需要接受有创机械通气的危重成人和儿童患者中，每日镇静中断与不进行每日镇静中断的比较。
完整摘要 · 中文译文
理论基础：每日镇静中断（DSI）旨在限制药物蓄积并促进更清醒的状态，从而缩短机械通气持续时间及其相关并发症。本文是对2014年首次发表的Cochrane系统评价的更新。 目的：评估DSI与不含DSI的镇静管理相比，对需要有创机械通气、静脉镇静的危重患者下列指标的影响：有创机械通气持续时间、死亡率、重症监护病房（ICU）住院时间、与镇静不足或过度相关的不良事件（包括气管内导管意外拔除和气管切开）、镇静及镇痛药物总用量，以及健康相关生活质量。 检索方法：我们检索了CENTRAL、MEDLINE All、Embase Classic+Embase、护理与联合卫生文献累积索引（CINAHL）、Web of Science核心合集和两个试验注册平台，同时进行了参考文献核查、引文检索，并与研究作者联系以确定纳入本评价的研究。最新检索日期为2025年10月8日。 纳入标准：我们纳入了在机械通气危重患者（成人及18岁以下婴儿或儿童）中，将DSI与不含DSI的镇静策略（方案化镇静、非方案化常规治疗（由临床医生酌情决定）或镇痛优先/无镇静）进行比较的随机对照试验（RCT）。 结局指标：我们的关键结局指标为机械通气持续时间（从随机分组至成功拔管或死亡）、死亡率和ICU住院时间（LO S）。我们的重要结局指标包括住院时间（LOS）、与镇静不足或过度相关的不良事件（如气管导管或其他管路或导管意外拔除、气管切开、新发谵妄、使用身体约束和心脏事件）、药物总剂量以及健康相关生活质量（HRQoL）。 偏倚风险：我们使用原始Cochrane工具RoB 1来评估随机对照试验中的偏倚。 综合方法：我们使用荟萃分析（随机效应模型）综合各结局的结果。我们根据预先确定的标准进行了亚组分析和敏感性分析。我们使用GRADE来评估证据的确定性。 纳入研究：本次更新纳入了23项试验（1项整群随机试验；18项成人随机对照试验，5项儿童试验），共5987名（4910名调整后）受试者（3238名成人，2750名（1673名调整后）儿童）。9项试验使用镇静方案作为对照，9项采用由临床团队自行决定镇静镇痛药物的“常规镇静实践”，5项采用镇痛优先或无镇静对照。 结果综合：与不包括每日镇静中断（DSI）的镇静策略相比，每日镇静中断可能缩短机械通气持续时间（均数差（MD）−0.15 log天数，95%置信区间（CI）−0.29至−0.01；I²=88%；18项研究，3815名受试者；低确定性证据）。这些数据转化为相对减少14%（95% CI 1%至25%）。与不包括DSI的镇静策略相比，每日镇静中断很可能降低死亡率（相对危险度（RR）0.88，95% CI 0.7 7 至 0.99；I2 = 0%；18 项研究，4057 名受试者；725 起事件；中等质量证据）。每日镇静中断可能缩短 ICU 住院时间（MD -0.12 log 天，95% CI -0.22 至 -0.02；I2 = 72%；18 项研究，4477 名受试者；中等质量证据）。这些数据相当于相对减少 11%（95% CI 2% 至 20%）。每日镇静中断可能缩短总住院时间（MD -0.12 log 天，95% CI -0.22 至 -0.02；I2 = 39%；13 项研究，3589 名受试者；中等质量证据）。这些数据相当于相对减少 11%（95% CI 2% 至 20%）。对于与镇静不足或过度相关的不良事件，每日镇静中断对气管内导管自行/意外拔除率可能几乎没有差异（RR 0.88，95% CI 0.66 至 1.19；P = 0.41，I2 = 0%；16 项研究，4342 名受试者；171 起事件；低质量证据），对管路或导管自行/意外拔除率也可能几乎没有差异（RR 1.44，95% CI 0.80 至 2.57；P = 0.22，I2 = 0%；7 项研究，1536 名受试者；42 起事件；低质量证据）。每日镇静中断可能降低气管切开率（RR 0.68，95% CI 0.55 至 0.85；P < 0.001，I2 = 0%；8 项研究，2503 名受试者；263 起事件；中等质量证据）。它可能对谵妄发生率几乎没有影响，但证据非常不确定（RR 0.92，95% CI 0.74 至 1.15；P = 0.48，I2 = 59%；4 项研究，1009 名受试者；520 起事件；极低质量证据）。与不进行每日镇静中断的镇静管理相比，每日镇静中断对 ICU 住院期间苯二氮䓬类、芬太尼或丙泊酚的总给药剂量可能几乎没有差异。 然而，证据非常不确定。每日镇静中断可能增加ICU住院期间吗啡的总给药剂量（MD 0.07 log mg，95% CI 0～0.13；P = 0.05，I² = 0%；4项研究，404名受试者；中等质量证据）。这些数据相当于相对增加7%（95% CI 0%～14%）。与不进行DSI的镇静管理相比，DSI对健康相关生活质量（HRQoL）可能几乎无差异，其中心理健康领域的证据非常不确定。证据质量受限于不一致性（统计学异质性）以及因置信区间过宽导致的不精确性，包括某些结局的置信区间同时涵盖获益和伤害。 作者结论：基于来自23项试验、纳入近6000名危重症患者的低至中等质量证据，我们发现与其他镇静方法相比，DSI可能缩短机械通气持续时间，并很可能降低死亡率、重症监护住院时间和总住院时间。每日镇静中断对意外拔除气管导管或其他管路或导管的这一不良结局可能几乎无影响，但很可能减少气管切开的需求。关于镇静剂量的证据非常不确定；然而，DSI可能增加阿片类药物的给药剂量。鉴于镇静剂量影响方面的证据非常不确定，未来试验应纳入镇静剂和镇痛剂总剂量以及谵妄和健康相关生活质量的数据，因为这些方面仍未得到充分评估。 资助：本综述未获得任何资助。 注册：注册号（CD009176）及 本综述的既往版本：Cochrane系统评价数据库，DOI: 10.1002/14651858.CD009176.pub2。研究方案可通过DOI 10.1002/14651858.CD009176.pub1获取。
完整摘要 · 英文原文
