機(jī)械通氣患者的鎮(zhèn)靜

sedationinmechanicalventilaton河北醫(yī)科大學(xué)第三醫(yī)院危重醫(yī)學(xué)科王智勇Maintaininganoptimallevelofcomfortandsafetyforcriticallyillpatientsisauniversalgoalforcriticalcarepractitioners.——SCCMTrachealsuctioningisolation,immobilization,physicalrestrains,lackofcommunication,andsleepdeprivationanger,frustration,anxiety,andmentalstressEXCESSIVESTIMULATIONPain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)身體應(yīng)激因素心理應(yīng)激因素病理生理改變神經(jīng)內(nèi)分泌反應(yīng)機(jī)體代謝改變敵意的環(huán)境恐懼、焦慮低溫、高熱皮質(zhì)激素↑碳水化合物有創(chuàng)監(jiān)測治療壓抑低血容量、缺氧ACTH↑高血糖、糖耐量↓機(jī)械通氣、反復(fù)吸痰疼痛不適饑餓、脫水、酸中毒胰高血糖素↑蛋白質(zhì)分解代謝↑疲勞、定向障礙睡眠異常感染、敗血癥腎素↑醛固酮↑脂肪分解↑報警、噪音、夜間光線過強(qiáng)與外界隔離、與家人交流減少藥物的不良反應(yīng)、肝腎損傷胰島素↓低T3綜合征脂肪酸消耗↑被體格檢查、采血次數(shù)過多擔(dān)心病情惡化、不能恢復(fù)醫(yī)源性因素ADH↑GH↑水鈉潴留、鉀排泄↑Intensivistsmustensureadequateanalgesia(forpainrelief)andsedation(foranxiolytic,hypnotic,andamnesticneeds)oftheICUpatient.Failuretomeetappropriatesedationgoalsmayhavedeleteriousphysicalandemotionaleffectsonthecriticallyillpatient(OverorUnder)-Sedationin

69%ICUPatients

——CriticalCare,2000,4(S):S110AchievingOptimalPatientComfortintheICUUndersedationAnxietyAgitationHypertensionTachycardiaArrhythmiasMyocardialischemiaWounddisruptionPatientinjury氣管插管、胃管、A/V導(dǎo)管意外拔除%Carrion,CCM2000；28：63AchievingOptimalPatientComfortintheICUOversedationDepersonalizationDelayedemergenceDelayedweaningPressureinjuryVenousstasisMuscleatrophyIncreasedcostInadequateadministrationofsedativescanleadtopatientanxietyandagitationandaddtothestressresponse,neurohumoralandendocrineresponsesthatmaycompromisepatientoutcomeICU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)靜長期持續(xù)鎮(zhèn)靜vs間斷鎮(zhèn)靜隨機(jī),對照試驗(yàn)ICU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,直至患者清醒對照組:持續(xù)鎮(zhèn)靜由ICU醫(yī)生判斷何時中斷鎮(zhèn)靜藥物——KressJP,PohlmanPS,O’ConnorMF,etal.NEnglJMed2000;342:1471-7長期持續(xù)鎮(zhèn)靜vs間斷鎮(zhèn)靜長期持續(xù)鎮(zhèn)靜vs間斷鎮(zhèn)靜機(jī)械通氣時間延長呼吸機(jī)相關(guān)性肺炎延遲性鎮(zhèn)靜或麻痹住ICU或住院時間延長醫(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)——BrookAD,AhrensTS,SchaiffR,etal.CritCareMed1999;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SedationAssessmentAsedationgoalshouldbeestablishedandregularlyredefinedforeachpatient.Regularassessmentandresponsetotherapyshouldbedocumented.(GradeC)Theuseofavalidatedsedationassessmentscale(SAS,MAAS,orVICS)isrecommended.(GradeB)Ramsay鎮(zhèn)靜評分標(biāo)準(zhǔn)1級 焦慮、激動或煩躁或兩者兼具2級 合作、定向力良好、安靜3級 僅對命令有反應(yīng)4級 對輕叩眉間反應(yīng)靈敏5級 對輕叩眉間反應(yīng)遲鈍6級 對輕叩眉間反應(yīng)無反應(yīng)SEDATIONTHERAPY理想的鎮(zhèn)靜藥物藥代動力學(xué)特點(diǎn)：臨床作用確切起效快速無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)無藥物相互作用理想的鎮(zhèn)靜藥物藥效動力學(xué)特征通過脂溶性迅速重新分布長時間給藥后無積蓄清除可靠，即使在肝腎功能受損患者代謝產(chǎn)物無活性理想的鎮(zhèn)靜藥物全身作用無急慢性毒性，無酶誘導(dǎo)和快速耐藥無呼吸抑制無循環(huán)干擾無不良內(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)特性給藥簡單方便、無需復(fù)雜裝置對塑料或玻璃無吸附與其他藥物無物理性相互作用水溶性好，無靜脈刺激性價格便宜SedationTherapy——BenzodiazepinesSedationTherapy——DiazepamDiazepamcancauseprolongeddose-relateddrowsiness,confusion,andimpairmentofpsychomotorandintellectualfunctions.Paradoxicexcitementcanoccur.Hypotension,bradycardia,cardiacarrest,respiratorydepression,andapneahavebeenassociatedwithrapidparenteralinjection.Allergicreactionshavebeenreported.Irritationattheinfusionsiteandthrombophlebitismayoccur.SedationTherapy——DiazepamProlongedeliminationofdiazepamanditsmetaboliteslimitsitsusefulnessintheICU.SedationTherapy——MidazolamItistwotothreetimesaspotentasdiazepamItsonsetofactionbeginswithin1-2minutesItsdurationofactionis0.5-2hoursItcanbeadministeredatarateof0.1mg/kgto2.5mg/kgSedationTherapy——MidazolamMidazolamordiazepamshouldbeusedforrapidsedationofacutelyagitatedpatients.(GradeC)Midazolamisrecommendedforshorttermuseonly,asitproducesunpredictableawakeningandtimetoextubationwheninfusionscontinuelongerthan48–72hours.(GradeA)SedationTherapy——MidazolamIntermittentdosesof2.5-5mg/2-3hAdministerin0.5-1mg/1-3minuntilthedesiredlevelofsedationisachievedLoadingdosesmaybeverybetween0.1to0.5mg/kgMaintenanceinfusionratesrangefrom0.1to20μg/kg/minMidazolamvsPropofol咪唑安定和異丙酚在ICU中的應(yīng)用n=103，需機(jī)械通氣的各類重癥病人IntensiveCareMed,1996;17(2):1204-1213Mid