BIS监测下早期应用右美托咪定对急性心源性肺水肿接受无创通气患者的影响

谭金锋; 段乐; 李珂巍; 项琳; 于波

doi:10.13201/j.issn.1001-1439.2022.10.010

BIS监测下早期应用右美托咪定对急性心源性肺水肿接受无创通气患者的影响

- 1.
  哈尔滨医科大学附属第二医院心血管内科国家教育部心肌缺血重点实验室(哈尔滨，150086)
- 2.
  哈尔滨医科大学附属第二医院麻醉科

详细信息

通讯作者: 于波，E-mail：dryu_hum@163.com

中图分类号: R54

收稿日期: 2022-06-20

刊出日期: 2022-10-13

Effects of early application of dexmedetomidine on patients with acute cardiogenic pulmonary edema receiving noninvasive ventilation under BIS monitoring

- 1.
  Department of Cardiology, The Second Affiliated Hospital, Harbin Medical University, The Key Laboratory of Myocardial Ischemia, Chinese Ministry of Education, Harbin, 150086, China
- 2.
  Department of Anesthesiology, The Second Affiliated Hospital, Harbin Medical University

More Information

Corresponding author: YU Bo, E-mail: dryu_hum@163.com

Received Date: 20 June 2022

Publish Date: 13 October 2022

摘要

摘要: 目的探讨脑电双频指数(BIS)监测下早期应用右美托咪定对急性心源性肺水肿(ACPE)接受无创通气(NIV)患者的影响。方法本研究是一项单中心、前瞻性、单盲、随机对照临床研究。入选2019年11月—2021年6月就诊于哈尔滨医科大学附属第二医院心血管内科CCU的ACPE并接受NIV患者共95例，随机分为右美托咪定组(DEX组，47例)、对照组(CON组，48例)。收集两组患者的基线特征及相关检查资料；比较两组患者的NIV时间，NIV失败率，RASS躁动-镇静评分，CCU停留时间和总住院时间，NIV耐受性评分，患者、管床护士及呼吸治疗师的满意度，谵妄发生率，1个月和1年全因死亡率。结果两组患者的基线特征相似。与CON组相比，DEX组NIV支持时间更短(P=0.027)，NIV失败率更低(P=0.032)，RASS评分更低(P< 0.01)，CCU停留时间(P=0.038)及总住院时间更短(P=0.028)，NIV耐受性评分更低(P< 0.05)，患者、管床护士及呼吸治疗师的满意度更高(P< 0.05)，谵妄发生率更低(P=0.023)，1个月和1年的全因死亡率无统计学差异。结论在BIS监测下早期应用右美托咪定可以有效改善ACPE并接受NIV患者的耐受性，缩短NIV时间和CCU停留时间，减少谵妄的发生，且是安全的，但并没有降低病死率。
- 心源性肺水肿，急性 /
- 右美托咪定 /
- 无创通气 /
- 脑电双频指数
Abstract: Objective To investigate the effects of early using dexmedetomidine on acute cardiogenic pulmonary edema(ACPE) patients with non-invasive ventilation(NIV) under BIS monitoring.Methods This study was a single center, prospective, single-blind, and randomized controlled clinical study. A total of 95 patients with ACPE undergoing NIV admitted to the Coronary Care Unit(CCU) of the Second Affiliated Hospital of Harbin Medical University from November 2019 to June 2021 were enrolled. All patients were randomly divided into the dexmedetomidine group(n=47) and the control group(n=48). Baseline and related examination data were collected. The duration of NIV, NIV failure rate, RASS sedation-agitation score, the duration of CCU stay, total hospitalization duration, NIV tolerance score, the satisfaction of patients, nurses, and respiratory therapists, the incidence of delirium, 1-month and 1-year all-cause mortality were compared between the two groups.Results Baseline characteristics were comparable between the two groups. Compared with the control group, the dexmedetomidine group had a shorter duration of NIV(P=0.027), CCU stay(P=0.038), and total hospitalization(P=0.028); lower NIV failure rate(P=0.032), RASS sedation-agitation score(P< 0.01), NIV tolerance score(P< 0.05), and the incidence of delirium(P=0.023); and higher satisfaction of patients, nurses, and respiratory therapists(P< 0.05). However, there was no difference in 1-month and 1-year all-cause mortality was observed between the two groups.Conclusion Early using dexmedetomidine could effectively improved tolerance, shorten the treatment time and reduce the occurrence of delirium in ACPE patients with NIV under BIS monitoring. The early application of NIV is safe but can't reduce the short-time and long-time mortality.
- cardiogenic pulmonary edema, acute /
- dexmedetomidine /
- non-invasive ventilation /
- BIS