RATIONALE: Daily sedation interruption (DSI) aims to limit drug accumulation and promote a more awake state, thereby reducing the duration of mechanical ventilation and its associated complications. This is an update of a Cochrane review first published in 2014. OBJECTIVES: To assess the effects of DSI versus sedation management without DSI on the duration of invasive mechanical ventilation, mortality, intensive care unit (ICU) length of stay, adverse events related to under- or oversedation (including accidental removal of endotracheal tube and tracheostomy), total doses of sedative and analgesic drug administered, and health-related quality of life, for critically ill people requiring intravenous sedation. SEARCH METHODS: We used CENTRAL, MEDLINE All, Embase Classic+Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science Core Collection, and two trial registers, together with reference checking, citation searching, and contact with study authors to identify the studies included in the review. The latest search date was 8 October 2025. ELIGIBILITY CRITERIA: We included randomised controlled trials (RCTs) comparing DSI with sedation strategies that did not include DSI (protocolised sedation, non-protocolised usual care (clinician discretion), or analgesia first/no sedation) in mechanically ventilated, critically ill people (adults and infants or children under 18 years of age). OUTCOMES: Our critical outcomes were duration of mechanical ventilation (from randomisation to successful extubation or death), mortality, and ICU length of stay (LOS). Our important outcomes included hospital LOS, adverse events related to under- or oversedation (e.g. accidental removal of endotracheal tube or other lines or catheters, tracheostomy, new onset of delirium occurrence, use of physical restraint, and cardiac events), total drug doses, and health-related quality of life (HRQoL). RISK OF BIAS: We used the original Cochrane tool, RoB 1, to assess bias in the RCTs. SYNTHESIS METHODS: We synthesised results for each outcome using meta-analysis (random-effects modelling). We conducted subgroup and sensitivity analyses according to pre-defined criteria. We used GRADE to assess the certainty of evidence. INCLUDED STUDIES: This update included 23 trials (one cluster-randomised trial; 18 RCTs in adults, five in children) with 5987 (4910 adjusted) participants (3238 adults, 2750 (1673 adjusted) children). Nine trials used a sedation protocol comparator, nine used 'usual sedation practices' with sedative and analgesic drugs at the clinical team's discretion, and five used analgesia-first or no-sedation comparators. SYNTHESIS OF RESULTS: Daily sedation interruption may reduce the duration of mechanical ventilation compared with sedation strategies that do not include DSI (mean difference (MD) -0.15 log days, 95% confidence interval (CI) -0.29 to -0.01; I2 = 88%; 18 studies, 3815 participants; low-certainty evidence). These data translate to a relative reduction of 14% (95% CI 1% to 25%). Daily sedation interruption probably reduces mortality compared with sedation strategies that do not include DSI (relative risk (RR) 0.88, 95% CI 0.77 to 0.99; I2 = 0%; 18 studies, 4057 participants; 725 events; moderate-certainty evidence). Daily sedation interruption probably reduces ICU LOS (MD -0.12 log days, 95% CI -0.22 to -0.02; I2 = 72%; 18 studies, 4477 participants; moderate-certainty evidence). These data translate to a relative reduction of 11% (95% CI 2% to 