术后躁动课件

Emergence Agitation/Delirium in children:Many Questions,Few Answers 1 1 全麻术后苏醒期患者经常出现躁动,一直是困扰临床麻醉医师和术后ICU 医生的难题。目前术后躁动的发生机制还不明确,术后躁动的诱发因素又很多,因此预防和治疗术后躁动的药物性及非药物性处理措施众多,但效果不一。2 2 定义定义从精神病理学讲,躁动是意识障碍的一种表现,很难给躁动一个统一的定义。躁动包括身体和精神两方面的内容:粗暴的动作;强烈或激动的情绪。另外,不能安静的瘫痪患者、使用呼吸机的昏迷患者出现人机对抗,也被认为有躁动现象。Cohen IL,Gallagher T,Pohlman AS,et al.Management of the agitatedCohen IL,Gallagher T,Pohlman AS,et al.Management of the agitated intensive care unit patient J .Crit Care Med,2002,30(Suppl 1):97-intensive care unit patient J .Crit Care Med,2002,30(Suppl 1):97-123.123.3 3 临床表现临床表现其临床症状多样化,表现为:身体不停的活动,持续烦躁不安,牵拉自己的衣服和床单,试图拔除动静脉套管或体内其他的导管;没有方向感,也许不知道自己的名字、不能交流,不能按指令活动,即使能交流,也表现思维混乱,语无伦次;有时大声喊叫或呻吟,经常过分抱怨疼痛及排尿感,体检常发现血压增高、心率和呼吸频率增快4 4 危害性危害性躁动患者可拔出气管导管,动静脉穿刺导管,不能进行有效治疗;血压增高、心率增快,可导致脑血管意外,诱发心肌缺血;呼吸频率太快,可使呼吸机治疗的患者发生人机对抗,使气道压力增高,通气不足,血氧分压降低,二氧化碳分压增高或降低,增加全身和心肌氧耗,延迟患者出院时间。5 5 诱因诱因 引起躁动的诱因是多方面的:术前用药:阿托品可致术后定向障碍和躁动不安。麻醉用药:有研究报道,异丙酚、依托咪酯、吸入麻醉药可引起术后躁动。精神状态:术前紧张、行为异常或从陌生的环境突然苏醒。自身的基础疾病:有脑疾患或精神病史者。代谢紊乱:低钠血症6 6 透析患者,大量输血输液及低血糖患者。各种不良刺激:包括疼痛、尿潴留、大小便失禁、吸痰、气管导管刺激、缺氧及CO2 潴留。其他:感染、肝肾功能障碍、麻醉药残留、年龄小、女性患者等。7 7 可能机制可能机制有害刺激是诱发和加重躁动的最常见原因,在临床上经常发现正常人可以忍耐的一些不良刺激(如尿管、胃管、吸痰刺激),而全麻苏醒期患者则对这些不良刺激敏感化,表现为痛苦难忍,躁动不安。刘仁玉刘仁玉,吴安生吴安生.术后躁动术后躁动J .J .国外医学麻醉学与复苏分册国外医学麻醉学与复苏分册,1995,16,1995,16(1):35-37.(1):35-37.8 8 Sachdev Sachdev 等认为等认为,躁动不安的神经解剖学基础可能躁动不安的神经解剖学基础可能是皮层或皮层下神经环路的异常。全麻术后苏醒是皮层或皮层下神经环路的异常。全麻术后苏醒时患者发生躁动的机制不清时患者发生躁动的机制不清,可能由于苏醒过快可能由于苏醒过快,中中枢恢复时间不一枢恢复时间不一,大脑皮质尚处于抑制状态时皮质大脑皮质尚处于抑制状态时皮质下中枢已被解放下中枢已被解放,出现中枢局灶敏化出现中枢局灶敏化,这种功能完整这种功能完整性的缺失影响患者对感觉的反应和处理能力性的缺失影响患者对感觉的反应和处理能力,在某在某些有害刺激的作用下些有害刺激的作用下,中枢神经系统表现为过度兴中枢神经系统表现为过度兴奋而诱发术后躁动。奋而诱发术后躁动。Sachdev P,Kruk J.Restlessness:the anatomy of a neuropsychiatric symptomJ .Sachdev P,Kruk J.Restlessness:the anatomy of a neuropsychiatric symptomJ .Aust N ZJ Psychiatry,1996,30(1):38-53.Aust N ZJ Psychiatry,1996,30(1):38-53.9 9 预防措施预防措施n n预防全麻术后躁动的方法很多,主要包括:n n尽量避免各种诱发因素。许多临床研究证实,术中镇痛完全对术后躁动有一定的预防作用1010 n n陶明哲根据曲马多的量效特性,在腹部手术结束时或术毕前30min 静脉给予1mg/kg 或2mg/kg 曲马多,发现术毕前30min 使用曲马多能降低术后躁动的发生率和严重程度,但不会延长患者的清醒和拔管时间,用药剂量之间差异无统计学意义n n陶明哲陶明哲,李少君李少君,白智萍白智萍,等等.曲马多抑制全麻恢复期躁动反应及其量效和时效的曲马多抑制全麻恢复期躁动反应及其量效和时效的研究研究J .J .中国临床药理学与治疗学中国临床药理学与治疗学,2003,8(3):299-301,2003,8(3):299-301.1111 n n。近年来,选择性2 2 受体激动剂可乐定和右旋美托咪定由于其镇静和镇痛作用也被用于预防术后躁动1212 n n使苏醒期中枢神经功能恢复协调,防止中枢敏感化n n张西京等研究报道,安氟醚用于开胸手术的麻醉,吸入麻醉终止后微量泵注异丙酚可降低术后躁动的发生率1313 n n异丙酚是常用的预防术后躁动的镇静剂,其作用机制是通过中枢氨基丁酸受体发挥作用,延长了苏醒时间,使脑功能恢复协调,预防躁动的发生。麻醉前口服咪唑安定减轻患儿术前紧张状态,预防术后躁动1414 n n非药物性治疗。大部分临床研究都侧重于药物的治疗,同时患者周围环境调节的非药物性治疗也不应忽视,其包括术前安慰,避免患者特别是小儿产生焦虑、恐惧感;术后环境舒适、温馨等。1515 Emergence delirium(ED)is not a new Emergence delirium(ED)is not a new phenomenon in clinical practice.In the early phenomenon in clinical practice.In the early 1960s,Eckenhoff et al.were the first to report 1960s,Eckenhoff et al.were the first to report the signs of hyperexcitation in patients emerging the signs of hyperexcitation in patients emerging from ether,or ketamine anesthesia,particularly from ether,or ketamine anesthesia,particularly when administered for tonsillectomy,when administered for tonsillectomy,thyroidectomy,and circumcision.Children thyroidectomy,and circumcision.Children experienced postanesthesia agitation more often experienced postanesthesia agitation more often than adults(12%than adults(12%13%vs 5.3%)13%vs 5.3%)Smessaert A,Schehr CA,Artusio JF Jr.Observations in the immediate Smessaert A,Schehr CA,Artusio JF Jr.Observations in the immediate postanaesthesia period.II.Mode of recovery.Br J Anaesth 1960;32:181postanaesthesia