1、机械通气患者的镇静sedation in mechanical ventilaton,河北医科大学第三医院危重医学科王智勇,Maintaining an optimal level of comfort and safety for critically ill patients is a universal goal for critical care practitioners.SCCM,Tracheal suctioning,isolation, immobilization, physical restrains, lack of communication, and sleep de
2、privation,anger, frustration, anxiety, and mental stress,EXCESSIVE STIMULATION,Pain,Pain and anxiety may adversely affect respiratory function, contribute to the development of a stress response, and increase cardiac morbidity,应激水平上升,交感神经兴奋, ,皮质醇胰高血糖素,儿茶酚氨,心排血量组织供氧 耗氧量,心肌缺氧组织缺氧,高应激状态的不利影响,机体高分解代谢低蛋白
3、血症组织缺氧性损害消化道出血、DIC高血糖、高游离氨基酸血症高水平的细胞因子对机体的损害多器官功能不全,危重病人的身心应激因素与神经内分泌代谢反应,Intensivists must ensure adequate analgesia (for pain relief) and sedation (for anxiolytic, hypnotic, and amnestic needs) of the ICU patient.,Failure to meet appropriate sedation goals may have deleterious physical and emotion
4、al effects on the critically ill patient,(Over or Under)-Sedation in 69% ICU Patients,Critical Care, 2000, 4(S): S110,Achieving Optimal Patient Comfort in the ICU,Undersedation,AnxietyAgitationHypertensionTachycardiaArrhythmiasMyocardial ischemiaWound disruption Patient injury,气管插管、胃管、A/V导管意外拔除,%,Ca
5、rrion, CCM 2000；28：63,Achieving Optimal Patient Comfort in the ICU,Oversedation,DepersonalizationDelayed emergenceDelayed weaning Pressure injuryVenous stasisMuscle atrophyIncreased cost,Inadequate administration of sedatives can lead to patient anxiety and agitation and add to the stress response,
6、neurohumoral and endocrine responses that may compromise patient outcome,ICU危重病人需要镇静，更重要的是需要合适的镇静。,危重患者的镇静方式,长期持续镇静 vs 间断镇静目标镇静 vs 经验镇静,长期持续镇静 vs 间断镇静,随机, 对照试验ICU中接受机械通气的成人患者(n = 128)分组干预组: 每日中断镇静药物, 直至患者清醒对照组:持续镇静由ICU医生判断何时中断镇静药物, Kress JP, Pohlman PS, OConnor MF, et al. N Engl J Med 2000; 342: 147
7、1-7,长期持续镇静 vs 间断镇静,长期持续镇静 vs 间断镇静,机械通气时间延长呼吸机相关性肺炎延迟性镇静或麻痹住ICU或住院时间延长医疗费用增加,目标镇静 vs 经验镇静,设计: 随机, 对照临床试验患者: 机械通气患者(n = 321)干预: 患者随机分为由护士执行目标镇静(n = 162)非设定目标镇静(n = 159), Brook AD, Ahrens TS, Schaiff R, et al. Crit Care Med 1999; 27(12): 2609-15,目标镇静 vs 经验镇静,目标镇静 vs 经验镇静,Sedation Assessment,A sedation
8、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 assessment scale (SAS, MAAS, or VICS) is recommended. (Grade B),Ramsay镇静评分标准,1级 焦虑、激动或烦躁或两者兼具2级合作、定向力良好、安静3级 仅对命令有反应4级对轻叩眉间反应
9、灵敏5级对轻叩眉间反应迟钝6级对轻叩眉间反应无反应,SEDATION THERAPY,理想的镇静药物,药代动力学特点：临床作用确切起效快速无耐药和停药综合征药理作用不受病理影响(休克、内环境紊乱)无药物相互作用,理想的镇静药物,药效动力学特征通过脂溶性迅速重新分布长时间给药后无积蓄清除可靠，即使在肝肾功能受损患者代谢产物无活性,理想的镇静药物,全身作用无急慢性毒性，无酶诱导和快速耐药无呼吸抑制无循环干扰无不良内分泌作用不增加肌肉张力,理想的镇静药物,药理治疗学特性给药简单方便、无需复杂装置对塑料或玻璃无吸附与其他药物无物理性相互作用水溶性好，无静脉刺激性价格便宜,Sedation Therap
10、yBenzodiazepines,Sedation TherapyDiazepam,Diazepam can cause prolonged dose-related drowsiness, confusion, and impairment of psychomotor and intellectual functions. Paradoxic excitement can occur. Hypotension, bradycardia, cardiac arrest, respiratory depression, and apnea have been associated with r
11、apid parenteral injection. Allergic reactions have been reported. Irritation at the infusion site and thrombophlebitis may occur.,Sedation TherapyDiazepam,Prolonged elimination of diazepam and its metabolites limits its usefulness in the ICU.,Sedation TherapyMidazolam,It is two to three times as pot
12、ent as diazepamIts onset 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 TherapyMidazolam,Midazolam or diazepam should be used for rapid sedation of acutely agitated patients. (Grade C)Midazolam is recommend
13、ed for short term use only, as it produces unpredictable awakening and time to extubation when infusions continue longer than 4872 hours. (Grade A),Sedation TherapyMidazolam,Intermittent doses of 2.5-5 mg / 2-3 hAdminister in 0.5-1mg / 1-3 min until the desired level of sedation is achievedLoading d
14、oses may be very between 0.1 to 0.5 mg/kgMaintenance infusion rates range from 0.1 to 20 g/kg/min,Midazolam vs Propofol,咪唑安定和异丙酚在ICU中的应用,n=103，需机械通气的各类重症病人Intensive Care Med,1996;17(2):1204-1213,Midazolam vs Propofol,随机比较咪唑安定与异丙酚在ICU中的长期镇静作用,n=67；两组相比，P0.001Intensive Care Med,1997;23(12):1258-1263,CAUTION,Sedated patients are at risk for venous stasis, thromboembolic events, pressure ulceration, and aspiration pneumonia.,