20%). Daily sedation interruption probably reduces hospital LOS (MD -0.12 log days, 95% CI -0.22 to -0.02; I2 = 39%; 13 studies, 3589 participants; moderate-certainty evidence). These data translate to a relative reduction of 11% (95% CI 2% to 20%). For adverse events related to under- or oversedation, DSI may result in little to no difference in the rate of self/accidental removal of the endotracheal tube (RR 0.88, 95% CI 0.66 to 1.19; P = 0.41, I2 = 0%; 16 studies, 4342 participants; 171 events; low-certainty evidence) or self/accidental removal of lines or catheters (RR 1.44, 95% CI 0.80 to 2.57; P = 0.22, I2 = 0%; 7 studies, 1536 participants; 42 events; low-certainty evidence). DSI probably reduces rates of tracheostomy (RR 0.68, 95% CI 0.55 to 0.85; P < 0.001, I2 = 0%; 8 studies, 2503 participants; 263 events; moderate-certainty evidence). It may result in little to no difference in the rate of delirium occurrence, but the evidence is very uncertain (RR 0.92, 95% CI 0.74 to 1.15; P = 0.48, I2 = 59%; 4 studies, 1009 participants; 520 events; very low-certainty evidence). Compared with sedation management without DSI, DSI may result in little to no difference in the total dose of benzodiazepines, fentanyl, or propofol administered over the ICU admission. However, the evidence is very uncertain. Daily sedation interruption probably increases the total dose of morphine administered over the ICU admission (MD 0.07 log mg, 95% CI 0 to 0.13; P = 0.05, I2 = 0%; 4 studies, 404 participants; moderate-certainty evidence). These data translate to a relative increase of 7% (95% CI 0% to 14%). DSI may result in little to no difference in HRQoL compared with sedation management without DSI, with evidence in the mental health domain being very uncertain. Evidence certainty is limited by inconsistency (statistical heterogeneity) and imprecision due to wide CIs, including CIs that encompass both benefit and harm for some outcomes. AUTHORS' CONCLUSIONS: Based on low- and moderate-certainty evidence from 23 trials including nearly 6000 critically ill people, we found that DSI may reduce the duration of mechanical ventilation and probably reduces mortality, intensive care LOS, and hospital LOS compared with other sedation methods. Daily sedation interruption may have little to no effect on the adverse outcomes of accidental removal of the endotracheal tube or other lines or catheters, but probably reduces the need for tracheostomy. The evidence on sedation dosing is very uncertain; however, DSI probably increases opioid dosing. Given the evidence on the effect on sedation dosing is very uncertain, future trials should include data on total sedative and analgesic doses as well as delirium and health-related quality of life, as these remain under-evaluated. FUNDING: This review received no funding. REGISTRATION: Registration (CD009176) and previous version of the review: Cochrane Database of Systematic Reviews via DOI: 10.1002/14651858.CD009176.pub2. Protocol available via DOI 10.1002/14651858.CD009176.pub1.