period.II.Mode of recovery.Br J Anaesth 1960;32:181 5.5.1616 1717 ANESTHESIA-RELATED FACTORSANESTHESIA-RELATED FACTORSn nRapid EmergenceRapid EmergencePostanesthesia agitation has been noted more oftenPostanesthesia agitation has been noted more oftenwith the newer,less soluble,inhaled anesthetics,such aswith the newer,less soluble,inhaled anesthetics,such asdesflurane and sevoflurane,than with other volatiledesflurane and sevoflurane,than with other volatileones.It has been postulated that rapid awakening afterones.It has been postulated that rapid awakening afterthe use of the insoluble anesthetics may initiate EA/EDthe use of the insoluble anesthetics may initiate EA/EDby worsening a childby worsening a child s underlying sense of apprehensions underlying sense of apprehensionwhen finding himself in an unfamiliar environmentwhen finding himself in an unfamiliar environment(9,22(9,22 24).Some parents claim the patient24).Some parents claim the patient s behaviors behaviorupon emergence was the same as when he was suddenlyupon emergence was the same as when he was suddenlyawakened from deep sleepawakened from deep sleep1818 However,recovery from propofol anesthesiaHowever,recovery from propofol anesthesiawhich is also rapid,is smooth and pleasant.which is also rapid,is smooth and pleasant.Several studies have shown that sevoflurane Several studies have shown that sevoflurane anesthesia is associated with a higher incidence anesthesia is associated with a higher incidence of EA/ED compared with propofol(25of EA/ED compared with propofol(25 28).28).Similar results were obtained when Similar results were obtained when desflurane/nitrous oxide anesthesia was desflurane/nitrous oxide anesthesia was compared with propofol/remifentanil anesthesiacompared with propofol/remifentanil anesthesiaUezono S,Goto T,Terui K,et al.Emergence agitation afterUezono S,Goto T,Terui K,et al.Emergence agitation aftersevoflurane versus propofol in pediatric patients.Anesth Analgsevoflurane versus propofol in pediatric patients.Anesth Analg2000;91:5632000;91:563 6 61919 Intrinsic Characteristics of an AnestheticIntrinsic Characteristics of an AnestheticDavis PJ,Greenberg JA,Gendelman M,Fertal K.Recovery characteristics of sevoflurane Davis PJ,Greenberg JA,Gendelman M,Fertal K.Recovery characteristics of sevoflurane and halothane in preschool-aged children undergoing bilateral myringotomy and and halothane in preschool-aged children undergoing bilateral myringotomy and pressure equalizationtube insertion.Anesth Analg 1999;88:34pressure equalizationtube insertion.Anesth Analg 1999;88:34 8.8.2020 Considering that sevoflurane-induced Considering that sevoflurane-induced electroencephalogram changes are similar to those electroencephalogram changes are similar to those observed during the administration of either observed during the administration of either desflurane or isofluranedesflurane or isoflurane，but different from changes but different from changes recorded with halothane,EA/ED may be related to recorded with halothane,EA/ED may be related to the similar CNS effects of these anesthetics,which the similar CNS effects of these anesthetics,which may affect brain activity by interfering with the may affect brain activity by interfering with the balance between neuronal synaptic inhibition and balance between neuronal synaptic inhibition and excitation in the CNSexcitation in the CNS Yli-Hankala A,Vakkuri A,Sarkela M,et