镇静镇痛全攻略.pptx

,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,#,ICU,的镇静与镇痛,李宛霞,定义,Sedation,镇静,The act of calming,especially by the administration of a sedative drug.,通过药物手段使病人处于平静安详的状态。,Hypnosis,催眠,A state of altered consciousness,artificially induced.,人为诱导使得意识改变。,定义,Analgesia,镇痛,A the blunting or absence of sensation of pain or noxious stimuli.,使疼痛或有害刺激减轻或消失,Amnesia,遗忘,The loss of impairment of memory.,失去或损害记忆,定义,Anxiety,焦虑,A state of intense apprehension,uncertainty and fear,一种强烈的忧虑，不确定和恐惧的状态,Agitation,躁动,A state of anxiety accompanied by motor restlessness.,焦虑伴有不停的运动,定义,Delirium,谵妄,An acutely changing or fluctuating mental status,disorganized thinking,不愉快的情绪改变伴有急性精神错乱及认知功能障碍。,ICU,病人镇静的目的,解除焦虑紧张,（配合镇痛药物）保证适度的镇痛效果,帮助睡眠或使病人一过性深度意识丧失,利于气管插管和机械通气的耐受,允许有创性治疗、监测、操作的开展,-,减轻痛苦，消除不良记忆,减轻机体应激反应与代谢负担,减少致命并发症的发生,缺乏有效镇静,焦虑,激惹,血压升高,心动过速,心律失常,伤口裂开,病人受伤,undersedation,与麻醉中的镇静比较,麻醉：正常生理状态 异常生理状态,一过性、短暂抑制一切生理反射和活动，程度深、完全遗忘、尽可能消除疼痛，配合有肌松药物。,ICU,：病理状态 生理状态,较为长期的过程，保留重要的生理反射，程度变化，需要医患交流，较少配合肌松药物。,麻醉,ICU,时间 短 相对较长,深度 深 意识丧失 浅 保留部分意识,生命体征 基本稳定 不稳定,运动,&,反射 抑制 尽可能保留,自主呼吸 消失 宜保留,气道管理 简单 严格,自行咳痰 避免 鼓励,药物蓄积 少 易发生,药物互相作用 少考虑 需注意,ICU,中实施麻醉样镇静,定向力丧失,保护反应丧失,脱机延迟,褥疮（压伤）,静脉淤滞（血栓）,肌肉萎缩,医药费用增加,oversedation,The fine balance,undersedation,oversedation,使,ICU,病人尽可能舒适,评估,Assessment,Sedation Agitation Scale,（,SAS,）,Motor Activity Assessment Scale(MAAS),Ramsay scale,Vancouver Interaction and Calmness Scale(VICS),Richmond agitation-sedation scale,（,RASS),Bispectral index(BIS),Ramsay scale,Score definition,1,病人焦虑、激惹、或躁动不安,2,病人合作、定向力良好、安静,3,病人能遵嘱反应（活动）,4,睡着，但对轻叩眉间或大声刺激反应迅速,5,睡着，但对轻叩眉间或大声刺激反应迟缓,6,熟睡，无任何反应,ICU,常用镇痛镇静药物,阿片类,opioids,(,硫酸）吗啡,MSO4,芬太尼,fentanyl,苯二氮卓类,benzodiazepines,氯硝安定,lorazepam,咪唑安定,midazolam,镇静,/,催眠类,丙泊酚,propofol,丁酰苯类 氟哌啶醇,heloperidol,受体拮抗剂,右美托嘧啶,dexmedetomidine,ICU,常用镇痛镇静药物,阿片类药物,结合中枢和周围神经系统的阿片受体,Mu-1,受体介导镇痛作用,Mu-2,受体会产生副作用，如呼吸抑制，心动过缓和成瘾症状,肝脏代谢,ICU,常用镇痛镇静药物,阿片类药物,硫酸吗啡,导致组胺释放，增加了继发于血管扩张后低血压的可能性,代谢产物吗啡,6,葡萄糖苷酸从尿液排出，肾功能衰竭时积聚，这种代谢产物的阿片作用是吗啡的数倍,推荐用于血流动力学稳定的患者,ICU,常用镇痛镇静药物,硫酸吗啡,应用剂量：,间断静脉：,0.01-0.15mg/kg q1-2hr,维持剂量：,0.07-0.5mg/kg/hr,ICU,常用镇痛镇静药物,阿片类药物,芬太尼,吗啡作用的,100,倍，脂溶性高，起效快,无活性的代谢产物，与血管扩张和组胺释放无关,ICU,常用镇痛镇静药物,芬太尼,Fentanyl or hydromorphone are preferred,for patients with hemodynamic instability or renal insufficiency.,(Grade of recommendation,C),推荐用于血流动力学不稳定和肾功能不全的患者。