ICU谵妄PPT课件

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方案谵妄治疗第1页/共51页流行病学Delirium occurs in up to 80% of patients admitted to intensive care unitsAlthough under-diagnosed, delirium is associated with a significant increase in morbidity and mortality in critical patients.ICU患者谵妄发生率接近80%尽管谵妄诊断不足

2、，谵妄与明显增加危重患者发病率和病死率相关第2页/共51页流行病学Delirium is common in the ICU, affecting 60% to 80% of mechanically ventilated patients and 20% to 50% of nonmechanically ventilated patients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第3页/共51页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方案谵妄治疗第4页/共51页概

3、念DeliriumDelirium in the intensive care unit (ICU) represents an acute form of organ acute form of organ dysfunctiondysfunction,which manifests as a rapidly developing disturbance of both both consciousness and cognitionconsciousness and cognition that tends to fluctuatefluctuate throughout the cour

4、se of a a dayday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。第5页/共51页谵妄的主要特征The American Psychiatric Association (APA)Diagnostic and Statistical Manual of Mental Disorders,fourth edition, text revision (DSM-IV) defines 4 key features of delirium:(1) disturbance of consciousness（意识）（意识） with reduced awar

5、eness of the environment and impaired ability to focus, sustain, or shift attention; (2) altered cognition（认知）（认知） (eg, impaired memory, language disturbance, or disorientation（定向障碍) or the development of a perceptual（知觉） disturbance (eg, hallucinations（幻觉）, delusions（妄想）, or illusions（错觉） that is n

6、ot better accounted for by preexisting or evolving dementia（痴呆）; 第6页/共51页谵妄的主要特征(3) disturbance that develops over a short period of time (hours to days) and tends to fluctuate during the course of the day;以精神状态急性变化及波动为特点(4) evidence of an etiologic factorevidence of an etiologic factor（病因学） (ie, de

7、lirium due to general medical condition （疾病），substance-induced delirium（药物诱发）， delirium due to multiple causes, or delirium not otherwise specified) 第7页/共51页谵妄分类-发病时间The classification of delirium can be The classification of delirium can be subdivided bysubdivided by course over time and course ove

8、r time and motor subtypesmotor subtypes. . 1.The terminology, according to the The terminology, according to the course over time, includescourse over time, includesa) prevalenta) prevalent（普遍型） (if it is detected at the time of admission); b) incidentb) incident（事件型） (if it emerges during the hospi

9、tal length of stay); c) persistentc) persistent（持久型） (if the symptoms persist over time)第8页/共51页谵妄分类-运动亚型2.The terminology according to motor subtypes includesThe terminology according to motor subtypes includes a) hyperactive deliriuma) hyperactive delirium 活动过多型(in which there is an increase in th

10、e psychomotor activity and agitation, with attempts to remove invasive devices);多语、运动增多、攻击行为、刻板动作、反应敏捷为主b) hypoactive deliriumb) hypoactive delirium 活动过少型(characterized by psychomotor slowing, apathy(淡漠), lethargy（昏睡） and a decrease in response to external stimuli); 面无表情、说话缓慢、运动迟缓、反应迟钝和精神萎靡 c) mixed

11、 delirium c) mixed delirium 混合型(with unpredictable fluctuation of symptoms between the first two subtypes)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、焦虑或易激惹第9页/共51页谵妄分类3.Additional definitions are described, which include subsyndromal deliriumsubsyndromal delirium （亚临床谵妄）delirium superimposed on

12、dementiadelirium superimposed on dementia（谵妄叠加痴呆）第10页/共51页谵妄分类-根据ICDSC评分工具4.defined its presence, using the Intensive Care Delirium Screening Checklist(ICDSC), in a population from an ICU. The ICDSC assigns a score from 0 to 8 pointsdelirium : a score 4 subsyndromal delirium: a score between 1 and 3

13、 第11页/共51页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方案谵妄治疗第12页/共51页谵妄的危害Increased risk for prolonged mechanical ventilation, catheter removal,self-extubation, and the need for physical restraints.In addition, delirium predisposes patients（有谵妄倾向患者） to longer hospital stays, with gr

