icu止痛和鎮(zhèn)靜ppt課件

1、,ICU的鎮(zhèn)靜與鎮(zhèn)痛（sedation and analgesia in ICU）,ICU的封閉管理—產(chǎn)生幽閉綜合癥環(huán)境陌生、機(jī)器設(shè)備眾多、噪音—焦慮、緊張、恐懼有創(chuàng)檢查和治療—疼痛,概述,疼痛與焦慮所致的并發(fā)癥,自主神經(jīng)系統(tǒng)受到刺激而釋放一些體液因子交感神經(jīng)系統(tǒng)的激活使心率、血壓和心肌耗氧量增加，心肌缺血或心肌梗死應(yīng)激時(shí)激素的釋放致血凝性增高及纖維蛋白溶解作用受抑制，以及誘發(fā)對(duì)胰島素的抗性、代謝率增高和蛋白質(zhì)加快分解淋巴細(xì)

2、胞和粒細(xì)胞數(shù)量減少而易發(fā)生免疫抑制,重癥病人獲得充分的鎮(zhèn)靜和鎮(zhèn)痛是ICU監(jiān)護(hù)的重要組成部分,解除焦慮、恐懼 減輕生理應(yīng)激反應(yīng) 解除疼痛 使機(jī)械通氣容易進(jìn)行 完成床邊護(hù)理、診斷與治療 恢復(fù)患者的晝夜生理節(jié)律,對(duì)于疼痛評(píng)價(jià),“直觀模擬量表(visual analogue scale, VAS) ”。該量表從“無(wú)痛”直到“從未經(jīng)歷過(guò)的最劇烈的疼痛’分成等級(jí)，讓患者以手指指著相應(yīng)的級(jí)別。VAS簡(jiǎn)便易行并有較高的可靠性和確實(shí)性，但卻忽略

3、了其他的量綱，例如疼痛的性質(zhì)等。對(duì)于危重患者來(lái)說(shuō)，有時(shí)無(wú)法主觀地表達(dá)其疼痛程度，從而不得不依賴護(hù)理該患者的護(hù)士所觀察到的一些行為跡象如面部表情、動(dòng)作、姿勢(shì)或一些生理學(xué)指標(biāo)如心動(dòng)過(guò)速、血壓增高或呼吸加快等來(lái)間接評(píng)價(jià)，但難以做到準(zhǔn)確。Elderly patients may have diffi-culty with VAS,NRS is also valid,correlates with VAS, and has been used t

4、oassess pain in cardiac surgical patients(21). Because patients can complete the NRS by writing or speaking, and becauseit is applicable to patients in many age groups, NRS may be preferable to VAS in critically ill pa

5、tients. Multidimensional tools,,The level of pain reported by the patient must be considered the current standard for assessment of pain and response to analgesia whenever possible.Use of the NRS is recommended to assess

6、 pain. (Grade of recommendation B)Patients who cannot communicate should be assessed through subjective observation of pain-related behaviors(movement, facial expression, and pos-turing) and physiological indicators (h

7、eart rate, blood pressure, and respiratory rate) and the change in these parameters following analgesic therapy.(Grade of recommendation B),廣泛用于評(píng)價(jià)意識(shí)水平的“格拉斯哥昏迷量表Glasgow coma scale)”只對(duì)有神經(jīng)系統(tǒng)缺陷的患者有效而較適用于內(nèi)科一外科ICU的是鉆點(diǎn)拉姆賽量表(6

8、-puint Ramsay scale)。后者是根據(jù)鎮(zhèn)靜深度的增加觀察運(yùn)動(dòng)反應(yīng)而制定的一種數(shù)字尺度，其缺點(diǎn)是不能用于攝人肌肉弛緩藥的患者還有“鎮(zhèn)靜一激動(dòng)量表( sedation-agitation scale,SAS)",“運(yùn)動(dòng)活性評(píng)價(jià)量表(motor activity assessmentscale, MAAS)"等也都具有類似的缺點(diǎn)。,對(duì)于疼痛和焦慮的評(píng)價(jià),常用于外科手術(shù)室的雙譜指數(shù)(bispectral i