,ICU,常用镇痛镇静药物,芬太尼,应用剂量：,间断静脉：,0.35-1.5ug/kg q0.5-1hr,维持剂量：,0.7-10 ug/kg/hr,ICU,常用镇痛镇静药物,苯二氮卓类,选择性作用于边缘系统,抗焦虑、镇静催眠、无镇痛,ICU,常用镇痛镇静药物,苯二氮卓类,地西泮,长效、,2-3,分钟内起效,活性代谢产物去烷基烷氟西泮略弱于地西泮，半衰期为,96,小时,外周静脉注射通常致疼痛和血栓性静脉炎,不被推荐常规用于,ICU,ICU,常用镇痛镇静药物,地西泮,应用剂量：,间断静脉：,0.03-0.3mg/kg q0.5-6hr,ICU,常用镇痛镇静药物,苯二氮卓类,劳拉西泮,(,氯硝安定）,中等程度、亲脂性弱于地西泮,起效稍有延迟，,5-20min,无活性代谢产物，高龄和肝功能受损对其代谢的影响相对较小,长期和大剂量使用会产生丙二醇中毒,ICU,常用镇痛镇静药物,劳拉西泮,Lorazepam,is recommended for the sedation of most patients via intermittent i.v.administration or continuous infusion,Grade of recommendation B,推荐劳拉西泮间断或持续注射用于大多数病人的镇静,ICU,常用镇痛镇静药物,劳拉西泮,应用剂量：,间断静脉：,0.02-0.06mg/kg q2-6hr,维持剂量：,0.01-0.1mg/kg/hr,ICU,常用镇痛镇静药物,苯二氮卓类,咪唑安定,短效、起效时间,2-5,分钟、迅速再分布，需持续注入。,短期使用未发现呼吸循环方面的副作用,停止注射后消除半衰期长至,30,小时，患者恢复清醒的时间长短不定,ICU,常用镇痛镇静药物,咪唑安定,Midazolam,is recommended for short term use only,as it produces unpredictable awakening and time to extubation when infusions continue longer than 48,72 hours,(Grade of recommendation,A),推荐咪达唑仑用于急性躁狂患者的快速镇静，连续使用超过,48-72,小时，会发生不可预知的清醒和自行拔管。,ICU,常用镇痛镇静药物,咪唑安定,应用剂量,间断静脉：,0.02-0.08mg/kg q0.5-2hr,维持剂量：,0.04-0.2mg/kg/hr,ICU,常用镇痛镇静药物,丙泊酚,镇静、催眠、抗焦虑等作用；无镇痛作用其他的作用包括气管扩张、抑制癫痫、肌松、可能还有抗炎和抗血小板作用,高度脂溶性、起效迅速（,1,2,分钟），作用短暂（,10,15,分钟），需持续静脉注射,降低脑代谢，降低颅内压,超短效，很少发生苏醒延迟,ICU,常用镇痛镇静药物,丙泊酚,Propofol,is the preferred sedative when rapid awakening(e.g.,for neurologic,assessment or extubation)is important.,Grade of recommendation,B,推荐用于需要快速清醒时的镇静，例如神经系统的评估或拔管。,ICU,常用镇痛镇静药物,丙泊酚,应用剂量：,负荷量：,1-1.5mg/kg,维持量：,5-80ug/kg/min,ICU,常用镇痛镇静药物,丙泊酚,Triglyceride concentrations,should be monitored after two days of propofol infusion,and total caloric intake from lipids should be included in the nutrition support prescription.,Grade of recommendation,B,ICU,常用镇痛镇静药物,氟哌啶醇,丁酰苯类神经镇静药物,3060,分钟后起效，持续,48,小时,不会引起呼吸抑制,ICU,常用镇痛镇静药物,氟哌啶醇,Haloperidol,is the preferred agent for the treatment of delirium in critically ill patients,(Grade of recommendation,C),推荐用于重症患者的谵妄治疗,ICU,常用镇痛镇静药物,氟哌啶醇,Patients should be monitored for,electrocardiographic changes,(QT interval prolongation and arrhythmias)when receiving haloperidol.,(Grade of recommendation,B),ICU,常用镇痛镇静药物,氟哌啶醇,应用剂量：,间断静脉,0.03-0.15mg/kg q0.5-6hr,维持剂量,0.04-0.15mg/kg/hr,撤药停药,withdrawal,Recommendation:The potential for opioid,benzodiazepine,and propofol withdrawal should be considered after high doses or more than approximately seven days of continuous therapy.Doses should be tapered systematically to prevent withdrawal symptoms.,Grade of recommendation B,每日唤醒,Daily awakening protocol,The titration of the sedative dose to a,defined endpoint is recommended with,systematic tapering of the dose or,daily interruption,with retitration to,minimize prolonged sedative effects.,Grade of recommendation,A,ICU,病人镇静镇痛流程图,下 课 啦,