右美托咪啶与异丙酚减少ICU老年患者谵妄的比较：系统回顾与Meta分析
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Dexmedetomidine versus propofol sedation in reducing delirium among older adults in the ICU: A systematic review and meta-analysis
背景与目的
谵妄在ICU是一种常见的疾病，据报道其发病率在70%以上。由于患者发病率和死亡率与谵妄明显相关，我们推测镇静可能改善ICU老年患者的预后。评价右美托咪啶镇静是否与ICU老年患者谵妄发生率的减少有关，并评估其与异丙酚镇静相比的风险和优点。
方 法
我们检索了Medline、EMBASE、循证医学评论、国际药物摘要、Scopus、临床试验网站和WHO Trials从数据库建立到2019年4月8日发表的文章。选择以比较ICU患者右美托咪啶和异丙酚镇静效果，研究结果为谵妄的发生率，并且患者平均/中位样本年龄至少为60岁的文章进行分析。在术中或作为全麻辅助使用右旋美托咪啶和异丙酚的研究排除在外。
结 果
有7项研究表明，与异丙酚相比，右美托咪啶镇静谵妄的发生率较低：n=1249；RR=0.70；95%CI为0.52-0.95；P=0.02。有3项研究表明，心动过缓的发生率在统计学上没有显著差异：n=278；RR=1.52；95%CI为0.85-2.72；P=0.16；有6项研究表明，低血压的发生率在统计学上没有显著差异：n=867名患者；RR=1.12；95%CI 0.86-1.45；P=0.42。与异丙酚相比，右美托咪啶镇静不会减少住院时间、ICU住院时间或机械通气时间。
结 论
与异丙酚相比，右美托咪定的镇静作用与ICU老年患者谵妄发生率降低相关，且心动过缓、低血压等副作用没有明显增加。对于ICU中有谵妄风险的老年患者，可以考虑用右美托咪啶实施镇静。
原始文献摘要
Pereira JV, Sanjanwala RM, Mohammed MK, et,al.Dexmedetomidine versus propofol sedation in reducing delirium among older adults in the ICU: A systematic review and meta-analysis.[J].Eur J Anaesthesiol 2020 Feb;37(2)DOI：10.1097/EJA.0000000000001131
BACKGROUND Delirium is common in the ICU, with incidence rates reported to be upwards of 70%. Due to the significant morbidity and mortality associated with delirium, it is hypothesised that a delirium-free sedative agent will improve outcomes in older adults admitted to the ICU.
OBJECTIVES To assess if dexmedetomidine sedation is associated with a reduction in ICU delirium among older adults, and to evaluate its risks and benefits compared with propofol sedation.
DESIGN Systematic review of randomised controlled trials and cohort studies with meta-analyses.
DATA SOURCES Articles published from database inception to 8 April 2019 were retrieved from Medline, EMBASE,Evidence-based Medicine Reviews, International Pharma-ceutical Abstracts, Scopus, ClinicalTrials.gov and WHOTrials.ELIGIBILITY Studies were included if they compared dexmedetomidine sedation with propofol in the ICU, reported the incidence of delirium as an outcome and had a mean/median sample age of at least 60. Studies that examined dexmedetomidine and propofol use intra-operatively or as part of general anaesthesia were excluded.
RESULTS Dexmedetomidine sedation was associated with a lower incidence of delirium when compared with propofol:seven studies, n¼1249; risk ratio 0.70; 95% confidence interval (CI) 0.52 to 0.95; P¼0.02. There was no statistically significant difference in the incidence of bradycardia: three studies, n¼278; risk ratio 1.52; 95% CI 0.85 to 2.72;P¼0.16, and hypotension: six studies, n¼867 patients; risk ratio 1.12; 95% CI 0.86 to 1.45;P¼0.42. Dexmedetomidine sedation did not reduce hospital length of stay, ICU length of stay or duration of mechanical ventilation compared with
propofol.
CONCLUSION Compared with propofol, dexmedetomidine sedation in the ICU is associated with lower delirium incidence among older adults with no significant increase in adverse events. In older adult ICU patients at risk of developing delirium, sedation with dexmedetomidine should be considered. Further research is warranted to elucidate and explain the mechanisms underlying this process, and to confirm our findings with large, multicentre trials.
麻醉学文献进展分享
贵州医科大学高鸿教授课题组
翻译：牛振瑛 编辑：冯玉蓉 审校：王贵龙