HTML全文

表 1 对照组和DEX组患者临床基线资料

Table 1. Clinical baseline data of two groups 例(%), X±S

项目	CON组(48例)	DEX组(47例)	P值
年龄/岁	59.5±10.7	59.4±10.5	0.957
男性	20(41.67)	23(48.94)	0.477
BMI/(kg·m^-2)	25.0±3.1	25.6±2.9	0.326
收缩压/mmHg	146.6±26.4	147.4±30.4	0.940
心率/(次·min^-1)	85.8±15.8	87.9±13.1	0.479
呼吸频率/(次·min^-1)	26.9±4.9	27.4±5.3	0.614
SpO₂/%	85.9±6.6	83.9±7.0	0.158
吸烟史	12(25.0)	17(36.2)	0.237
饮酒史	11(22.9)	10(21.3)	0.847
合并症
AMI	7(14.6)	9(19.1)	0.552
糖尿病	8(16.7)	6(12.8)	0.592
高血压	21(43.8)	17(36.2)	0.451
心房颤动	4(8.3)	6(12.8)	0.712^a
慢性阻塞性肺疾病	4(8.3)	5(10.6)	0.974^a
扩张型心肌病	3(6.3)	1(2.1)	0.625^a
非药物治疗
CRRT	2(4.2)	3(6.4)	0.981^a
IABP	4(8.3)	2(4.3)	0.713^a
PCI	9(18.8)	10(21.3)	0.758
起搏器	2(4.2)	1(2.1)	> 0.999
RASS评分	1.25±0.98	1.34±1.09	0.671
^a连续性校正χ²检验。SpO₂：脉搏血氧饱和度；CRRT：连续性肾脏替代治疗；IABP：主动脉内球囊反搏；PCI：经皮冠状动脉介入。

下载: 导出CSV

表 2 实验室参数

Table 2. Laboratory parameters X±S

项目	基线	NIV后第2天	出院前
CON组(48例)
白细胞/(×10⁹·L^-1)	12.57±3.02	10.45±3.33¹⁾
NP-proBNP/(pg·mL^-1)	2800.69±2721.96	1717.36±1723.32¹⁾
hs-CRP/(mg·L^-1)	9.48±3.40	6.25±2.11¹⁾
LVEF/%	43.0±9.0		45.4±8.0
DEX组(47例)
白细胞/(×10⁹·L^-1)	13.42±3.23	9.13±2.24¹⁾²⁾
NP-proBNP/(pg·mL^-1)	2586.83±2922.45	1031.11±1085.14¹⁾²⁾
hs-CRP/(mg·L^-1)	9.62±3.11	5.32±1.59¹⁾²⁾
LVEF/%	39.8±9.0		47.9±5.8¹⁾
与同组基线比较，¹⁾ P < 0.05；与CON组同时间点比较，²⁾ P < 0.05。

下载: 导出CSV

表 3 临床治疗及预后相关指标

Table 3. Clinical treatment and prognosis related data 例(%), X±S, M(P₂₅, P₇₅)

项目	CON组(48例)	DEX组(47例)	P值	χ² /t/Z值
护士和呼吸治疗师满意度/分	4.63±1.79	6.11±1.87	< 0.001^a	3.943
患者满意度/分	5.13±2.05	6.11±2.01	0.021^a	2.354
谵妄	11(22.92)	3(6.38)	0.023^b	5.166
NIV持续时间/h	23.58±15.39	17.23±11.94	0.027^a	2.243
RASS评分	1.4±1.1	-0.7±1.4	< 0.001^a	8.052
CCU停留时间/d	3(2，5)	2(2，3)	0.038^e	2.079
总住院时间/d	9(7，13)	7(6，10)	0.028^e	2.204
1个月全因死亡	6(12.5)	2(4.26)	0.281^b	1.161
1年全因死亡	8(16.67)	5(10.64)	0.393^d	0.731
不良事件
低血压	5(10.42)	7(14.89)	0.511^d	0.431
心动过缓	2(4.17)	6(12.77)	0.254^b	1.299
呼吸抑制	0(0)	1(2.13)	0.495^c
^a独立样本t检验，^b连续性校正χ²检验，^cFisher精确检验，^d χ²检验，^e非参数秩和检验。