al.Epileptiform Yli-Hankala A,Vakkuri A,Sarkela M,et al.Epileptiform electroencephalogram during mask induction of anesthesia electroencephalogram during mask induction of anesthesia with sevoflurane.Anesthesiology 1999;91:1596 with sevoflurane.Anesthesiology 1999;91:1596 603.603.2121 SURGERY-RELATED FACTORSn nPainInadequate pain relief may be the cause ofagitation,particularly after short surgical procedures for which peak effects of analgesics may be delayed until the child is completely awake.Davis PJ,Greenberg JA,Gendelman M,Fertal K.Recovery characteristics of sevoflurane Davis PJ,Greenberg JA,Gendelman M,Fertal K.Recovery characteristics of sevoflurane and halothane in preschool-agedchildren undergoing bilateral myringotomy and and halothane in preschool-agedchildren undergoing bilateral myringotomy and pressure equalization tube insertion.Anesth Analg 1999;88:34pressure equalization tube insertion.Anesth Analg 1999;88:34 8.8.2222 n nFentanyl,given either IV 2.5 ug/kg or intranasally 2ug/kg during moderately painful surgery,also decreased EA.2 2 receptor agonists may offer advantages in preventing EA because they have both analgesic and sedative properties.2323 nSurgery Type2424 PATIENT-RELATED FACTORSn nAge Generally,younger children are more likely to show altered behavior upon recovery from anesthesia(5,19).The subpopulation of those aged 25 yr seems to be the most vulnerable as they are easily confused and frightened by unexpected and unpredictable experiences2525 Aono et al.found that ED appeared more oftenwith sevoflurane than with halothane in preschoolboys aged 35 yr(40%vs 10%).The difference was not observed in the school-aged population.Aono J,Ueda W,Mamiya K,et al.Greater incidence of deliriumduring recovery from sevoflurane in preschool boys.Anesthesiology1997;87:1298 3002626 n nTemperament Children who are more emotional,more impulsive,less social,and less adaptable to environmental changes were identified to be at risk for developing postanesthesia agitation.Rothbart MK,Ahadi SA,Evans DE.Temperament and personality:Rothbart MK,Ahadi SA,Evans DE.Temperament and personality:origins and outcomes.J Pers Soc Psychol 2000;78:122 origins and outcomes.J Pers Soc Psychol 2000;78:122 35.35.2727 ADJUNCT MEDICATIONNumerous drugs,including anticholinergics,droperidol,barbiturates,opioids,benzodiazepines,and metoclopramide,may contribute to behavioral disturbancesafter anesthesia.Galford RE.Problems in anesthesiology:approach to diagnosis.Boston,MA:Little,Galford RE.Problems in anesthesiology:approach to diagnosis.Boston,MA:Little,Brown&Company,1992:341Brown&Company,1992:341 3.3.2828 How to understand?2929 3030 PREVENTION AND TREATMENT the EA/ED etiology is still nknown,a clear-cut strategy for its prevention has not been developed.Table 2 summarizes some measures that are considered to be helpful in its prevention.3131 premedication Data on the possible role of premedication in reducing EA/ED have been conflicting.Preoperative administration of midazolam decreased postoperative agitation after both sevoflurane and desflurane anesthesia,with no delay in discharge from hospital.3232 Both oral ketamine and oral transmucosal fentanyl citrate were also helpful,although the latter increased the incidence of side effects.Kararmaz A,Kaya S,Turhanoglu S,Ozyilmaz MA.Oral ketamine Kararmaz A,Kaya S,Turhanoglu S,Ozyilmaz MA.Oral ketamine premedication can prevent emergence agitation in children after desflurane