重症患者镇痛镇静治疗

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,重症患者镇痛镇静治疗,我们的工作环境,镇静镇痛,Canadian survey of the use of,sedatives , analgesics , and neuromuscular blocking,agent s in critically ill patients. Crit Care Med , 2006,Mehta S , Burry L , Fischer S , et,A total of 273 of 448 eligible physicians (60%) responded.,Daily interruption of continuous infusions of sedatives or analgesics is practiced by 40% of intensivists.,A sedation scoring system is used by 49% of respondents.,The incidence of ICU uncomfortable events was as high as 96.9 % in the recruited 163 cases. 83 of 163 patients (50.9 %) experienced severe uncomfortable events (SUE) .,Patients received MV longer than 48 hours showed a slight higher incidence of SUE, with no statistical significance , compared with those patients received MV less than 48 hours (59.7 %,vs,44.8 %,P, 0.05) .,61 patients received no sedatives nor analgesics showed significantly higher incidence of SUE compared with those patients received either sedatives or analgesics (73.8 %,vs,37.3 %,P, 0.01) .,Systemic sedation based on analgesics could effectively protect patients from SUE (OR: 0.125 ; 95 %CI : 0.052 0.298 ;,P, 3d),镇静，丙泊酚与咪唑安定相比，丙泊酚苏醒更快、拔管更早。在诱导期丙泊酚较易出现低血压，而咪唑安定易发生呼吸抑制，用药期间咪唑安定可产生更多的遗忘。,指南推荐：,丙泊酚,PK,咪唑安定,对急性躁动病人可以使用咪唑安定或丙泊酚来获得快速的镇静,需要快速苏醒的镇静可选择丙泊酚,短期的镇静可选用丙泊酚或咪唑安定,指南推荐：,丙泊酚,PK,咪唑安定,国外医学护理学分册,2003,年第,22,卷第,11,期,丙泊酚,PK,咪唑安定,Intensive Care Med,1997;23(12):1258-1263,丙泊酚,+,咪唑安定,咪唑安定,-,异丙酚序贯治疗,“,三明治,”方案：,即开始和停止镇静前应用丙泊酚，期间使用咪唑安定以提供相似的有效镇静以减少丙泊酚的用量，并减少彼此的不良反应。,咪唑安定具有镇静效果确切、顺应性遗忘作用以及价格便宜等优势,而在患者唤醒前,4h,改用异丙酚镇静,可充分发挥其苏醒快的特点,避免苏醒延迟引起患者躁动以及循环波动,提高机械通气患者镇静及每日唤醒安全性。,具体用法是,:,首先在,5,10 min,内经静脉泵入丙泊酚,100,200 mg,诱导患者进入理想的镇静水平,然后以最小有效的泵注速度泵入咪唑安定维持适宜的镇静深度,最后在停止机械通气前,4 h,左右停用咪唑安定,改用丙泊酚维持平稳的镇静效果,直至停用机械通气。,Sequential administration with midazolam,-,propofol effectively improved the daily arousal safety of patients with mechanical ventilation. 2007,反馈,-,调节,镇静深度的观察及调节,所有患者每,2-4h,进行镇静深度评价，调整药物泵入剂量使躁动,-,镇静评分,(,agitation sedation scale , SAS,),维持在,3-4,分,/,Ramsay scale,：,3-4,级,每日唤醒（,daily interruption),所有患者均于每日固定时间停止泵入所有镇静、镇痛药至完全唤醒。评价标准为呼唤能睁眼，并能完成指令动作。达到标准后进行脱机评价,(,自主呼吸实验,SBT),。,对不能脱机者按停药前,1/ 2,剂量开始镇静,-,镇痛治疗，并逐步调节药物泵入量至镇静目标。,推荐意见,10:,对接受镇静治疗的病人，应提倡实施每,日唤醒计划。,( A,级,),评价镇痛需求,确定目标镇静,评分,丙泊酚,100,200 mg,维持适宜,镇静深度,丙泊酚,0.5-2mg/kg,诱导进入,理想的镇静,咪唑安定,50mg,匀速泵入,芬太尼,0.2-0.5mg,逐渐减量,直至唤醒,镇痛镇静,镇痛镇静,推荐意见,11,：镇静药长期,( 7d),或大剂量使用后，停,药过程应逐渐减量以防戒断症状出现。,( C,级,),撤离：,镇痛镇静治疗中监测,完善的生命体征监测,有效地气道管理手段,初始治疗的小剂量试验性治疗,无监测 勿镇静,总结,正确客观地明确镇静需要,基石,选择合理的镇痛镇静方案,关键,实施过程中动态严密监测,保障,治疗过程中调整药物剂量,目标,Thank You !,谢谢观赏,