ICU镇痛躁动谵妄指南解读1.ppt

,2013,ICU成人患者疼痛，躁动，谵妄处理临床实践指南解读 2013,Clinical Practice Guidelines for the Management of Pain,Agitation,and Delirium in Adult Patients in the Intensive Care Unit,ICU镇痛镇静的临床意义,解除患者的焦虑，恐慌；减轻生理应激反应；解除疼痛；使机械通气容易进行；顺利完成床边护理、诊断与治疗；恢复患者昼夜生理节律；.。,减少并发症及死亡率减少ICU入住日及住院日减少医疗费用,Pain,Agitation,Delirium 2013,PAD guidelines,Crit Care Med 2002,30:119141,Crit Care Med 2013,41:263306,2013,PAD guidelines,该指南由美国重症医学院（The American College of Critical Care Medicine ACCM），美国重症医学会（Society of Critical Care Medicine SCCM)美国健康体系药学家协会（American Society of Health-System Pharmacists ASHP）支持完成。该指南得到美国胸科医师学院（the American College of Chest Physicians ACCP）的认可；得到美国呼吸治疗学会（the American Association for Respiratory Care AARC）的支持；美国重症医学（CCM）发表：2013；41（1）：263-306,ACCM组成了来自于多专业、多机构的20人特别工作组,密切合作6年共同制定此指南。通过全球8个临床收索引擎数据库，收评 ICU相关的疼痛与止痛，躁动与镇静，谵妄与相关结果的19,000篇文献。,2013,PAD guidelines,指南以陈述（statements)and 与推荐意见(recommendations)的方式表达：-53个“陈述与推荐意见”（2013 PAD Guidelines）-28个“推荐意见”（2002 ASG Guidelines）每一项陈述的证据质量分为：高（A）中（B）低/很低（C）推荐意见的强度分为：强（1）弱（2）支持与反对意见分为：支持（+）反对（-）对推荐意见强烈的使用“We recommend”（推荐.）对推荐意见较弱的使用“We suggest”（建议.）对无任何证据或无专家共识的使用“no recommendation”(0),What do the 2013,PAD Guidelines Say?,疼痛与镇痛Pain and Analgesia,ICU疼痛的发病率Incidence of Pain in ICU Patients,成年内科、外科、创伤ICU患者常经历疼痛折磨，包括休息与常规ICU治疗的时间（B）Adult medical,surgical,and trauma ICU patients routinely experience pain,both at rest and with routine ICU care(B).在心外科病人疼痛普遍并且没有得到治疗；女性比男性经历的疼痛更严重（B）Pain in adult cardiac surgery patients is common and poorly treated;women experience more pain than men after cardiac surgery(B).ICU操作性疼痛普遍存在（B）Procedural pain is common in adult ICU patients(B).,77%的病人在ICU经历着中度/重度疼痛，38%存在慢性疼痛,ICU疼痛评估Pain Assessment in ICU Patients,推荐对所有ICU患者应常规进行疼痛监测（+1B）We recommend that pain be routinely monitored in all adult ICU patients(+1B).解读说明：ICU患者的日常疼痛评估和改善他们临床预后相关。疼痛评估和减少镇痛药用量，ICU住院时间缩短（LOS），以及机械通气时间减少有显著相关性。疼痛评估对于恰当的治疗很有必要，因此对所有ICU患者执行常规疼痛评估的强烈建议是适当的，因为这样做利远远大于弊（as the benefits strongly outweigh the risks.）。,患者对疼痛的自我描述被认为是“金标准”，临床医生应该尝试首先让患者自己评价他们自己的疼痛。（B）A patients self-report of pain is considered the“gold standard,”and clinicians should always attempt to have a patient rate his or her own pain first（B).,ICU疼痛评估Pain Assessment in ICU Patients,指南反对单纯根据生命体征（或包括生命体征在内的观察性疼痛量表）评估成年ICU患者的疼痛(-2C)。但指南同时建议生命体征可以作为患者需要接受进一步评估疼痛的线索(+2C)。We do not suggest that vital signs(or observational pain scales that include vital signs)be used alone for pain assessment in adult ICU patients(2C).We suggest that vital signs may be used as a cue to begin further assessment of pain in these patients,however(+2C).,ICU疼痛评估Pain Assessment in ICU Patients,如何对不能自述表达疼痛的患者进行疼痛的评估？,对于不能自行描述疼痛但运动功能正常，且表情行为可以被观察的ICU患者（不包括颅脑外伤），“行为疼痛评分表（BPS）”和“重症疼痛观察工具（CPOT）是监测这类ICU患者疼痛的最有效和可靠的疼痛量表。