ICU谵妄及ABCDE集束化预防方案课件.ppt

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 Deliriumoccursinupto80 ofpatientsadmittedtointensivecareunits Althoughunder 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 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 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 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 谵妄的主要特征 TheAmericanPsychiatricAssociation APA DiagnosticandStatisticalManualofMentalDisorders fourthedition textrevision DSM IV defines4keyfeaturesofdelirium 1 disturbanceofconsciousnesswithreducedawarenessoftheenvironmentandimpairedabilitytofocus sustain orshiftattention 2 alteredcognition eg impairedmemory languagedisturbance ordisorientation orthedevelopmentofaperceptual 知觉 disturbance eg hallucinations 幻觉 delusions 妄想 orillusions 错觉 thatisnotbetteraccountedforbypreexistingorevolvingdementia 痴呆 谵妄的主要特征 3 disturbancethatdevelopsoverashortperiodoftime hourstodays andtendstofluctuateduringthecourseoftheday 4 evidenceofanetiologicfactor ie deliriumduetogeneralmedicalcondition substance induceddelirium deliriumduetomultiplecauses ordeliriumnototherwisespecified 谵妄分类 发病时间 Theclassificationofdeliriumcanbesubdividedbycourseovertimeandmotorsubtypes 1 Theterminology accordingtothecourseovertime includesa prevalent ifitisdetectedatthetimeofadmission b incident ifitemergesduringthehospitallengthofstay andc persistent ifthesymptomspersistovertime 谵妄分类 运动亚型 2 Theterminologyaccordingtomotorsubtypesincludesa hyperactivedelirium inwhichthereisanincreaseinthepsychomotoractivityandagitation withattemptstoremoveinvasivedevices b hypoactivedelirium characterizedbypsychomotorslowing apathy 淡漠 lethargy 昏睡 andadecreaseinresponsetoexternalstimuli andc mixeddelirium withunpredictablefluctuationofsymptomsbetweenthefirsttwosubtypes 谵妄分类 3 Additionaldefinitionsaredescribed whichincludesubsyndromaldelirium 亚临床谵妄 anddeliriumsuperimposedondementia 谵妄叠加痴呆 谵妄分类 根据ICDSC评分工具 4 defineditspresence usingtheIntensiveCareDeliriumScreeningChecklist ICDSC inapopulationfromanICU TheICDSCassignsascorefrom0to8points delirium ascore 4subsyndromaldelirium ascorebetween1and3 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 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 increasedriskforprolongedmechanicalventilation catheterremoval self extubation andtheneedforphysicalrestraints Inaddition deliriumpredisposespatients 有谵妄倾向患者 tolongerhospitalstays withgreaterhealthcarecosts increasedriskofdeathduringthehospitalization andincreasedoddsofinstitutionalizationfollowingdischarge Evenafterhospitaldischarge theamountoftimeapatienthasbeendeliriousintheICUpredictslong termcognitiveimpairment physicaldisability anddeathuptoayearlater 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 TheaveragemedicalICUpatienthas11ormoreriskfactorsfordevelopingdelirium 11whichcanbedividedintobaseline predisposing andhospital 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thescaleusedinthisenvironmentmusta havethecapacitytoevaluatetheprimarycomponentsofdelirium forexample awareness inattention disorganizedthoughtandfluctuationcourse b musthaveprovenvalidityandreliabilityinICUpopulations c mustinvolveafastandeasyevaluation andd shouldnotnecessitatethepresenceofpsychiatricprofessionals 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 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ofCAM ICU EnglishversionsofCAM 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 2019 12 20 44 可编辑 ICU谵妄预防 Onthewhole theconstellation 系列 ofriskfactorsfordeliriumaffectingindividualICUpatientsvariesfrompatienttopatientandthusanindividualizedstrategyfordeliriumpreventionshouldbesought3riskfactorsinparticular sedatives immobility andsleepdisruption arewidespreadintheICU 通过镇静管理预防谵妄 avoidanceofbenzodiazepinesisanimportantstrategywhenseekingtobothpreventdeliriumandreduceitsduration 通过疼痛管理预防谵妄 Painisamodifiableriskfactorfordelirium andinadequatepaincontrolisafrequentcauseforagitationintheICU Whenpainisnotassessedandtreated patientsmaybeinappropriatelygivenasedativemedicationratherthanananalgesicmedication Insummary thesedatasuggestthatopioids 阿片类 usedtotreatpainareprotectiveagainstthedevelopmentofdelirium whereasthoseusedatdoseshighenoughtocausesedationmayincreasetheriskofdelirium Therefore patientsshouldundergoregularpainassessments andwhenpainisdetectedeffectivedosesofananalgesic 镇痛 medicationshouldbegiven takingcaretoavoidinducingheavysedation ICU患者早期活动预防谵妄 datassuggestaroleforearlymobilityinthereductionofthedurationofdeliriumamongcriticallyillpatients 改善睡眠预防谵妄 SleepdeprivationisnearlyuniversalforICUpatients withtheaverageICUpatientsleepingbetween2and8hoursina24 hourperiod Noise reductionstrategies suchasearplugs normalizingday nightillumination 白天照明 minimizingcare relatedinterventionsduringnormalsleepinghours andinterventionspromotingpatientcomfortandrelaxationarelowriskandofteninexpensive andshouldbeimplementedtopreventdelirium 药物干预预防谵妄 therearecurrentlynomedicationsapprovedbytheUSFoodandDrugAdministrationforthepreventionortreatmentofdelirium 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 ABCDEApproach DeliriumintheICUisfrequentlymultifactorial soitisunlikelythatasingleinterventioncanpreventorreducedeliriumwithregularity 规则性 Therefore abundledapproachcombiningevidence basedpracticesinsedationmanagement ventilatorweaning deliriummanagement andearlymobilityandexercise whichisreferredtoastheABCDEapproach hasbeenproposedtoimprovemultipleoutcomes includingpreventingandreducingthedurationofdeliriumintheICU WhatIstheAB