【作者】 张娟；

【导师】 胡啸玲； 王桥生；

【作者基本信息】 南华大学 ， 临床医学（专业学位）， 2018， 硕士

【摘要】 目的:观察以右美托咪定为基础的早期目标导向浅镇静方案对脓毒症相关性脑病（Sepsis-associated Encephalopathy,SAE）患者的疗效及初步探索其影响机制。方法:选择2017年4月至12月在南华大学附属第一医院重症监护室接受治疗的SAE患者60例,年龄≥18岁,随机分为右美托咪定镇静组（简称D组）和丙泊酚镇静组（简称P组）,其中D组30例,P组30例,D组予0.2-0.7μg/（kg·h）的右美托咪定镇静;P组予负荷剂量:1-3mg/kg,维持剂量:0.5-4mg/（kg·h）的丙泊酚镇静,两组患者镇静疗程达72小时以上。两组的镇静目标为RASS评分-2至+1分。当RASS评分≥2分时,D组予丙泊酚辅助镇静,以达到镇静目标。当RASS评分≤-3时,减少右美托咪定或丙泊酚的剂量,以达到镇静目标。记录各组患者性别、年龄、身高、体重、入科诊断;每组患者接受镇静治疗前（T₀）,进行SOFA评分、APACHEII评分,并检测血清IL-6、CRP、S-100β蛋白、神经元特异性烯醇化酶（Neuron-specific Enolase,NSE）浓度;在两组接受镇静治疗后,第1（T₁）、3（T₃）、7（T₇）天进行CAM-ICU评分、SOFA评分,检测血清IL-6、CRP、S-100β蛋白、NSE浓度;记录两组患者7天内谵妄持续时间、瑞芬太尼的用量,随访并记录两组患者28天的预后情况。结果:1.两组患者血清IL-6、CRP浓度在T₁、T₃、T₇均显著下降,差异有统计学意义（P<0.05）;T₃、T₇时,D组患者血清IL-6、CRP浓度较P组显著降低,差异有统计学意义（P<0.05）。2.两组患者SOFA评分在T₃、T₇时显著下降,差异有统计学意义（P<0.05）;T₃、T₇时,D组患者SOFA评分较P组显著降低,差异有统计学意义（P<0.05）。3.两组患者血清S100β浓度在T₃、T₇时显著下降,差异有统计学意义（P<0.05）;T₃时,血清S100β浓度D组患者较P组显著降低,差异有统计学意义（P<0.05）。4.两组的NSE浓度在T₇时显著下降,差异有统计学意义（P<0.05）;T₇时,D组的NSE浓度较P组显著下降,差异有统计学意义（P<0.05）。5.两组患者的CAM-ICU阳性率在T₁、T₃、T₇时差异均无统计学意义（P>0.05）;D组的谵妄持续时间（3.71±0.76）天与P组的谵妄时间（5.00±1.29）天比较,差异有统计学意义（P<0.05）。6.两组患者的28天死亡率比较,D组4人死亡（13.33%）,P组6人死亡（20.00%）,两组死亡率差异无统计学意义（P>0.05）。结论:以右美托咪定为基础的早期目标导向浅镇静方案能减轻SAE患者的全身炎症反应,减轻患者的脑损伤,但不能降低患者28天的死亡率。更多还原

【Abstract】 OBJECTIVE:To observe the efficacy of the early goal-directed light sedation based on dexmedetomidine in patients with sepsis-associated encephalopathy（SAE）and to explore its underlying mechanisms.METHODS:A total of 60 adult patients with SAE who were treated in the Intensive Care Unit of the First Affiliated Hospital of University of South China from April to December of 2017 were divided into dexmedetomidine sedation group（abbreviated:group D,n=30）and propofol sedation（abbreviated:group P,n=30）by random number method.Then the patients in group D was treated with dose of 0.2-0.7μg/（kg·h）dexmedetomidine,however,the patients in group P was given a loading dose of 1-3 mg/kg propofol and then maintenance dose was 0.5-4mg/（kg·h）to keep sedation.The two groups of sedative treatment lasted more than 72 hours.The patients’ sedative goal was RASS score of-2 to+1.When the RASS score was more than 2 points,Group D was injected with propofol to achieve the sedative goal.When the RASS score was≤-3,reduced the dosage of dexmedetomidine or propofol to achieve the sedative goal.The gender,age,height and weight,diagnosis of each group were recorded.Before each group of patients received sedative treatment（T₀）,APACHEII scores and SOFA scores were performed.Peripheral blood was collected and detected levels of IL-6,CRP,S-100βprotein and NSE.After two group received sedation at the first（T₁）,3（T₃）,and 7（T₇）days,collected CAM-ICU scores、SOFA scores,and serum IL-6,CRP,S-100βand NSE.The duration of delirium within 7days and the amount of remifentanil,the prognosis of 28 days in two group were recorded.RESULTS:1.Levels of serum IL-6、CRP in both groups were significantly lower at T₁,T₃,and T₇（P<0.05）.At T₃ and T₇,levels of serum IL-6、CRP in group D were significantly lower than those in group P（P<0.05）.2.The scores of SOFA in the two groups were significantly decreased at T₃ and T₇（P<0.05）.At T₃ and T₇,the score of the D group was significantly lower than that in the group P（P<0.05）.3.Levels of serum S100βin both groups decreased significantly at T₃ and T₇（P<0.05）.At T₃,levels of serum S100βin group D were significantly lower than those in group P（P<0.05）.4.Levels of serum NSE in both groups decreased significantly at T₇（P<0.05）.At T₇,levels of serum NSE in group D were significantly lower than those in group P（P<0.05）.5.There was no significant difference in the CAM-ICU scores between the two groups at T₁,T₃,and T₇（P>0.05）.The duration of delirium in group D（3.71±0.76）days and that in group P（5.00±1.29）days,there was significantly lower in group D than in group P（P<0.05）.6.The 28-day mortality rate in the two groups was compared with 4deaths in group D（13.33%）and 6 deaths in group P（20.00%）,there was no statistically significant difference in mortality between the two groups（P>0.05）.CONCLUSIONS:The early goal-directed light sedation based on dexmedetomidine can reduce systemic inflammatory response of patients with SAE,reduce brain damage in patients,but can not reduce the 28-day mortality.更多还原