（B）The Behavioral Pain Scale(BPS)and the Critical-Care Pain Observation Tool(CPOT)are the most valid and reliable behavioral pain scales for monitoring pain（B）,ICU疼痛评估Pain Assessment in ICU Patients,The Behavioral Pain Scale(BPS)&the Critical-Care Pain Observation Tool(CPOT),The Behavioral Pain Scale(BPS)：面部表情 上肢运动 呼吸机耐受性 每项指标评分范围：14分 1分没有疼痛 4分极度疼痛 总分312分 The Critical-Care Pain Observation Tool(CPOT)：面部表情 肢体动作 呼吸机耐受性 肌肉紧张度 每项指标评分范围：02分 0分没有疼痛 2分极度疼痛,The Behavioral Pain Scale(BPS),The Critical-Care Pain Observation Tool(CPOT),疼痛的治疗Treatment of Pain in ICU Patients,指南推荐在成人ICU拔出胸管之前预先使用止痛药或非药物干预（如：放松），以减轻患者疼痛（+1C）。We recommend that preemptive analgesia and/or nonpharmacologic interventions(e.g.,relaxation)be administered to alleviate pain in adult ICU patients prior to chest tube removal(+1C).指南建议在实施其他介入的或可能导致疼痛的操作时，应预先使用止痛药或非药物干预，以减轻疼痛（+2C）We suggest that for other types of invasive and potentially painful procedures in adult ICU patients,preemptive analgesic therapy and/or nonpharmacologic interventions may also be administered to alleviate pain(+2C).指南建议所有行机械通气的ICU患者应采用镇痛优先的镇静方法（+2B)。We suggest that analgesiafirst sedation be used in adult ICU patients who are mechanically ventilated(+2B).,指南推荐静脉应用阿片类药物作为一线首选用药治疗非神经病理性疼痛（+1C）。We recommend that IV opioids be considered as the firstline drug class of choice to treat nonneuropathic pain in critically ill patients(+1C).所有可应用的静脉阿片类药物，在滴定至相似的疼痛强度终点时，均具有同等效应（C）。All available IV opioids,when titrated to similar painintensity endpoints,are equally effective(C).,疼痛的治疗Treatment of Pain in ICU Patients,解读说明：指南不再优先推荐芬太尼，认为所有阿片类药物疗效相似,指南建议应用非阿片类药物来减少阿片类药物的用量（或彻底解除静脉应用阿片类药物的需求），以减少阿片类药物相关的副作用（+2C）。We suggest that nonopioid analgesics be considered to decrease the amount of opioids administered(or to eliminate the need for intravenous opioids altogether),and to decrease opioidrelated side effects(+2C).指南推荐对于神经病理性疼痛肠道内应用加巴喷丁，或卡马西平，来辅助静脉应用阿片类药物（+1A）We recommend that either enterally administered gabapentin or carbamazepine,in addition to intravenous opioids,should be considered for treatment of neuropathic pain(+1A).,疼痛的治疗Treatment of Pain in ICU Patients,躁动与镇静Agitation and Sedation,Agitation,是一种伴有不停动作的易激惹状态，或者说是一种伴随着挣扎动作的极度焦虑状态。在ICU中，70%以上的患者发生过躁动。引起焦虑的原因均可以导致躁动。另外，某些药物的不良反应、休克、低氧血症，低血糖、酒精及其他药物的戒断反应、机械通气不同步等也是引起躁动的常见原因。研究显示最易使重症患者焦虑、躁动的原因依次为：疼痛、失眠、经鼻或经口腔的各种插管、失去支配自身能力的恐惧感以及身体其他部位的各种管道限制等。,ICU镇静的意义与原则,由于躁动和焦虑在ICU常见并可导致严重后果，因此ICU患者镇静显得尤为重要。镇静实施前应消除可能导致患者躁动的原因，如疾病本身，谵妄，低氧血症，低血糖或者酒精等药物戒断症状等。,指南指出保持患者轻度（浅）镇静水平与临床结局改善有关（如：缩短机械通气时间，缩短ICU住院天数LOS）(B）Maintaining light levels of sedation in adult ICU patients is associated with improved clinical outcomes(e.g.,shorter duration of mechanical ventilation and a shorter ICU length of stay LOS)(B).保持轻度（浅）镇静水平可能增加患者生理应激反应，但同时并不增加心肌缺血的发生率（B）Maintaining light levels of sedation increases the physiologic stress response,but is not associated with an increased incidence of myocardial ischemia(B).,ICU患者维持轻度镇静的受益大于风险。,指南推荐患者镇静用药应该滴定式镇静方式以维持轻度镇静水平，而不是深度镇静水平，除非存在临床反指征（+1B）We recommend that sedative medications be titrated to maintain a light rather than a deep level of sedation in adult ICU patients,unless clinically contraindicated(+1B).,镇静深度与临床结局Depth of sedation vs.clinical outcomes,怎样评估镇静？