premedication can prevent emergence agitation in children after desflurane anaesthesia.Paediatr Anaesth 2004;14:477anaesthesia.Paediatr Anaesth 2004;14:477 82.82.3333 preemptive analgesic approachescaudal block,fentanyl,ketorolac,clonidine,and dexmedetomidine,have been recommended to eliminate pain as a potential source of discomfort and agitation.One trial suggests that IV fentanyl 1u g/kg before the conclusion of sevoflurane anesthesia decreases EA even after nonpainful procedures,while leaving the time of discharge unchanged.3434 As for managing EA/ED,certain steps should be taken to protect the child from self-injury.Holding,as a means of providing physical restraint,and engaging more than one caregiver are often necessary.As the child may be upset by environmental stimuli,it is important to provide a quiet,darkened recovery room.3535 “Rescue”medication includes analgesics,benzodiazepines,and hypnotics.Fentanyl IV 12 g/kg,propofol IV 0.51.0 mg/kg,and midazolam IV 0.02 0.10 mg/kg have all been used for the treatment of ED.A single bolus dose of dexmedetomidine 0.5 ug/kg was also shown to be efficient in the PACU for EDTobias JD,Berkenbosch JW,Russo P.Additional experience with dexmedetomidine in pediatric patients.South Med J 2003;96:87153636 SUMMARY It appears that almost half a century after the first cases of emergence agitation/emergence delirium(EA/ED)were reported,we do not know much more about its etiology,nor do we have a reliable assessment tool or clear-cut preventive strategy for this short-lived but troublesome clinical event.3737 n nBoth sevoflurane and desflurane(and possibly isoflurane)are indisputably associated with a higher incidence of altered behavior upon emergence than are either halothane or propofol.3838 n nIt is doubtless that younger age,preoperative anxiety,and pain are all important contributory factors.3939 n nHowever,there are still many questions that deserve answersn nWhat links the abovementioned inhaled anesthetics to EA/ED?Are we able to identify a child who is at risk for the development of ED without engaging psychologists to interpret extensive questionnaires about their temperaments?4040 n nObviously,further trials are necessary to discover the underlying causes of EA/ED and to determine which factors might help predict and potentially prevent it4141 focusn npain must be tightly controlled and standardized measuring tools used to evaluate postanesthesia behavior.4242 4343 4444 4545 4646 n nAnesth Analg.2009 Apr;108(4):1157-60.Anesth Analg.2009 Apr;108(4):1157-60.n nThe effect of low-dose remifentanil on responses to The effect of low-dose remifentanil on responses to the endotracheal tube during emergence from the endotracheal tube during emergence from general anesthesia.general anesthesia.n nAouad MTAouad MT,Al-Alami AAAl-Alami AA,Nasr VGNasr VG,Souki FGSouki FG,Zbeidy Zbeidy RARA,Siddik-Sayyid SMSiddik-Sayyid SM.n nBACKGROUND:Emergence from general anesthesia BACKGROUND:Emergence from general anesthesia can be associated with coughing,agitation,and can be associated with coughing,agitation,and hemodynamic disturbances.Remifentanil may hemodynamic disturbances.Remifentanil may attenuate these responses.attenuate these responses.n nCONCLUSIONS:Low-dose remifentanil during CONCLUSIONS:Low-dose remifentanil during emergence did not prolong wake-up but reduced emergence did not prolong wake-up but reduced the incidence and severity of agitation from the the