機(jī)械通氣患者的鎮(zhèn)靜

1、機(jī)械通氣患者的鎮(zhèn)靜sedation in mechanical ventilaton,河北醫(yī)科大學(xué)第三醫(yī)院危重醫(yī)學(xué)科王智勇,Maintaining an optimal level of comfort and safety for critically ill patients is a universal goal for critical care practitioners.——SCCM,,,Tracheal sucti

2、oning,,isolation, immobilization, physical restrains, lack of communication, and sleep deprivation,,anger, frustration, anxiety, and mental stress,EXCESSIVE STIMULATION,Pain,Pain and anxiety may adversely affect respirat

3、ory function, contribute to the development of a stress response, and increase cardiac morbidity,應(yīng)激水平上升,交感神經(jīng)興奮,↙ ↘,皮質(zhì)醇↑胰高血糖素↑,兒茶酚氨↑,↘,↙,心排血量↓組織供氧↓ 耗氧量↑,↓,心肌缺氧組織缺氧,↓,高應(yīng)激狀態(tài)的不利影響,機(jī)體高分解代謝—低蛋

4、白血癥組織缺氧性損害—消化道出血、DIC高血糖、高游離氨基酸血癥高水平的細(xì)胞因子對(duì)機(jī)體的損害多器官功能不全,危重病人的身心應(yīng)激因素與神經(jīng)內(nèi)分泌代謝反應(yīng),Intensivists must ensure adequate analgesia (for pain relief) and sedation (for anxiolytic, hypnotic, and amnestic needs) of the ICU patien

5、t.,Failure to meet appropriate sedation goals may have deleterious physical and emotional effects on the critically ill patient,(Over or Under)-Sedation in 69% ICU Patients,——Critical Care, 2000, 4(S): S110,Achieving Op

6、timal Patient Comfort in the ICU,,,Undersedation,AnxietyAgitationHypertensionTachycardiaArrhythmiasMyocardial ischemiaWound disruption Patient injury,氣管插管、胃管、A/V導(dǎo)管意外拔除,%,Carrion, CCM 2000；28：63,Achieving Optimal P

7、atient Comfort in the ICU,,,Oversedation,DepersonalizationDelayed emergenceDelayed weaning Pressure injuryVenous stasisMuscle atrophyIncreased cost,Inadequate administration of sedatives can lead to patient anxiety

8、 and agitation and add to the stress response, neurohumoral and endocrine responses that may compromise patient outcome,ICU危重病人需要鎮(zhèn)靜，更重要的是需要合適的鎮(zhèn)靜。,危重患者的鎮(zhèn)靜方式,長(zhǎng)期持續(xù)鎮(zhèn)靜 vs 間斷鎮(zhèn)靜目標(biāo)鎮(zhèn)靜 vs 經(jīng)驗(yàn)鎮(zhèn)靜,長(zhǎng)期持續(xù)鎮(zhèn)靜 vs 間斷鎮(zhèn)靜,隨機(jī), 對(duì)照試驗(yàn)ICU

9、中接受機(jī)械通氣的成人患者(n = 128)分組干預(yù)組: 每日中斷鎮(zhèn)靜藥物, 直至患者清醒對(duì)照組:持續(xù)鎮(zhèn)靜由ICU醫(yī)生判斷何時(shí)中斷鎮(zhèn)靜藥物,—— Kress JP, Pohlman PS, O’Connor MF, et al. N Engl J Med 2000; 342: 1471-7,長(zhǎng)期持續(xù)鎮(zhèn)靜 vs 間斷鎮(zhèn)靜,長(zhǎng)期持續(xù)鎮(zhèn)靜 vs 間斷鎮(zhèn)靜,機(jī)械通氣時(shí)間延長(zhǎng)呼吸機(jī)相關(guān)性肺炎延遲性鎮(zhèn)靜或麻痹住ICU或住院時(shí)間延長(zhǎng)

10、醫(yī)療費(fèi)用增加,目標(biāo)鎮(zhèn)靜 vs 經(jīng)驗(yàn)鎮(zhèn)靜,設(shè)計(jì): 隨機(jī), 對(duì)照臨床試驗(yàn)患者: 機(jī)械通氣患者(n = 321)干預(yù): 患者隨機(jī)分為由護(hù)士執(zhí)行目標(biāo)鎮(zhèn)靜(n = 162)非設(shè)定目標(biāo)鎮(zhèn)靜(n = 159),—— Brook AD, Ahrens TS, Schaiff R, et al. Crit Care Med 1999; 27(12): 2609-15,目標(biāo)鎮(zhèn)靜 vs 經(jīng)驗(yàn)鎮(zhèn)靜,目標(biāo)鎮(zhèn)靜 vs 經(jīng)驗(yàn)鎮(zhèn)靜,S

