ICU谵妄PPT课件.ppt

Delirium-谵妄诊断及ABCDE谵妄预防策略,南华大学附属第一医院ICU黄丽萍,2019/12/15,1,内容,谵妄的流行病学谵妄概念、主要特征和分类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,2019/12/15,2,流行病学,Deliriumoccursinupto80%ofpatientsadmittedtointensivecareunitsAlthoughunder-diagnosed,deliriumisassociatedwithasignificantincreaseinmorbidityandmortalityincriticalpatients.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,2019/12/15,3,流行病学,DeliriumiscommonintheICU,affecting60%to80%ofmechanicallyventilatedpatientsand20%to50%ofnonmechanicallyventilatedpatients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,2019/12/15,4,内容,谵妄的流行病学谵妄概念、主要特征和分类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,2019/12/15,5,概念,Deliriumintheintensivecareunit(ICU)representsanacuteformoforgandysfunction,whichmanifestsasarapidlydevelopingdisturbanceofbothconsciousnessandcognitionthattendstofluctuatethroughoutthecourseofaday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。,2019/12/15,6,谵妄的主要特征,TheAmericanPsychiatricAssociation(APA)DiagnosticandStatisticalManualofMentalDisorders,fourthedition,textrevision(DSM-IV)defines4keyfeaturesofdelirium:(1)disturbanceofconsciousness（意识）withreducedawarenessoftheenvironmentandimpairedabilitytofocus,sustain,orshiftattention;(2)alteredcognition（认知）(eg,impairedmemory,languagedisturbance,ordisorientation（定向障碍)orthedevelopmentofaperceptual（知觉）disturbance(eg,hallucinations（幻觉）,delusions（妄想）,orillusions（错觉）thatisnotbetteraccountedforbypreexistingorevolvingdementia（痴呆）;,2019/12/15,7,谵妄的主要特征,(3)disturbancethatdevelopsoverashortperiodoftime(hourstodays)andtendstofluctuateduringthecourseoftheday;以精神状态急性变化及波动为特点(4)evidenceofanetiologicfactor（病因学）(ie,deliriumduetogeneralmedicalcondition（疾病），substance-induceddelirium（药物诱发），deliriumduetomultiplecauses,ordeliriumnototherwisespecified),2019/12/15,8,谵妄分类-发病时间,Theclassificationofdeliriumcanbesubdividedbycourseovertimeandmotorsubtypes.1.Theterminology,accordingtothecourseovertime,includesa)prevalent（普遍型）(ifitisdetectedatthetimeofadmission);b)incident（事件型）(ifitemergesduringthehospitallengthofstay);c)persistent（持久型）(ifthesymptomspersistovertime),2019/12/15,9,谵妄分类-运动亚型,2.Theterminologyaccordingtomotorsubtypesincludesa)hyperactivedelirium活动过多型(inwhichthereisanincreaseinthepsychomotoractivityandagitation,withattemptstoremoveinvasivedevices);多语、运动增多、攻击行为、刻板动作、反应敏捷为主b)hypoactivedelirium活动过少型(characterizedbypsychomotorslowing,apathy(淡漠),lethargy（昏睡）andadecreaseinresponsetoexternalstimuli);面无表情、说话缓慢、运动迟缓、反应迟钝和精神萎靡c)mixeddelirium混合型(withunpredictablefluctuationofsymptomsbetweenthefirsttwosubtypes)症状在不断变化,患者精神状态也随时在改变，患者可能在一段时间情感淡漠,短时间又变得不安宁、焦虑或易激惹,2019/12/15,10,谵妄分类,3.Additionaldefinitionsaredescribed,whichincludesubsyndromaldelirium（亚临床谵妄）deliriumsuperimposedondementia（谵妄叠加痴呆）,2019/12/15,11,谵妄分类-根据ICDSC评分工具,4.defineditspresence,usingtheIntensiveCareDeliriumScreeningChecklist(ICDSC),inapopulationfromanICU.TheICDSCassignsascorefrom0to8pointsdelirium:ascore4subsyndromaldelirium:ascorebetween1and3,2019/12/15,12,内容,谵妄的流行病学谵妄概念、主要特征和分类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,2019/12/15,13,谵妄的危害,Increasedriskforprolongedmechanicalventilation,catheterremoval,self-extubation,andtheneedforphysicalrestraints.Inaddition,deliriumpredisposespatients（有谵妄倾向患者）tolongerhospitalstays,withgreaterhealthcarecosts,increasedriskofdeathduringthehospitalization,andincreasedoddsofinstitutionalizationfollowingdischarge.Evenafterhospitaldischarge,theamountoftimeapatienthasbeendeliriousintheICUpredictslong-termcognitiveimpairment,physicaldisability,anddeathuptoayearlater.,2019/12/15,14,2019/12/15,15,2019/12/15,16,2019/12/15,17,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,2019/12/15,18,ICU谵妄的风险因素,老年、发病前已存在认知障碍与痴呆、已有谵妄病史、危重症患者、同时罹患多种疾病、应用多种药物及精神性药物和营养不良。