9、ndex,BIS),是借腦電圖來(lái)提供大腦皮質(zhì)及皮質(zhì)下區(qū)之間相互作用的信息，從而將意識(shí)狀態(tài)從。0－100分加以計(jì)分，用以評(píng)價(jià)患者麻醉時(shí)的鎮(zhèn)靜程度。最近有些學(xué)者將BIS擴(kuò)展到用于ICU患者，但所獲結(jié)果并不一致,對(duì)于疼痛和焦慮的評(píng)價(jià),Ramsay鎮(zhèn)靜分級(jí),1級(jí) 病人焦慮、煩躁不安2級(jí) 病人合作、清醒入睡3級(jí) 病人僅對(duì)指令有反應(yīng)4級(jí) 病人入睡、輕叩眉間反應(yīng)敏捷5級(jí) 病人入睡、輕叩眉間反應(yīng)遲鈍6級(jí) 深睡或麻醉狀態(tài)(Bri

10、tish Journal of Intensive Care. 1992,516),鎮(zhèn)靜分級(jí)評(píng)分,Ramsay評(píng)分、OAA/S評(píng)分、VAS評(píng)分充分鎮(zhèn)靜 Ramsay評(píng)分3、4級(jí)診斷和治療性操作 Ramsay評(píng)分5、6級(jí),鎮(zhèn)靜藥物,通過(guò)影響γ-氨基丁酸（GABA）與中樞神經(jīng)系統(tǒng)GABAA受體的親和力，加強(qiáng)抑制性遞質(zhì)GABA的中樞抑制作用，達(dá)到鎮(zhèn)靜催眠的作用,鎮(zhèn)靜藥物,小劑量：鎮(zhèn)靜作用，用于治療焦慮、緊張

11、中等劑量：催眠作用，用于催眠大劑量：麻醉和抗驚厥作用,鎮(zhèn)靜藥物,鎮(zhèn)靜作用強(qiáng) 對(duì)呼吸、循環(huán)影響小 一定的鎮(zhèn)痛作用 作用時(shí)間短 無(wú)藥物蓄積作用,理想鎮(zhèn)靜劑,? 嗎啡 ? 哌替啶? 芬太尼 ? 阿芬太尼? 氟哌利多 ? 安定? 咪唑安定 ? 異丙嗪使用最廣泛的藥物： 苯二氮卓類藥物 異丙酚,ICU中常用的鎮(zhèn)靜藥和鎮(zhèn)痛藥,術(shù)

12、后鎮(zhèn)靜 術(shù)后24h鎮(zhèn)靜渡過(guò)手術(shù)后急性恢復(fù)期 機(jī)械通氣支持 纖維支氣管鏡檢查 PCS-抗焦慮 腦外傷病人——預(yù)防顱內(nèi)壓升高,鎮(zhèn)靜藥物應(yīng)用的適應(yīng)癥,地西泮曾廣泛用于危重患者。它溶于脂類而發(fā)生再分布，對(duì)于呼吸或循環(huán)系統(tǒng)抑制作用小，但危重患者對(duì)其抑制呼吸和降低血壓的作用可能很敏感。長(zhǎng)期攝人能因活性產(chǎn)物而使鎮(zhèn)靜作用延長(zhǎng)，故不宜于TCU中的鎮(zhèn)靜使用。地西浮有助于長(zhǎng)期住院及不能很快脫離呼吸機(jī)的患者的恢復(fù)。由于地西洋只溶于有機(jī)

13、溶劑，故靜注時(shí)可引起疼痛及靜脈炎。地西浮由肝微粒體系統(tǒng)的酶代謝為兩種活性產(chǎn)物去甲地西洋和奧沙西泮。在肝或腎功能不全患者及老年人，地西浮的排除半衰期顯著延長(zhǎng)，故對(duì)這類人使用時(shí)需很慎重。,地西泮,勞拉西泮勞拉西浮比地西伴的藥效高5一10倍，優(yōu)選用于長(zhǎng)期治療成人危重患者的焦慮。其作用與地西洋相仿，但攝人后不發(fā)生注射部位的疼痛或靜脈炎。勞拉西洋的脂溶性較差，故需較長(zhǎng)時(shí)間才有峰效應(yīng)它比咪達(dá)哇侖的作用持久且較少引起低血壓，兩者介導(dǎo)相同的順行性遺忘

14、，但勞拉西伴的價(jià)格較低，長(zhǎng)期攝人時(shí)誘發(fā)較能預(yù)示的覺(jué)醒。由于勞拉西浮是在丙二醇中稀釋的，故在溶液中不穩(wěn)定，并在靜脈導(dǎo)管中可發(fā)生沉淀。攝人大劑量勞拉西洋或持續(xù)滴注時(shí)曾發(fā)生丙二醇的毒性作用，如急性腎小管壞死、乳酸酸中毒及滲透性過(guò)高狀態(tài)。勞拉西浮也可口服，但丙二醇能使一些患者發(fā)生腹瀉。勞拉西浮在肝中被葡糖醛酸化為無(wú)活性產(chǎn)物。,咪唑安定,咪達(dá)哇侖作用時(shí)Ail短、溶于水、在生理性pH時(shí)嗜脂并迅速跨越血腦屏障。由于其在體內(nèi)發(fā)生快速再分布，故作用時(shí)間遠(yuǎn)

