镇静和谵妄英文ppt课件.pptVIP

SEDATION and DELIRIUMMANAGEMENT Regina Pillai, MD; Shannon Geddes, MD; Rebecca Logiudice, RN, MS; Carey Thomson, MD, MPH for the Critical Care Committee Critical Care Services, Mount Auburn Hospital Outline Agitation in Critically Ill Patients Case Vignette of an ICU patient Richmond Agitation Scale Pharmacologic approaches to treating agitation Delirium Adverse consequences of medications used to treat agitation and promote sedation Importance of daily wake-ups Case Vignette Mr. R is a 46 y.o admitted to the ICU with pancreatitis. Intubated on hospital day 4 for acute respiratory distress and SIRS. Mr. R remains intubated for 19 days. He develops MSOF, delirium, and agitation. He receives continuous IV fentanyl, propofol and prn benzodazipines for sedation. Case Vignette On ICU day 14 (10 days intubated), Mr. R opens his eyes spontaneously, but is not able to focus or follow commands. He is biting his ET tube, kicking his legs, and pulling at his restraints. Evaluate his sedation based on this description. Case VignetteICU Day 14 Sedation Orders Ativan 1 mg IV q 1 hour, prn CIWA 10 Ativan 2 mg IV q 1 hour, prn CIWA 20 Ativan 1 mg fq 4 hours, prn agitation, hold for deep sedation Haldol 1mg IM, q 4 hours prn agitation Benadryl 50 mg, q 8 hours, prn Fentanyl drip 25 – 100 mcg/min – titrate for sedation/pain Propofol drip 20 – 50 mcg/kg/min – titrate to sedation Days Intubated Fentanyl Propofol Ativan Haldol Other 1 50 mcg/hr x 14 hr T=700mcg 25 –33 mcg/h 0.5mg 2 50 mcg/hr x 10 hr, 75 mcg/hr x 14 hr T = 1550mcg 10 – 25 mcg/h 1mg 3 100 mcg/hr x 8 hr, 150 mcg/hr x 16 hr T=3200mcg off 1mg 4 150mcg/h x2, 200mcg/hr x 14, 100mcg/hr x10 T=4100mcg 1mg 5 150mcg/hr x 2 200mcg/hr x 20 T=4300mcg 5mg 6 200mcg/hr x 24 T=4800mcg 8mg 7 200mcg/hr x 24hr 9mg 8 200mcg/hr x 24hr Versed 2mg 9 200mcg/hr x 24hr Benadryl 50 mg 10 20