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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河北医科大学第三医院危重医学科王智勇王智勇Maintaining an optimal level of comfort and safety for critically ill patients is a universal goal for critical care practitioners.SCCMTracheal Tracheal suctioningsuctioningisolation,immobilization,physical restrains,lack
2、of communication,and sleep deprivationanger,frustration,anxiety,and mental stressEXCESSIVE STIMULATIONPainPainPain 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交感神经兴奋 皮质醇皮质醇 胰高血糖素胰高血糖素 儿茶酚氨儿茶酚氨 心排血量
3、心排血量组织供氧组织供氧 耗氧量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身体应激因素心理应激因素病理生理改变神经内分泌反应机体代谢改变敌意的环境恐惧、焦虑低温、高热皮质激素碳水化合物有创监测治疗压抑低血容量、缺氧ACTH 高血糖、糖耐量机械通气、反复吸痰疼痛不适饥饿、脱水、酸中毒胰高血糖素蛋白质分解代谢疲劳、定向障碍睡眠异常感染、败血症肾素醛固酮脂肪分解报警、噪音、夜间光线过强与外界隔离、与家人交流减少药物的不良反应、肝肾损伤胰岛
4、素低T3综合征脂肪酸消耗被体格检查、采血次数过多担心病情恶化、不能恢复医源性因素ADH GH 水钠潴留、钾排泄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 emotional effects on the critical
5、ly ill patient(Over or Under)-Sedation in 69%ICU Patients Critical Care,2000,4(S):S110Achieving Optimal Patient Comfort in the ICUAnxietyAnxietyAgitationAgitationHypertensionHypertensionTachycardiaTachycardiaArrhythmiasArrhythmiasMyocardial ischemiaMyocardial ischemiaWound disruption Wound disruptio
6、n Patient injuryPatient injury气管插管、胃管、A/V导管意外拔除%Carrion,CCM 2000；28：63Achieving Optimal Patient Comfort in the ICUDepersonalizationDepersonalizationDelayed emergenceDelayed emergenceDelayed weaning Delayed weaning Pressure injuryPressure injuryVenous stasisVenous stasisMuscle atrophyMuscle atrophyIn
7、creased costIncreased costInadequate administration of sedatives can lead to patient anxiety and agitation and add to the stress response,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
8、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;342:1471-7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
9、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 AssessmentA sedation 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 VIC
10、S)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
11、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 TherapyBenzodiazepinesSedation TherapyDiazepamDiazepam can cause prolonged dose-related drowsiness,confusion,and impairment of psychomotor and intellectual functions.Paradoxic excitement can occur.Hypotension,bradycardia,cardiac a
12、rrest,respiratory depression,and apnea have been associated with rapid parenteral injection.Allergic reactions have been reported.Irritation at the infusion site and thrombophlebitis may occur.Sedation TherapyDiazepamProlonged elimination of diazepam and its metabolites limits its usefulness in the
13、ICU.Sedation TherapyMidazolamIt is two to three times as potent 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/kgSedation TherapyMidazolamMidazolam or diazepam should be used for rapid sedation of
14、acutely agitated patients.(Grade C)Midazolam is recommended for short term use only,as it produces unpredictable awakening and time to extubation when infusions continue longer than 4872 hours.(Grade A)Sedation TherapyMidazolamIntermittent doses of 2.5-5 mg/2-3 hAdminister in 0.5-1mg/1-3 min until t
15、he desired level of sedation is achievedLoading doses may be very between 0.1 to 0.5 mg/kgMaintenance infusion rates range from 0.1 to 20 g/kg/minMidazolam 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):1204-1213Midazolam vs Propofol随机比较咪唑安定与异丙酚在随机比较咪唑安定与异丙酚在ICUICU中的长期镇静作用中的长期镇静作用n=67；两组相比，P0.001Intensive Care Med,1997;23(12):1258-1263CAUTION Sedated patients are at risk for venous stasis,thromboembolic events,pressure ulceration,and aspiration pneumonia.