呼吸重症镇静课件.pptVIP

INTERVENTION A 4Es framework (engage, educate, execute, evaluate) was used as part of the quality improvement process. A new sedation protocol was created and implemented, which recommends a target RASS of 0 (alert and calm) and requires failure of intermittent sedative dosing prior to starting continuous infusions. In addition, twice-daily delirium screening using the CAM-ICU was introduced into routine practice. CONCLUSION: Through a structured quality improvement process, use of sedative infusions can be substantially decreased and days awake without delirium significantly increased, even in severely ill, mechanically ventilated patients with acute lung injury 镇静解决的呼吸生理问题不同 （中到重度） AECOPD:使患者耐受呼吸机治疗，即保持小气道开放之目的，尽可能保留自主呼吸、咳嗽反射和纤毛运动。 ARDS： 有效抑制自主呼吸（必要时肌松），最小程度保留咳嗽反射（改善肺顺应性和呼吸机机相关肺损伤）。 AECOPD与ARDS患者镇静的不同点 AECOPD 镇静：缺乏证据 Stepwise sedation for elderly patients with mild/moderate COPD during upper gastrointestinal endoscopy. World J Gastroenterol. 2013 Aug 7;19(29):4791-8. World J Gastroenterol. 2013 Aug 7;19(29):4791-8. NMBA in ARDS: a systematic review and meta-analysis of RCTs Alhazzani et al. Critical Care 2013, 17:R43 CCM NEJM CCM Oxygenation at 24 to 72 hours Forest plot comparing neuromuscular blockers and placebo for barotrauma outcome Duration of mechanical ventilation Mortality 镇静剂带来的药物相关损害不同 AECOPD:气道反应性 ARDS： 炎症反应与免疫调节，过度镇静 AECOPD与ARDS患者镇静的不同点 Figure 3 shows preferred sedation drug choices. Overall, benzodiazepines alone (33%) or opioids alone (29%) were most frequently chosen as the sedation regimen of choice. Lorazepam alone (18%) was next in frequency of use, followed by midazolam (15%), morphine (21%), and fentanyl (8%).Propofol-containing regimens (7%) and dexmedetomidine-containing regimens (5%) were rarely chosen ?rst line. Compared with Europeans physicians, North Americans were more likely to choose a benzodiazepine-only regimen (39% vs. 25%, p .001) or dexmedetomidine- containing regimen (6% vs. 0%, p .001) but were less lik