15、短于地西伴。為此它與丙泊酚被推薦用于短期(< 24 h )治療危重患者的焦慮。咪達(dá)哇侖的藥效較地西浮高2一3倍。其不良反應(yīng)為呼吸抑制和低血壓，特別是存在血容量不足和攝人大劑量時(shí)。持久滴注有時(shí)導(dǎo)致較長(zhǎng)時(shí)間的作用，特別是在危重患者(由于活性代謝產(chǎn)物蓄積所致)。在肝廓清功能不足的患者，咪達(dá)噢侖的排除半衰期可延長(zhǎng)到2一4h甚至12 h。在持續(xù)滴注時(shí)藥物間相互作用可能突出，例如由于紅霉素、丙泊酚及地西伴都抑制細(xì)胞色素P450系統(tǒng)和咪達(dá)嘩侖的

16、延遲代謝而造成預(yù)料不到的鎮(zhèn)靜作用。,丙泊酚為一種烷基酚，不溶于水，其劑型為豆油、日一油和蛋磷脂中的I%懸液，在體內(nèi)能提供4 602.4 kJ " L-‘的熱量。它有良好的鎮(zhèn)靜和催眠作用，但不止痛，其作用機(jī)制可能涉及中樞神經(jīng)系統(tǒng)中的GABA受體。滴注時(shí)可達(dá)到預(yù)期的鎮(zhèn)靜水平，中斷用藥后可迅速恢復(fù)，在ICU中它與咪達(dá)噢侖被推4短時(shí)間(24 h)使用。它可誘致低血壓和心肌抑制。曾報(bào)道長(zhǎng)期攝人時(shí)患者發(fā)生高甘油三醋血癥和胰腺炎。為了防止

17、感染，盛丙泊酚的瓶子和滴注管道都應(yīng)侮12 h更換一次，從瓶中抽出的液體也不應(yīng)保存6h以上。它也可引起注射時(shí)疼痛及代謝性酸中毒、橫紋肌溶解及循環(huán)性虛脫。它在肝中代謝，但由于其廓清超過(guò)肝血流速度，故已證明還有肝外代謝通路，為此丙泊酚在肝功能衰竭患者的作用時(shí)間仍較短暫。,丙泊酚,氟派啶醇,氟派啶醇為丁酰苯型抗精神病藥，已用于治療危重患者的諾妄。給ICU患者靜注的生物利用度較好且可預(yù)示其作用程度，但FDA未批準(zhǔn)其腸道外給藥?？刂棋Ｍ膭┝總€(gè)體間

18、差異很大。對(duì)于急性激動(dòng)的患者開(kāi)始給予2 mg，繼而每隔15一20 mi。將劑量倍增一次。氟娠嚨醇有一些重要的不良反應(yīng):降低癲痛發(fā)作闡、突發(fā)錐體外系反應(yīng)、使QT間期延長(zhǎng)等。心律不齊及攝人可延長(zhǎng)QT間期的藥物如胺碘酮或普魯卡因膠的患者應(yīng)慎用。曾報(bào)道35 mg的低劑量可引起娜間期明顯延長(zhǎng)，靜注20 mg后幾分鐘內(nèi)即可發(fā)生。,右美托咪陡為一種a2激動(dòng)劑型新鎮(zhèn)靜藥，正推薦用于ICU。它比可樂(lè)定結(jié)合a2受體的親和力高8倍，且作用時(shí)間較短。其優(yōu)點(diǎn)是有

19、顯著鎮(zhèn)靜作用而只極輕度減少每分鐘的換氣量。插管和除管時(shí)減少血液動(dòng)力學(xué)反應(yīng)，減輕對(duì)外科手術(shù)的應(yīng)激反應(yīng)，加強(qiáng)止痛藥的作用。1999年，MA批準(zhǔn)它作為鎮(zhèn)靜劑短期(< 24 h)給危重患者滴注右美托咪陡的不良反應(yīng)包括使血壓先升高繼而降低和心動(dòng)過(guò)緩。為此對(duì)于危重患者不能推注及持續(xù)滴注給藥。肝功能不全時(shí)其清除可能延遲。血容量不足、心動(dòng)過(guò)緩或心輸出量低的患者可能易于發(fā)生不良反應(yīng)，故患者的選擇極為重要。,右美托咪啶,苯二氮卓類：抗焦慮、鎮(zhèn)靜、遺忘