14、eater health care costs, increased risk of death during the hospitalization, and increased odds of institutionalization following discharge.Even after hospital discharge, the amount of time a patient has been delirious in the ICU predicts long-term cognitive impairment, physical disability, and deat

15、h up to a year later.第13页/共51页第14页/共51页第15页/共51页第16页/共51页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方案谵妄治疗第17页/共51页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 IC

16、U 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。第18页/共51页第19页/共51页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方案谵妄治疗第20页/共51页谵妄评估ICU理想的谵妄评估工具 a)have the capacity to evaluate the primary components of delirium (for example, awareness, inattention, disorganized thought and fluctuation course);b)m

17、ust have proven validity and reliability in ICU populations; c)must involve a fast and easy evaluation; d)should not necessitate the presence of psychiatric professionals第21页/共51页ICU谵妄评估工具1.the Confusion Assessment Method-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.the Intensive Care Deliri

18、um Screening Checklist(ICDSC)第22页/共51页CAM-ICU第23页/共51页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（意识模糊评定法（CAMCAM法）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%。第24页/共51页葡萄牙版本of CAM-ICU第25页/共51页English versions of CAM-ICU第26页/共51页RASS评分第27

19、页/共51页第28页/共51页谵妄评分工具有效性第29页/共51页谵妄鉴别诊断第30页/共51页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方案谵妄治疗第31页/共51页ICU谵妄预防On the whole, the constellation（系列） of risk factors for delirium affecting individual ICU patients varies from patient to patient and thus an individualized individualiz

20、ed （个性化）strategy for delirium strategy for delirium prevention should be soughtprevention should be sought3 risk factors in particular, sedatives,sedatives,（镇静药物） immobility, immobility,（无法移动） and sleep disruption and sleep disruption, are widespread in the ICU第32页/共51页苯二氮卓类药物使用是发生谵妄的危险因素avoidance o

21、f benzodiazepinesavoidance of benzodiazepines（苯二氮卓类） is an important is an important strategystrategy when seeking to both prevent delirium and reduce its duration.第33页/共51页通过疼痛管理预防谵妄Pain is a modifiable（更改）risk factor for delirium, and inadequate pain control is a frequent cause for agitation in th

22、e ICU.When pain is not assessed and treated, patients may be inappropriately given a sedative medication rather than an analgesic（止痛） medication.第34页/共51页In summary, these data suggest that opioids(阿片类) used to treat pain are protective against the development of protective against the development o

23、f deliriumdelirium, whereas those used at doses highdoses high enough to cause sedation（镇静） may increase the risk of deliriumincrease the risk of delirium. Therefore, patients should undergo regular pain assessments（疼痛评估）, and when pain is detected, effective doses of an analgesic medication （镇痛药物）s

24、hould be given, taking care to avoid inducing heavy sedation(诱导镇静）.第35页/共51页ICU患者早期活动预防谵妄datas suggest a role for early mobility（活动） in the reduction the reduction of the duration of deliriumof the duration of delirium among critically ill patients.第36页/共51页改善睡眠预防谵妄Sleep deprivation（睡眠剥夺） is nearly

25、universal for ICU patients, with the average ICU patientsleeping between 2 and 8 hours in a 24-hour period.第37页/共51页ICU病房中过多的噪音及灯光Noise-reduction strategies (such as earplugs), normalizing day-night illumination(白天照明), minimizing care-related interventions during normal sleeping hours, and intervent

26、ions promoting patient comfort and relaxation are low risk and often inexpensive, and should be implemented to prevent delirium.第38页/共51页药物干预预防谵妄there are currently no medications approved by the US Food and Drug Administration for the prevention or treatment of delirium. .第39页/共51页内容谵妄的流行病学谵妄概念、主要特

27、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方案谵妄治疗第40页/共51页预防谵妄- ABCDE Approach Delirium in the ICU is frequently multifactorial（多因素）, so it is unlikely that a single intervention can prevent or reduce delirium with regularity(规则性).Therefore, a bundled approach combining evidence-based practices in sedation management（镇静药物管理）, ventilator weaning(脱机）, delirium management, and early mobility and exercise, which is referred to as the ABCDE approach, has been proposed to improve multiple outcomes, including preventing and reducing the duration of delirium in the ICU第41页/共51页Wh