机械通气患者的镇静课件

机械通气患者的镇静

sedationinmechanicalventilaton河北医科大学第三医院危重医学科王智勇Maintaininganoptimallevelofcomfortandsafetyforcriticallyillpatientsisauniversalgoalforcriticalcarepractitioners.——SCCMTrachealsuctioningisolation,immobilization,physicalrestrains,lackofcommunication,andsleepdeprivationanger,frustration,anxiety,andmentalstressEXCESSIVESTIMULATIONPainPainandanxietymayadverselyaffectrespiratoryfunction,contributetothedevelopmentofastressresponse,andincreasecardiacmorbidity应激水平上升交感神经兴奋↙↘皮质醇↑胰高血糖素↑儿茶酚氨↑↘↙心排血量↓组织供氧↓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Intensivistsmustensureadequateanalgesia(forpainrelief)andsedation(foranxiolytic,hypnotic,andamnesticneeds)oftheICUpatient.(OverorUnder)-Sedationin

69%ICUPatients

——CriticalCare,2000,4(S):S110气管插管、胃管、A/V导管意外拔除%Carrion,CCM2000；28：63AchievingOptimalPatientComfortintheICUOversedationDepersonalizationDelayedemergenceDelayedweaningPressureinjuryVenousstasisMuscleatrophyIncreasedcostInadequateadministrationofsedativescanleadtopatientanxietyandagitationandaddtothestressresponse,neurohumoralandendocrineresponsesthatmaycompromisepatientoutcomeICU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经验镇静目标镇静vs经验镇静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SEDATIONTHERAPY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SedationTherapy——BenzodiazepinesSedationTherapy——DiazepamDiazepamcancauseprolongeddose-relateddrowsiness,confusion,andimpairmentofpsychomotorandintellectualfunctions.Paradoxicexcitementcanoccur.Hypotension,bradycardia,cardiacarrest,respiratorydepression,andapneahavebeenassociatedwithrapidparenteralinjection.Allergicreactionshavebeenreported.Irritationattheinfusionsiteandthrombophlebitismayoccur.SedationTherapy——DiazepamProlongedeliminationofdiazepamanditsmetaboliteslimitsitsusefulnessintheICU.SedationTherapy——MidazolamItistwotothreetimesaspotentasdiazepamItsonsetofactionbeginswithin1-2minutesItsdurationofactionis0.5-2hoursItcanbeadministeredatarateof0.1mg/kgto2.5mg/kgSedationTherapy——MidazolamMidazolamordiazepamshouldbeusedforrapidsedationofacutelyagitatedpatients.(GradeC)Midazolamisrecommendedforshorttermuseonly,asitproducesunpredictableawakeningandtimetoextubationwheninfusionscontinuelongerthan48–72hours.(GradeA)SedationTherapy——MidazolamIntermittentdosesof2.5-5mg/2-3hAdministerin0.5-1mg/1-3minuntilthedesiredlevelofsedationisachievedLoadingdosesmaybeverybetween0.1to0.5mg/kgMaintenanceinfusionratesrangefrom0.1to20µg/kg/minMidazolamvsPropofol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IntensiveCareMed,1996;17(2):1204-1213MidazolamvsPropofol随机比较咪唑安定与异丙酚在ICU中的长期镇静作用n=67；两组相比，P<