20、、抗驚厥1、地西潘（diapezam)：起效時(shí)間3-5min，半衰期20-36hrs。2、咪達(dá)唑侖（midazolam)：作用快，半衰期短（1.5-2.5hrs)，靜脈注射不痛。易引起低血壓3、勞拉西泮（lorazepam)：脂溶性,鎮(zhèn)靜藥物,異丙酚(propofol)常作為icu連續(xù)靜脈用藥有遺忘效應(yīng)外周靜脈注射痛對(duì)腦外傷患者有腦保護(hù)作用抗惡心嘔吐作用可控性好，睡-醒轉(zhuǎn)瞬間,鎮(zhèn)靜藥物,氟哌啶醇：強(qiáng)神經(jīng)安定藥，主要用

21、于精神極度興奮、狂亂、錯(cuò)亂及譫妄。排除疼痛焦慮無(wú)呼吸抑制可產(chǎn)生椎體外系綜合癥可延長(zhǎng)QT間期,鎮(zhèn)靜藥物,依托咪酯（etomidate)美索比托(methohexital)右旋美托咪啶（dexmedetomidine),鎮(zhèn)靜藥物,鎮(zhèn)痛藥,分類：中樞性鎮(zhèn)痛藥： 解熱、鎮(zhèn)痛、抗炎藥,嗎啡被推薦為ICU中使用的一線藥，它溶于水，與脂溶性阿片類藥如芬太尼相比，其峰效應(yīng)出現(xiàn)晚(30二，而芬太尼為

22、4 ruin).攝人后通過(guò)阻滯交感神經(jīng)及對(duì)竇房結(jié)的直接作用而導(dǎo)致靜脈擴(kuò)張及心率變慢。其主要不良反應(yīng)為易于造成呼吸抑制，其他還有鎮(zhèn)靜、惡心、腸絞痛及奧狄括約肌痙攣，而不依賴于受體的不良反應(yīng)則為釋放組胺而導(dǎo)致的低血壓、心動(dòng)過(guò)速，敏感患者可能發(fā)生支氣管痙攣。嗎啡的排除半衰期為2一4 h.其活性代謝產(chǎn)物嗎啡-6-葡糖醛酸可發(fā)生蓄積而導(dǎo)致腎衰患者發(fā)生鎮(zhèn)靜過(guò)度。,嗎啡,阿片生物堿類鎮(zhèn)痛藥,【藥動(dòng)學(xué)】吸收：口服吸收，有首過(guò)效應(yīng)，皮下注射可吸收。

23、 結(jié)合：三分之一 分布：廣泛，少量透過(guò)血腦屏障進(jìn)入中樞而發(fā)揮作用。 代謝：大部分在肝，與葡萄糖醛酸結(jié)合，10%成為去甲嗎啡 排泄：腎，少量乳汁排泄。 注意：可透過(guò)胎盤屏障，胎兒血腦屏障功能較差，又能經(jīng)乳汁分泌，故應(yīng)用時(shí)應(yīng)注意?！舅幚碜饔谩?.中樞神經(jīng)系統(tǒng) 鎮(zhèn)痛鎮(zhèn)靜作用 抑制呼吸 鎮(zhèn)咳 催吐、縮瞳 2.消化系統(tǒng) 3. 心血管系統(tǒng) ①促使組胺釋放， ②抑制中樞使交感神

24、經(jīng)張力下降 ③抑制呼吸，使體內(nèi)CO2升高，使腦血管擴(kuò)張，顱內(nèi)壓升高。【不良反應(yīng)】：1. 治療量下引起：惡心、嘔吐、便秘、排困難、體位性低血壓、呼吸抑制等。2. 耐受性和依賴性戒斷癥狀：興奮、失眠、腺體分泌增加、震顫，嘔吐、腹瀉焦慮、瞳孔散大,嗎啡,對(duì)于有血液動(dòng)力學(xué)不穩(wěn)定性或?qū)岱冗^(guò)敏的危重患者，人工合成的阿片類藥芬太尼是優(yōu)選止痛藥，它比嗎啡的藥效高80一loo倍。它與嗎啡有類似的基于阿片受體的不良反應(yīng)，但不釋放組胺。它只引起較輕的