How do we assess sedation?,镇静深度监测Monitoring depth of sedation,“Richmond躁动-镇静评分（RASS）”与“镇静-躁动评分（SAS）”是ICU患者测量镇静质量与镇静深度的最真实与可靠的镇静评估工具（B）。The Richmond Agitation-Sedation Scale(RASS)and Sedation-Agitation Scale(SAS)are the most valid and reliable sedation assessment tools for measuring quality and depth of sedation in adult ICU patients(B).指南不推荐客观脑功能检测方法（如：听觉诱发电位AEPs,脑电双频指数BIS,麻醉趋势指数NI,病人状态指数PSI,状态熵SE）用于非昏迷、非肌松的重症患者作为基本的镇静深度监测方法，因为这些监测方法不能替代患者主观镇静系统的评分结果（-1B）We do not recommend that objective measures of brain function(e.g.,auditory evoked potentials AEPs,Bispectral Index BIS,Narcotrend Index NI,Patient State Index PSI,or state entropy SE)be used as the primary method to monitor depth of sedation in noncomatose,nonparalyzed critically ill adult patients,as these monitors are inadequate substitutes for subjective sedation scoring systems(1B).,指南建议在应用肌松药物的ICU患者使用客观脑功能的监测（如：AEPs,BIS,NI,PSI,或SE）作为补充，因为在这些患者，主观镇静监测无法取得（+2B）We suggest that objective measures of brain function(e.g.,auditory evoked potentials AEP,Bispectral Index BIS,Narcotrend Index NI,Patient State Index PSI,or state entropy SE)be used as an adjunct to subjective sedation assessments in adult ICU patients who are receiving neuromuscular blocking agents,as subjective sedation assessments may be unobtainable in these patients(+2B).,镇静深度监测Monitoring depth of sedation,Richmond躁动-镇静评分（RASS）Richmond Agitation and Sedation Scale RASS,RASS镇静程度评估表(Richmond Agitation-Sedation Scale),镇静-躁动评分Sedation-Agitation scale,SAS,镇静-躁动评分Sedation-Agitation scale,SAS,简单可行的方法,open eyesmaintain eye contact squeeze handstick out tongue wiggle toes,建议：护理床旁实时评估，调整用药；（每日唤醒）每日查房就以上5条进行评估，满足3条,镇静药物的选择Choice of Sedatives in ICU Patients,指南建议机械通气的患者采用非苯二氮卓类的镇静药物方案（丙泊酚、右美托咪啶均可），可能优于苯二氮卓类药物（咪达唑仑、或劳拉西泮），并改善临床结局（+2B）。We suggest that sedation strategies using nonbenzodiazepine sedatives(either propofol or dexmedetomidine)may be preferred over sedation with benzodiazepines(either midazolam or lorazepam)to improve clinical outcomes in mechanically ventilated adult ICU patients(+2B).,解读说明：新指南不再建议首先使用苯二氮卓类药物，无论镇静时间长短，推荐异丙酚或右美托咪啶。,DELIRIUM,谵 妄,ICU谵妄的流行病学 Epidemiology of Delirium in ICU Patients.,谵妄的主要特点是：1、意识水平的紊乱（如，对环境意识清晰度的降低），注意力的集中、维持和转移的能力下降。2、认知功能的改变（如，记忆功能障碍、神志不清、语言障碍），或知觉受损的进展（如，幻觉、妄想）。,Delirium highly prevalent in ICU,Increased incidence in ventilated patientsIncidence in critically ill patients range from 35-60%.Up to 81.7%of mechanically ventilated pts developed delirium at some point during Vanderbilt study.Underdiagnosed conditionDelirium goes undiagnosed in 66%of patients,-Ely EW et al.Delirium as a predictor of mortality in mechanically ventilated patients in the ICU.JAMA 2004;291:1753-62-Ely EW et al.The impact of delirium in the intensive care unit on hospital length of stay.Intensive Care Med 2001;27:1892-1900-Inouye SK et al.Nurses recognition of delirium and its symptoms.Arch Intern Med.2001;161:2467-2473.,Subtypes of Delirium,Hyperactive-paranoid,agitatedReadily recognized,best prognosisPurely hyperactive:1.6%of delirium episodesHypoactive-withdrawn,quiet,paranoid“Quiet delirium”Often