A 69-year-old man with diabetes is mechanically ventilated for severe sepsis and acute respiratory distress syndrome due to community-acquired pneumonia. On day one, he receives assist-control ventilation with fraction of inspired oxygen (FIO2) of 0.7 and positive end-expiratory pressure (PEEP) of 12 cm H2O; by day three, FIO2 is 0.45 and PEEP is 6 cm H2O. He is on a propofol infusion and has received intermittent fentanyl, but now appears to be in no pain. His Richmond Agitation-Sedation Scale score is -4, indicating that he responds to physical, and not to verbal, stimulation.
Which of the following is the best course of action regarding weaning him from sedation and ventilation?
A. Change propofol infusion to intermittent bolus sedation and change to pressure support ventilation.
B. Stop sedation and, once awake, start a spontaneous breathing trial.
C. Switch from propofol to fentanyl and reduce PEEP to 5 cmH2O.
D. Gradually reduce both the sedation dosage and the ventilatory support.
答案解析：
当Girard等人在觉醒和呼吸对照试验中综合了自发觉醒和自主呼吸时，结果是ICU和住院时间均减少了4天。患者的1年生存率绝对风险降低14%，这是重症监护随机试验中有史以来最大的生存优势之一。患者的自行拔管率确实较高，但再插管率并不较高，表明他们准备拔管，但团队太慢。还观察到昏迷减轻，但谵妄未减轻。仅在败血症亚组（约占研究人群的一半）中，昏迷和谵妄持续时间均缩短。对于已接受方案镇静治疗的机械通气成人，增加每日镇静中断可能不会有减少机械通气或ICU住院时间的额外获益。
正确答案：B
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