下载: 导出CSV

表 4 NIV相关数据

Table 4. NIV related data X±S

时间	CON组		DEX组
时间	例数	NIV耐受评分	例数	NIV耐受评分
0 h	48	2.2±1.1	47	2.0±1.0
30 min	48	2.4±1.1	47	2.2±1.1
1 h	46	2.4±1.2	47	1.9±1.0¹⁾
2 h	46	2.5±1.2	46	2.0±1.0¹⁾
4 h	38	2.5±1.1	42	1.8±1.0¹⁾
8 h	35	2.5±1.0	30	1.6±0.8¹⁾
16 h	27	2.6±1.0	21	1.5±0.8¹⁾
24 h	22	2.8±1.1	13	1.1±0.6¹⁾
36 h	12	2.5±1.0	7	1.4±0.8
与CON组同时间点比较，¹⁾ P < 0.05。

下载: 导出CSV

参考文献(12)

[1]	Lee S. Dexmedetomidine: present and future directions[J]. Korean J Anesthesiol, 2019, 72(4): 323-330. doi: 10.4097/kja.19259
[2]	Devlin JW, Al-Qadheeb NS, Chi A, et al. Efficacy and safety of early dexmedetomidine during noninvasive ventilation for patients with acute respiratory failure: a randomized, double-blind, placebo-controlled pilot study[J]. Chest, 2014, 145(6): 1204-1212. doi: 10.1378/chest.13-1448
[3]	Demuro JP, Mongelli MN, Hanna AF. Use of dexmedetomidine to facilitate non-invasive ventilation[J]. Int J Crit Illn Inj Sci, 2013, 3(4): 274-275. doi: 10.4103/2229-5151.124161
[4]	Bersten AD, Holt AW, Vedig AE, et al. Treatment of severe cardiogenic pulmonary edema with continuous positive airway pressure delivered by face mask[J]. N Engl J Med, 1991, 325(26): 1825-1830. doi: 10.1056/NEJM199112263252601
[5]	Nava S, Carbone G, DiBattista N, et al. Noninvasive ventilation in cardiogenic pulmonary edema: a multicenter randomized trial[J]. Am J Respir Crit Care Med, 2003, 168(12): 1432-1437. doi: 10.1164/rccm.200211-1270OC
[6]	Gray A, Goodacre S, Newby DE, et al. Noninvasive ventilation in acute cardiogenic pulmonary edema[J]. N Engl J Med, 2008, 359(2): 142-151. doi: 10.1056/NEJMoa0707992
[7]	Akada S, Takeda S, Yoshida Y, et al. The efficacy of dexmedetomidine in patients with noninvasive ventilation: a preliminary study[J]. Anesth Analg, 2008, 107(1): 167-170. doi: 10.1213/ane.0b013e3181732dc2
[8]	Vital FM, Saconato H, Ladeira MT, et al. Non-invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary edema[J]. Cochrane Database Syst Rev, 2008, (3): CD005351.
[9]	Lewis K, Piticaru J, Chaudhuri D, et al. Safety and Efficacy of Dexmedetomidine in Acutely Ill Adults Requiring Noninvasive Ventilation: A Systematic Review and Meta-analysis of Randomized Trials[J]. Chest, 2021, 159(6): 2274-2288. doi: 10.1016/j.chest.2020.12.052
[10]	Bao N, Tang B. Organ -Protective Effects and the Underlying Mechanism of Dexmedetomidine[J]. Mediators Inflamm, 2020, 2020: 6136105.
[11]	张玉辉, 高亚坤, 肖连波, 等. 右美托咪啶对体外循环下心脏瓣膜置换术患者心肌缺血再灌注损伤的影响[J]. 临床心血管病杂志, 2015, 31(11): 1195-1197.
[12]	沈宁, 贺蓓. 无创通气治疗不能降低急性心源性肺水肿患者的短期病死率[J]. 中华医学杂志, 2008, 88(34): 2413.