1、南华大学附属第一医院ICU 王桥生,Delirium -谵妄,内容,谵妄的流行病学谵妄概念、主要特征和分类谵妄的目前关注情况谵妄的危害谵妄的风险因素谵妄评估及诊断谵妄的预防谵妄预防的集束化方案-ABCDE方案谵妄治疗,流行病学,Delirium occurs in up to 80% of patients admitted to intensive care units. Although under-diagnosed, delirium is associated with a significant increase in morbidity and mortality in crit
2、ical patients.ICU患者谵妄发生率接近80%尽管谵妄诊断不足，谵妄与明显增加危重患者发病率和病死率相关,流行病学,Delirium is common in the ICU, affecting 60% to 80% of mechanically ventilated patients and 20% to 50% of nonmechanically ventilated patients谵妄在ICU很常见60-80%机械通气患者发生谵妄20-50%非机械通气患者发生谵妄,内容,谵妄的流行病学谵妄概念、主要特征和分类谵妄的目前关注情况谵妄的危害谵妄的风险因素谵妄评估及诊断谵妄
3、的预防谵妄预防的集束化方案-ABCDE方案谵妄治疗,概念,Delirium in the intensive care unit (ICU) represents an acute form of organ dysfunction,which manifests as a rapidly developing disturbance of both consciousness and cognition that tends to fluctuate throughout the course of a day谵妄以急性器官功能障碍为表现形式：倾向于1天内波动性的、迅速发展的意识和认知紊乱。
4、,谵妄的主要特征,The American Psychiatric Association (APA)Diagnostic and Statistical Manual of Mental Disorders,fourth edition, text revision (DSM-IV) defines 4 key features of delirium:(1) disturbance of consciousness with reduced awareness of the environment and impaired ability to focus, sustain, or shi
5、ft attention; (2) altered cognition (eg, impaired memory, language disturbance, or disorientation) or the development of a perceptual（知觉） disturbance (eg, hallucinations（幻觉）, delusions（妄想）, or illusions（错觉）) that is not better accounted for by preexisting or evolving dementia（痴呆）;,谵妄的主要特征,(3) distur
6、bance that develops over a short period of time (hours to days) and tends to fluctuate during the course of the day;(4) evidence of an etiologic factor (ie, delirium due to general medical condition, substance-induced delirium, delirium due to multiple causes, or delirium not otherwise specified),谵妄
7、分类-发病时间,The classification of delirium can be subdivided by course over time and motor subtypes. 1.The terminology, according to the course over time, includesa) prevalent (if it is detected at the time of admission); b) incident (if it emerges during the hospital length of stay); and c) persistent
8、(if the symptoms persist over time),谵妄分类-运动亚型,2.The terminology according to motor subtypes includes a) hyperactive delirium (in which there is an increase in the psychomotor activity and agitation, with attempts to remove invasive devices); b) hypoactive delirium (characterized by psychomotor slowi
9、ng, apathy(淡漠), lethargy（昏睡） and a decrease in response to external stimuli); and c) mixed delirium (with unpredictable fluctuation of symptoms between the first two subtypes),谵妄分类,3.Additional definitions are described, which include subsyndromal delirium （亚临床谵妄）and delirium superimposed on dementi
10、a（谵妄叠加痴呆）,谵妄分类-根据ICDSC评分工具,4.defined its presence, using the Intensive Care Delirium Screening Checklist(ICDSC), in a population from an ICU. The ICDSC assigns a score from 0 to 8 points, delirium : a score 4 subsyndromal delirium: a score between 1 and 3,内容,谵妄的流行病学谵妄概念、主要特征和分类谵妄的目前关注情况谵妄的危害谵妄的风险因素谵
11、妄评估及诊断谵妄的预防谵妄预防的集束化方案-ABCDE方案谵妄治疗,目前ICU谵妄关注情况,镇静和谵妄评估现状,使用现有谵妄评估方法的频率,ICU谵妄评估的障碍,护理人员对谵妄评估的看法,内容,谵妄的流行病学谵妄概念、主要特征和分类谵妄的目前关注情况谵妄的危害谵妄的风险因素谵妄评估及诊断谵妄的预防谵妄预防的集束化方案-ABCDE方案谵妄治疗,谵妄的危害,increased risk for prolonged mechanical ventilation, catheter removal,self-extubation, and the need for physical restraint
12、s.In addition, delirium predisposes patients（有谵妄倾向患者） to longer hospital stays, with greater health care costs, increased risk of death during the hospitalization, and increased odds of institutionalization following discharge.Even after hospital discharge, the amount of time a patient has been deli
13、rious in the ICU predicts long-term cognitive impairment, physical disability, and death up to a year later.,内容,谵妄的流行病学谵妄概念、主要特征和分类谵妄的目前关注情况谵妄的危害谵妄的风险因素谵妄评估及诊断谵妄的预防谵妄预防的集束化方案-ABCDE方案谵妄治疗,ICU谵妄的风险因素,The average medical ICU patient has 11 or more risk factors for developing delirium,11which can be div
14、ided into baseline (predisposing) and hospital-related (precipitating) factors,内容,谵妄的流行病学谵妄概念、主要特征和分类谵妄的目前关注情况谵妄的危害谵妄的风险因素谵妄评估及诊断谵妄的预防谵妄预防的集束化方案-ABCDE方案谵妄治疗,谵妄评估,ICU理想的谵妄评估工具 the scale used in this environment must a) have the capacity to evaluate the primary components of delirium (for example, awa