存在多种危险因素的患者更易发生谵妄。ICU病房中过多的噪音及灯光，频繁的护理操作、疼痛使得患者睡眠剥夺或者昼夜节律紊乱是诱发谵妄的危险因素之一。有研究表明，高血压病和乙醇中毒与ICU谵妄有关。高龄和疾病严重程度是内科ICU发生谵妄的独立预测因子。,2019/12/15,19,2019/12/15,20,内容,谵妄的流行病学谵妄概念、主要特征和分类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,2019/12/15,21,谵妄评估,ICU理想的谵妄评估工具a)havethecapacitytoevaluatetheprimarycomponentsofdelirium(forexample,awareness,inattention,disorganizedthoughtandfluctuationcourse);b)musthaveprovenvalidityandreliabilityinICUpopulations;c)mustinvolveafastandeasyevaluation;d)shouldnotnecessitatethepresenceofpsychiatricprofessionals,2019/12/15,22,ICU谵妄评估工具,1.theConfusionAssessmentMethod-ICU(CAM-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.theIntensiveCareDeliriumScreeningChecklist(ICDSC),2019/12/15,23,CAM-ICU,24,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%。,2019/12/15,25,葡萄牙版本ofCAM-ICU,2019/12/15,26,EnglishversionsofCAM-ICU,2019/12/15,27,RASS评分,2019/12/15,28,2019/12/15,29,谵妄评分工具有效性,2019/12/15,30,谵妄鉴别诊断,2019/12/15,31,内容,谵妄的流行病学谵妄概念、主要特征和分类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,2019/12/15,32,ICU谵妄预防,Onthewhole,theconstellation（系列）ofriskfactorsfordeliriumaffectingindividualICUpatientsvariesfrompatienttopatientandthusanindividualized（个性化）strategyfordeliriumpreventionshouldbesought3riskfactorsinparticular,sedatives,（镇静药物）immobility,（无法移动）andsleepdisruption,arewidespreadintheICU,2019/12/15,33,苯二氮卓类药物使用是发生谵妄的危险因素,avoidanceofbenzodiazepines（苯二氮卓类）isanimportantstrategywhenseekingtobothpreventdeliriumandreduceitsduration.,2019/12/15,34,通过疼痛管理预防谵妄,Painisamodifiable（更改）riskfactorfordelirium,andinadequatepaincontrolisafrequentcauseforagitationintheICU.Whenpainisnotassessedandtreated,patientsmaybeinappropriatelygivenasedativemedicationratherthanananalgesic（止痛）medication.,2019/12/15,35,Insummary,thesedatasuggestthatopioids(阿片类)usedtotreatpainareprotectiveagainstthedevelopmentofdelirium,whereasthoseusedatdoseshighenoughtocausesedation（镇静）mayincreasetheriskofdelirium.Therefore,patientsshouldundergoregularpainassessments（疼痛评估）,andwhenpainisdetected,effectivedosesofananalgesicmedication（镇痛药物）shouldbegiven,takingcaretoavoidinducingheavysedation(诱导镇静）.,2019/12/15,36,ICU患者早期活动预防谵妄,datassuggestaroleforearlymobility（活动）inthereductionofthedurationofdeliriumamongcriticallyillpatients.,2019/12/15,37,改善睡眠预防谵妄,Sleepdeprivation（睡眠剥夺）isnearlyuniversalforICUpatients,withtheaverageICUpatientsleepingbetween2and8hoursina24-hourperiod.,2019/12/15,38,ICU病房中过多的噪音及灯光,Noise-reductionstrategies(suchasearplugs),normalizingday-nightillumination(白天照明),minimizingcare-relatedinterventionsduringnormalsleepinghours,andinterventionspromotingpatientcomfortandrelaxationarelowriskandofteninexpensive,andshouldbeimplementedtopreventdelirium.,2019/12/15,39,药物干预预防谵妄,therearecurrentlynomedicationsapprovedbytheUSFoodandDrugAdministrationforthepreventionortreatmentofdelirium.,2019/12/15,40,内容,谵妄的流行病学谵妄概念、主要特征和分类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,2019/12/15,41,预防谵妄-ABCDEApproach,DeliriumintheICUisfrequentlymultifactorial（多因素）,soitisunlikelythatasingleinterventioncanpreventorreducedeliriumwithregularity(规则性).Therefore,abundledapproachcombiningevidence-basedpracticesinsedationmanagement（镇静药物管理）,ventilatorweaning(脱机）,deliriummanagement,andearlymobilityandexercise,whichisreferredtoastheABCDEapproach,hasbeenproposedtoimprovemultipleoutcomes,includingpreventingandreducingthedurationofdeliriumintheICU,2019/12/15,42,WhatIstheABCDEBundle?,TheABCDEbundleismulticomponentapproachdesigned