not well recognized,misdiagnosedPurely hypoactive episodes 43.5%Mixed-combinationMost common in ICU patients 54.9%Worst prognosis,Peterson JF,et al.Delirium and Its Motoric Subtypes:A Study of 614 Critically Ill Patients.J Am Geriatr Soc 54:479-484,2006.,Subtypes of Delirium,Hyperactive“agitated”,“aggressive”continual movement(fidgeting,pulling at clothes,lines,tubes,moving side to side)disorientated to person or placecomplex commands followed less than simple oneslanguage unintelligible or inappropriate responsescall out or shoutpain exaggeratedabnormal vital signtsparanoid,Hypoactive“pleasantly confused”peacefulsmile,nod,say yes to all questionsflatlethargicwithdrawnquietparanoid,Borthwick et al.(UKCPA)2006Pun and Ely.Chest 2007;132:624 36 Peterson et al.J Am Geriatr Soc 2006;54:479 84,Subtypes of Delirium,Mixedfluctuate hyperactive+hypoactive,Subtypes of Delirium,Borthwick et al.(UKCPA)2006Pun and Ely.Chest 2007;132:624 36 Peterson et al.J Am Geriatr Soc 2006;54:479 84,Subtypes of Delirium,Hypoactive,mixed more common than hyperactive,Delirium in ventilated patients,Independent predictor of mortality(3-fold increase)and increased length of stay in ventilated pts.After adjusting for confounders,delirium was also associated with a 39%increase in ICU costs.,Eli EW et al.Delirium as a predictor of mortality in mechanically ventilated patients in the ICU.JAMA 2004;291:1753-62Milbrandt EB et al.Costs Associated with Delirium in Mechanically Ventilated Patients.Crit Care Med 2004;32:955-962,2004,Delirium duration and 30-day mortality 2010 Shehabi et al.(SEDCOM group)Crit Care Med 2010;38:2311-2318 Prospective cohort analysis of SEDCOM,68 ICUs in 5 countries,354 ventilated medical&surgical ptsDelirium 64.4%,Graph from:Riker 2011 update on ICU sedation,analgesia and delirium 2011.,Outcomes associated with delirium,3 times more likely to die3 times higher re-intubation rate29%more likely to remain in ICU,41%in hospital1 extra day in delirium=over 10 extra days in hospital1 extra day in delirium=10%higher risk of death39%higher ICU$,31%higher hospital$5 times lower MMSE score at 1 year,简单智能量表(minimental state examination,MMSE),认知功能评价量表,与谵妄相关的结局Outcomes associated with delirium,谵妄与ICU患者死亡率增加有关（A）。Delirium is associated with increased mortality in adult ICU patients(A).谵妄与ICU患者住ICU时间与住院时间延长有关（A）。Delirium is associated with prolonged ICU and hospital LOS in adult ICU patients(A).谵妄与ICU患者住ICU后认知功能障碍有关（B）。Delirium is associated with the development of post-ICU cognitive impairment in adult ICU patients(B).,谵妄的危险因素Delirium risk factors,4项基线危险因素与ICU发生谵妄有显著正相关：(B)已经存在的痴呆（preexisting dementia）高血压（history of hypertension）酗酒病史（alcoholism）入院时病情高度危重（a high severity of illness at admission）。,昏迷是ICU患者发生谵妄的独立危险因素（B）。Coma is an independent risk factor for the development of delirium in ICU patients(B)苯二氮卓类药物应用可能是成人ICU患者发生谵妄的危险因素（B）。