15、reness, inattention, disorganized thought and fluctuation course); b) must have proven validity and reliability in ICU populations; c) must involve a fast and easy evaluation; and d) should not necessitate the presence of psychiatric professionals,ICU谵妄评估工具,1.the Confusion Assessment Method-ICU (CAM
16、-ICU)把RASS评分整合到CAM-ICU确定有效的两个版本：葡萄糖牙版本和英国版本2.the Intensive Care Delirium Screening Checklist(ICDSC),CAM-ICU,ICU谵妄诊断,DSM-是目前谵妄最主要的诊断标准，较专业且繁琐意识模糊评定法（CAM法）：包括4个方面1.急性起病，病程波动2.注意力障碍3.思维混乱4.意识清晰水平改变：清晰（阴性)、警惕、嗜睡、昏睡、昏迷诊断：1和2存在，加上3或者4的任意一条即为CAM(+),表示谵妄存在。敏感性86%，特异性100%。,葡萄牙版本of CAM-ICU,English versions of
17、 CAM-ICU,RASS评分,谵妄评分工具有效性,谵妄鉴别诊断,内容,谵妄的流行病学谵妄概念、主要特征和分类谵妄的目前关注情况谵妄的危害谵妄的风险因素谵妄评估及诊断谵妄的预防谵妄预防的集束化方案-ABCDE方案谵妄治疗,非ICU患者谵妄预防,ICU谵妄预防,On the whole, the constellation（系列） of risk factors for delirium affecting individual ICU patients varies from patient to patient and thus an individualized strategy for
18、delirium prevention should be sought3 risk factors in particular, sedatives, immobility, and sleep disruption, are widespread in the ICU,通过镇静管理预防谵妄,avoidance of benzodiazepines is an important strategy when seeking to both prevent delirium and reduce its duration.,通过疼痛管理预防谵妄,Pain is a modifiable ris
19、k factor for delirium, and inadequate pain control is a frequent cause for agitation in the ICU. When pain is not assessed and treated, patients may be inappropriately given a sedative medication rather than an analgesic medication.,In summary, these data suggest that opioids(阿片类) used to treat pain
20、 are protective against the development of delirium, whereas those used at doses high enough to cause sedation may increase the risk of delirium. Therefore, patients should undergo regular pain assessments, and when pain is detected effective doses of an analgesic（镇痛） medication should be given, tak
21、ing care to avoid inducing heavy sedation.,ICU患者早期活动预防谵妄,datas suggest a role for early mobility in the reduction of the duration of delirium among critically ill patients.,改善睡眠预防谵妄,Sleep deprivation is nearly universal for ICU patients, with the average ICU patient sleeping between 2 and 8 hours in
22、 a 24-hour period.,Noise-reduction strategies (such as earplugs), normalizing day-night illumination(白天照明), minimizing care-related interventions during normal sleeping hours, and interventions promoting patient comfort and relaxation are low risk and often inexpensive, and should be implemented to
23、prevent delirium.,药物干预预防谵妄,there are currently no medications approved by the US Food and Drug Administration for the prevention or treatment of delirium.,内容,谵妄的流行病学谵妄概念、主要特征和分类谵妄的目前关注情况谵妄的危害谵妄的风险因素谵妄评估及诊断谵妄的预防谵妄预防的集束化方案-ABCDE方案谵妄治疗,预防谵妄- ABCDE Approach,Delirium in the ICU is frequently multifactori
24、al, so it is unlikely that a single intervention can prevent or reduce delirium with regularity(规则性)Therefore, a bundled approach combining evidence-based practices in sedation management, ventilator weaning, delirium management, and early mobility and exercise, which is referred to as the ABCDE app
25、roach, has been proposed to improve multiple outcomes, including preventing and reducing the duration of delirium in the ICU,What Is the ABCDE Bundle?,The ABCDE bundle is multicomponent approach designed to improve patient outcome by facilitating clinical team collaboration, standardizing care proce
26、sses, and breaking the cycle of oversedation and prolonged ventilation. With many demands on critical care staff there is a great need to align and support the people, processes, and technology focused on improving the comfort and outcome of patients who require admission to an ICU. The ABCDE bundle
27、 promotes patient wakefulness through sedation down-titration and optimal sedative and analgesic choice that facilitates early mobilization, delirium recognition, and extubation.,谵妄监测与评估,Recent expert guidelines advocate（提倡） the use of the Confusion Assessment Method for the ICU (CAM-ICU) or the Intensive Care Unit Delirium Screening Checklist (ICDSC),
