浅镇静,要多浅？要点.pptx

浅镇静，要多浅？ “….But what I see these days are paralyzed, sedated patients, Lying without motion, appearing to be dead, except for the Monitors that tell me otherwise.” Thomas L. Petty a young polio patient. Copenhagen 1952 当今镇静所关注的问题 Crit Care Med 2013; 41:263–306 成人ICU患者 维持轻度镇静可改善临床预后 目标：轻度镇静 2002 需要根据患者情况设置镇静目标 Rationales for light Sedation Crit Care Med 2013; 41:263–306 对成人ICU患者，维持轻度镇静可改善临床预后（如缩短机械通气时间及ICU住院时间）（B） Benefit from light sedation 机械通气时间 ICU住院时间 死亡率 也可能降低谵亡的发生率 Light versus deep sedation on mental health after critical illness Crit Care Med 2009; 37: 2527–2534 Design: 随机, 非盲, 对照试验. Setting: 单中心三级医院. Patients: 需要机械通气的成人ICU患者. Interventions: 患者随机分成轻度镇静 组 (患者清醒配合, Ramsay 评分1-2, n=69) or 深度镇静组 (患者嗜睡, 外界刺激能醒, Ramsay 评分 3-4, n=68 ). 区别什么是浅镇静和深镇静. 解释浅镇静的临床预后. 临床试验研究. Proportion of time spent on target Ramsay sedation goal Ramsay 1–2,白色柱子体 Ramsay 3–4, 黑色柱状体 Crit Care Med 2009; 37: 2527–2534 死亡率, 住院时间, 器官衰竭,机械通气时间 Crit Care Med 2009; 37: 2527–2534 Lancet 2010; 375: 475–80 轻度镇静还是不镇静? Procedures (No sedation) This group received morphine in bolus doses (2·5 or 5 mg i.v) as needed. If delirium was suspected, intravenous haloperidol was given as bolus doses (1, 2·5, or 5 mg), but if the patient still seemed uncomfortable after this treatment, the patient was sedated with propofol for 6 h. Lancet 2010; 375: 475–80 Sedatives and morphine usage mg/kg/hr No sedation (n = 55) sedation (n = 58) Propofol 0 (0–0·515) 0·773 (0·154–1·648 ) Midazolam 0 (0–0) 0·0034 (0–0·0240) Morphine 0·0048 (0·0014–0·011) 0·0045 (0·002–0·0064) Halopiredol 0 (0–0·0145) 0 (0–0) 评价 镇痛+浅镇静 过度镇静+镇痛 Lancet 2010; 375: 475–80 镇静组Propofol 实际给与量： 54.11mg/hr (中位数) =1% propofol 5-6ml/hr 还有咪唑安定+吗啡 =至少有50%患者是过度镇静 Lancet 2010; 375: 475–80 避免过度镇静造成的不良影响 The incidence of sub-optimal sedation in the ICU: a systematic review Jackson所进行一项荟萃分析发现，即使在控制相对严格的随机对照研究中（RCT），不恰当镇静的患者比例仍可能高达60%以上。 进一步分析发现，所有入选文献