的(3.8±0.8)分(t =2.213,P <0.05)。右美托咪定+瑞芬太尼组患者RSS、换药后患者自身及医师对麻醉的满意度评分分别为(3.13±0.32)、(3.44±0.41)、(3.13±0.25)分,均明显优于瑞芬太尼组的(1.82±0.24)、(2.71±0.23)、(2.53±0.41)分,t =2.226、2.684、7.702,P <0.01。右美托咪定+瑞芬太尼组患者的瑞芬太尼用量为(282±19)μg,明显少于瑞芬太尼组的(340±31)μg(t =9.896,P <0.01)。2组患者呼吸抑制及低血压发生率比较,差异无统计学意义(χ 2=0.211、0.154,P >0.05)。右美托咪定+瑞芬太尼组患者心动过缓发生率明显高于瑞芬太尼组(χ 2=6.008,P <0.05),恶心呕吐等消化道症状发生率明显低于瑞芬太尼组(P <0.05)。(3)2组患者给药前心率、MAP、呼吸频率、SpO2比较,差异无统计学意义(t =0.444、0.892、1.059、1.039,P >0.05)。右美托咪定+瑞芬太尼组患者给药10、15、25 min时心率分别为(83±11)、(78±10)、(82±14)次/min,明显低于瑞芬太尼组的(95±10)、(87±12)、(89±12)次/min(t =5.592、3.992、2.630,P <0.05或P <0.01)。右美托咪定+瑞芬太尼组患者给药15、25 min时MAP分别为(69.4±3.1)、(73.8±2.2)mmHg(1 mmHg=0.133 kPa),明显低于瑞芬太尼组的(75.4±3.0)、(78.1±3.5)mmHg(t =9.181、7.206,P <0.01)。2组患者给药后各时间点呼吸频率比较,差异无统计学意义(t =1.489、1.862、1.963,P >0.05)。右美托咪定+瑞芬太尼组患者给药15 min时SpO2为0.972±0.018,明显低于瑞芬太尼组的0.979±0.015(t =2.070,P <0.05)。 结论 小剂量瑞芬太尼单独应用于烧伤ICU清醒非插管患者换药时的镇痛治疗效果确切,但易出现恶心呕吐等不良反应;瑞芬太尼复合右美托咪定在保证镇痛效果的同时,具有减少麻醉镇痛用药剂量,提高患者镇静效果及麻醉满意度,减少各种不良反应等优点,但同时会增加患者心动过缓的发生率,对循环有一定的抑制作用。Abstract: Objective To observe the analgesic and sedative effect and safety of application of dexmedetomidine combined with remifentanil in dressing change of conscious patients with non-intubation in burn intensive care unit. Methods Forty patients conforming to the study criteria hospitalized in our burn intensive care unit from April 2015 to April 2017 were selected. Prospective, randomized, and double-blind method was used for the design. Patients were divided into dexmedetomidine group and dexmedetomidine+ remifentanil group according to the random number table, with 20 cases in each group. Patients in the two groups were respectively given corresponding drugs during dressing change. The frequency and time of dressing change, Verbal Rating Scale (VRS) score of patients during dressing change (at drug administration for 25 minutes) and after dressing change (25 min after dressing change), Ramsay Sedation Score (RSS) during dressing change, satisfaction level for anesthesia of the patients and physicians after dressing change, dosage of remifentanil, and various adverse effects during and after dressing change were recorded. The heart rate, mean arterial blood pressure (MAP), respiratory rate, and pulse oxygen saturation (SpO2) before drug administration and at 10, 15, and 25 minutes after drug administration were also recorded. Data were processed with analysis of variance for repeated measurement,t test, chi-square test, and Fisher′s exact probability test. Results (1) Totally 38 patients completed the trial. There were no statistically significant differences between patients in two groups in gender, American Association of Anesthesiologist Grading, age, weight, and total burn area (χ 2=0.230, 0.146,t =0.224, 0.351, 0.367,P >0.05). (2) The frequency of dressing change of patients in two groups were both 48 times. The time of dressing change and VRS scores during dressing change of patients in two groups were similar (t =0.821, 1.522,P >0.05). The VRS score of patients in dexmedetomidine+ remifentanil group after dressing change was (3.1±0.4) points, obviously lower than (3.8±0.8) points in remifentanil group (t =2.213,P <0.05). The RSS, satisfaction level scores for anesthesia of the patients and physicians after dressing change in dexmedetomidine+ remifentanil group were (3.13±0.32), (3.44±0.41), and (3.13±0.25) points, respectively, obviously better than (1.82±0.24), (2.71±0.23), (2.53±0.41) points in remifentanil group (t =2.226, 2.684, 7.702,P <0.01). The dosage of remifentanil of patients in dexmedetomidine+ remifentanil group was (282±19) μg, obviously less than (340±31) μg in remifentanil group (t =9.896,P <0.01). There were no statistically significant differences between patients in two groups in rates of respiratory inhibition and hypotension (χ 2=0.211, 0.154,P >0.05). Compared with those in remifentanil group, the rates of nausea, vomiting, and other gastrointestinal symptoms of patients in dexmedetomidine+ remifentanil group were obviously reduced (P <0.05), but the rate of bradycardia was obviously increased (χ 2=6.008,P <0.05). (3) There were no statistically significant differences between patients in two groups in heart rate, MAP, respiratory frequency, and SpO2 before drug administration (t =0.444, 0.892, 1.059, 1.039,P >0.05). The heart rates of patients in dexmedetomidine+ remifentanil group at 10, 15, and 25 minutes after drug administration were (83±11), (78±10), and (82±14) times per minute, respectively, significantly lower than (95±10), (87±12), and (89±12) times per minute in remifentanil group (t =5.592, 3.992, 2.630,P <0.05 orP <0.01). The MAP of patients in dexmedetomidine+ remifentanil group at 15 and 25 minutes after drug administration were (69.4±3.1) and (73.8±2.2) mmHg (1 mmHg=0.133 kPa), respectively, significantly lower than (75.4±3.0) and (78.1±3.5) mmHg in remifentanil group (t =9.181, 7.206,P <0.01). There were no statistically significant differences between patients in two groups in respiratory frequency at each time point after drug administration (t =1.489, 1.862, 1.963,P >0.05). The SpO2 of patients in dexmedetomidine+ remifentanil group at 15 minutes after drug administration was 0.972±0.018, obviously lower than 0.979±0.015 in remifentanil group (t =2.070,P <0.05). Conclusions Application of remifentanil with small dosage has effective analgesia for conscious burn patients with non-intubation during dressing changes, however, adverse effects such as nausea and vomiting are likely to occur. Remifentanil combined with dexmedetomidine not only guarantee the analgesic effect, but also reduce the dosage of analgesics, improve the sedative effect and satisfaction of the patients for anesthesia, and reduce various adverse effects. However, it will increase the incidence of bradycardia and has some inhibition effect on circulation at the same time.-
Key words:
- Burns /
- Analgesia /
- Conscious sedation /
- Dexmedetomidine /
- Remifentanil /
- Verbal Rating Scale /
- Ramsay Sedation Score
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