Benzodiazepine use may be a risk factor for the development of delirium in adult ICU patients(B).,谵妄的危险因素Delirium risk factors,关于丙泊酚应用于成人ICU发生谵妄的相关性目前依据不充分（C）There are insufficient data to determine the relationship between propofol use and the development of delirium in adult ICU patients(C).对于有风险发生谵妄的成人ICU机械通气患者，应用经脉输注右美托咪定与输注苯二氮卓类药物相比，可能与谵妄发生率较低有关（B）。In mechanically ventilated adult ICU patients at risk of developing delirium,dexmedetomidine infusions administered for sedation may be associated with a lower prevalence of delirium compared to benzodiazepine infusions(B).,谵妄的检测与监测Detecting and monitoring delirium,指南推荐对ICU患者进行常规谵妄监测（+1B）We recommend routine monitoring of delirium in adult ICU patients(+1B).“ICU精神错乱评估法”（CAM-ICU）和“重症监护谵妄筛查表”（ICUSC）在成人ICU是最真实和可靠的的谵妄监测工具（A）The Confusion Assessment Method for the ICU(CAM-ICU)and the Intensive Care Delirium Screening Checklist(ICDSC)are the most valid and reliable delirium monitoring tools in adult ICU patients(A).,谵妄诊断：精神错乱评估法（CAM-ICU）,谵妄诊断：精神错乱评估法（CAM-）,谵妄诊断：精神错乱评估法（CAM-）,谵妄诊断：精神错乱评估法（CAM-）,注：若患者有特征和，或者特征，或者特征，就诊断为谵妄。,重症监护谵妄筛查表,重症监护谵妄筛查表,苯二氮卓类药物的戒断症状：表现为焦虑、情绪激动、震颤、头痛、出汗、失眠、恶心、呕吐、痉挛、肌肉痉挛、多动谵妄以及偶尔发作。接受右美托咪定7天输液治疗的患者，在停药后2448小时内，发生戒断症状，最常见的临床表现为恶心、呕吐和兴奋。一项前瞻性研究表明：停药后戒断症状发生率右美托咪定为4.9%和咪唑安定为8.2%。,重视ICU药物戒断性谵妄,JAMA 2009;301:489499,重视ICU药物戒断性谵妄,因此，对于阿片和/或其他镇静药物的治疗中，给药治疗时间较长（如数天）的患者，为了减少戒断谵妄的危险，应花数天时间逐渐减量停药。Opioids and/or sedatives administered for prolonged periods(i.e.,days)should be weaned over several days in order to reduce the risk of drug withdrawal.,关于酒精戒断性谵妄,酒精（ETOH）依赖性在所有住院患者中有15%20%。外科手术和创伤患者约大8%-31%的酒精依赖。并且在住院期间会发展为酒精戒断综合征（Alcohol Withdrawal Syndrome AWS），出现神经和植物神经功能障碍的症状。AWS的症状可从轻微到致命！15%有AWS的住院患者表现全身强直阵挛发作，5%发生震颤性谵妄（delirium tremens DTs）。DTs为一种危及生命的合并中枢神经系统兴奋（激动、谵妄、癫痫发作）和交感神经兴奋（高血压、心动过速、心律失常）的临床症状与表现。尽管苯二氮卓类药物的真实性和安全性仍不确定，但苯二氮卓类药物仍被认为是酒精戒断治疗的主要用药物。,Drug Alcohol Rev 1995;14:4954 Acta Anaesthesiol Scand 1996;40:649656 J Gen Intern Med 1989;4:432444 Crit Care Med 2010;38:23112318,指南不推荐在ICU患者使用预防性谵妄药物治疗方案，因为没有明确的证据显示能够减少谵妄的发生率与持续时间。（0，C）We provide no recommendation for using a pharmacologic delirium prevention protocol in adult ICU patients,as no compelling data demonstrate that this reduces the incidence or duration of delirium in these patients(0,C).,ICU谵妄的预防Delirium prevention in ICU,指南不建议在成人ICU患者中使用氟哌啶醇或非典型抗精神病药物预防谵妄。（-2C）We do not suggest that either haloperidol or atypical antipsychotics be administered to prevent delirium in adult ICU patients(2C).关于ICU患者使用右美托咪定预防谵妄，指南没有推荐意见，因为没有较强的证据证实该药预防性治疗的有效性。（0，C）We provide no recommendation for the use of dexmedetomidine to prevent delirium in adult ICU patients,as there is no compelling evidence regarding its effectiveness in these patients(0,C).,ICU谵妄的预防Delirium prevention in ICU,指南推荐ICU患者在病情允许时实行早期活动以减少谵妄的发生率与持续时间（+1B）We recommend performing early mobilization of adult ICU patients whenever feasible to reduce the incidence and duration of delirium(+1B).,ICU谵妄的治疗Delirium Treatment in ICU Patients,在ICU患者使用氟哌啶醇治疗中，没有发表的证据显示氟哌啶醇能够缩短谵妄的持续时间。（No Evidence）There is no published evidence that treatment with haloperidol reduces the duration of delirium in adult ICU patients(No Evidence).指南不推荐ICU患者