incidence and severity of agitation from the endotracheal tube.endotracheal tube.4747 n nBr J Anaesth.2009 Dec;103(6):817-21.Br J Anaesth.2009 Dec;103(6):817-21.n nEffects of maintaining a remifentanil infusion on Effects of maintaining a remifentanil infusion on the recovery profiles during emergence from the recovery profiles during emergence from anaesthesia and tracheal extubation.anaesthesia and tracheal extubation.n nBACKGROUND:Emergence from anaesthesia BACKGROUND:Emergence from anaesthesia and tracheal extubation can be associated with and tracheal extubation can be associated with hyperdynamic circulatory responses.).hyperdynamic circulatory responses.).CONCLUSIONS:Maintaining a remifentanil CONCLUSIONS:Maintaining a remifentanil infusion reduced haemodynamic changes infusion reduced haemodynamic changes,agitation and coughing associated with tracheal,agitation and coughing associated with tracheal extubation almost without significantly delaying extubation almost without significantly delaying recovery from anaesthesia.recovery from anaesthesia.4848 n nBr J Anaesth.2010 Feb;104(2):216-23.Epub Br J Anaesth.2010 Feb;104(2):216-23.Epub 2010 Jan 3.2010 Jan 3.n nPharmacological prevention of sevoflurane-and Pharmacological prevention of sevoflurane-and desflurane-related emergence agitation in desflurane-related emergence agitation in children:a meta-analysis of published studies.children:a meta-analysis of published studies.n nCONCLUSIONS:This meta-analysis found that CONCLUSIONS:This meta-analysis found that propofol,ketamine,fentanyl,and preoperative propofol,ketamine,fentanyl,and preoperative analgesia had a prophylactic effect in preventing analgesia had a prophylactic effect in preventing EA.EA.4949 n nJ Pediatr(Rio J).2008 Mar-Apr;84(2):107-13.J Pediatr(Rio J).2008 Mar-Apr;84(2):107-13.n nEmergence agitation in pediatric anesthesia:Emergence agitation in pediatric anesthesia:current features.current features.n nCONCLUSION:No single factor can identified as CONCLUSION:No single factor can identified as the cause of postoperative agitation,which the cause of postoperative agitation,which should therefore be considered a syndrome should therefore be considered a syndrome made up of biological,pharmacological,made up of biological,pharmacological,psychological and social components,and which psychological and social components,and which anesthesiologists and pediatric intensive care anesthesiologists and pediatric intensive care specialists should be prepared to identify,specialists should be prepared to identify,prevent and intervene appropriately as prevent and intervene appropriately as necessary.necessary.5050 n nJ Anesth.2007;21(1):19-23.Epub 2007 Jan 30.n nPropofol reduces the incidence of emergence agitation in preschool-aged children as well as in school-aged children:a comparison with sevoflurane.n n CONCLUSION:Propofol,in comparison with sevoflurane,resulted in a lower incidence of EA,with no relation to age.5151 n nBr J Anaesth.2006 Jun;96(6):747-53.Epub 2006 May 2.n nEmergence delirium in adults in the post-anaesthesia care unit.n nCONCLUSIONS:Preoperative benzodiazepines,breast and abdominal surgery and surgery of long duration are risk factors for emergence delirium5252 53写在最后写在最后成功的基础在于好的学习习惯成功的基础在于好的学习习惯The foundation of success lies in good habits 结束语当你尽了自己的最大努力时，失败也是伟大的，所以不要放弃，坚持就是正确的。When You Do Your Best,Failure Is Great,So DonT Give Up,Stick To The End演讲人：XXXXXX 时 间：XX年XX月XX日