11、edation Assessment,A sedation goal should be established and regularly redefined for each patient. Regular assessment and response to therapy should be documented. (Grade C)The use of a validated sedation assessme

12、nt scale (SAS, MAAS, or VICS) is recommended. (Grade B),,Ramsay鎮(zhèn)靜評(píng)分標(biāo)準(zhǔn),1級(jí) 焦慮、激動(dòng)或煩躁或兩者兼具2級(jí)合作、定向力良好、安靜3級(jí) 僅對(duì)命令有反應(yīng)4級(jí)對(duì)輕叩眉間反應(yīng)靈敏5級(jí)對(duì)輕叩眉間反應(yīng)遲鈍6級(jí)對(duì)輕叩眉間反應(yīng)無(wú)反應(yīng),SEDATION THERAPY,理想的鎮(zhèn)靜藥物,藥代動(dòng)力學(xué)特點(diǎn)：臨床作用確切起效快速無(wú)

13、耐藥和停藥綜合征藥理作用不受病理影響(休克、內(nèi)環(huán)境紊亂)無(wú)藥物相互作用,理想的鎮(zhèn)靜藥物,藥效動(dòng)力學(xué)特征通過(guò)脂溶性迅速重新分布長(zhǎng)時(shí)間給藥后無(wú)積蓄清除可靠，即使在肝腎功能受損患者代謝產(chǎn)物無(wú)活性,理想的鎮(zhèn)靜藥物,全身作用無(wú)急慢性毒性，無(wú)酶誘導(dǎo)和快速耐藥無(wú)呼吸抑制無(wú)循環(huán)干擾無(wú)不良內(nèi)分泌作用不增加肌肉張力,理想的鎮(zhèn)靜藥物,藥理治療學(xué)特性給藥簡(jiǎn)單方便、無(wú)需復(fù)雜裝置對(duì)塑料或玻璃無(wú)吸附與其他藥物無(wú)物理性相互作用水溶性好，無(wú)

14、靜脈刺激性?xún)r(jià)格便宜,Sedation Therapy——Benzodiazepines,Sedation Therapy——Diazepam,Diazepam can cause prolonged dose-related drowsiness, confusion, and impairment of psychomotor and intellectual functions. Paradoxic excitement can

15、occur. Hypotension, bradycardia, cardiac arrest, respiratory depression, and apnea have been associated with rapid parenteral injection. Allergic reactions have been reported. Irritation at the infusion site and thrombo

16、phlebitis may occur.,Sedation Therapy——Diazepam,Prolonged elimination of diazepam and its metabolites limits its usefulness in the ICU.,Sedation Therapy——Midazolam,It is two to three times as potent as diazepamIts onset

17、 of action begins within 1-2 minutes Its duration of action is 0.5-2 hoursIt can be administered at a rate of 0.1 mg/kg to 2.5 mg/kg,Sedation Therapy——Midazolam,Midazolam or diazepam should be used for rapid sedation o

18、f acutely agitated patients. (Grade C)Midazolam is recommended for short term use only, as it produces unpredictable awakening and time to extubation when infusions continue

19、longer than 48–72 hours. (Grade A),Sedation Therapy——Midazolam,Intermittent doses of 2.5-5 mg / 2-3 hAdminister in 0.5-1mg / 1-3 min until the desired level of sedation i

20、s achievedLoading doses may be very between 0.1 to 0.5 mg/kgMaintenance infusion rates range from 0.1 to 20 µg/kg/min,Midazolam vs Propofol,咪唑安定和異丙酚在ICU中的應(yīng)用,n=103，需機(jī)械通氣的各類(lèi)重癥病人Intensive Care Med,1996;17(2):1204-

21、1213,Midazolam vs Propofol,隨機(jī)比較咪唑安定與異丙酚在ICU中的長(zhǎng)期鎮(zhèn)靜作用,n=67；兩組相比，P<0.001Intensive Care Med,1997;23(12):1258-1263,CAUTION,Sedated patients are at risk for venous stasis, thromboembolic events, pressure ulceration, and