25、血液動(dòng)力學(xué)改變，但不影響心肌收縮力的狀態(tài)。快速攝人大劑量時(shí)可引起心動(dòng)過(guò)緩與胸壁僵硬。由于芬太尼溶于脂類，故小劑量時(shí)因從腦再分布至其他組織而使作用短暫。較大的蓄積劑量則依賴于排除而非再分布，在此情況下其作用時(shí)間延長(zhǎng)而與嗎啡相似(兩者排除平衰期相似)。在肝或腎功能不全的患者，芬太尼的藥代動(dòng)力學(xué)無(wú)顯著改變。芬太尼的代謝產(chǎn)物雖可發(fā)生蓄積，但大多無(wú)活性、無(wú)毒。只有當(dāng)肝功能嚴(yán)重不全患者攝人大劑量時(shí)，芬太尼的藥代動(dòng)力學(xué)才可能發(fā)生改變。,芬太尼,哌替啶

26、,【作用】1. 中樞神經(jīng)系統(tǒng)：與嗎啡相似，較弱。持續(xù)時(shí)間短。 鎮(zhèn)痛，鎮(zhèn)靜 抑制呼吸 催吐：興奮CTZ 無(wú)鎮(zhèn)咳作用 可成癮 眩暈：可增加前庭器官的敏感性,2. 平滑肌：類似嗎啡，但較弱。 腸道：提高張力，不致便秘。也無(wú)止瀉作用。 膽道：平滑肌痙攣，提高膽內(nèi)壓，比嗎啡弱。 支氣管平滑肌：影響小，大劑量可致收縮。 子宮：不對(duì)抗催產(chǎn)素對(duì)子宮的作用。不縮短 產(chǎn)程。3. 心血管

27、 體位性低血壓：同嗎啡 腦血管擴(kuò)張：抑制呼吸使CO2積蓄。,哌替啶,【不良反應(yīng)】 治療量與嗎啡相似：惡心、嘔吐、體位性低血壓、眩暈等 久用易成癮 抑制呼吸 震顫、肌肉痙攣、驚厥：與其代謝產(chǎn)物去甲哌替啶有關(guān)。,氫嗎啡酮為一種半合成阿片類藥，藥效為嗎啡的5一to倍。其起效時(shí)間與作用持續(xù)時(shí)間均與嗎啡相似。它對(duì)血液動(dòng)力學(xué)只有輕度作用，不引起組胺釋放，而且誘發(fā)痙癢、鎮(zhèn)靜、惡心和嘔吐的不良反應(yīng)也小于嗎啡，

28、因而對(duì)于不能耐受嗎啡的患者是一個(gè)良女子的替換藥。氫嗎啡酮與嗎啡相同，也是借與葡糖醛酸著綴合而被代謝的，但也被還原型輔酶I (NADPH)還原酶還原成兩種活性代謝物，后者比母體化合物的止痛作用強(qiáng)，但產(chǎn)量很少，只有在腎衰患者或在較長(zhǎng)時(shí)間內(nèi)攝人大劑量時(shí)才蓄積到有毒性的數(shù)量,氫嗎啡酮,美沙酮,氯胺酮,阿片類：中樞陣痛，呼吸抑制、欣快嗎啡：(morphine)水溶性，起效慢，作用時(shí)間長(zhǎng)。低血壓哌替啶（pethdine)：其代謝產(chǎn)物去甲哌替啶可

29、在體內(nèi)累積中度引起瞳孔擴(kuò)大、震顫、驚厥。藥物依賴芬太尼（fentanyl),鎮(zhèn)痛藥物,芬太尼（fentanil)：鎮(zhèn)痛效能是嗎啡的100倍。高度脂溶性，作用迅速。分布廣泛。持續(xù)靜脈應(yīng)用時(shí)半衰期可從30min逐漸延長(zhǎng)至9-16hrs，長(zhǎng)時(shí)間應(yīng)用時(shí)注意半衰期的變化。對(duì)血壓影響較小。迷走興奮，可引起心率減慢舒芬太尼（sufentanil)阿芬太尼( alfentanil),鎮(zhèn)痛藥物,耐藥性、依賴性和撤藥反應(yīng),耐藥性：隨時(shí)間的延長(zhǎng)藥效降低

30、，或需加大劑量才能保持藥效不減,撤藥反應(yīng)：中樞神經(jīng)系統(tǒng)紊亂：易激惹、精神狂亂、注意力不集中、打哈欠、肌張力增加等交感神經(jīng)興奮：心動(dòng)過(guò)速、血壓增高、出汗、發(fā)熱、氣急胃腸道反應(yīng),ICU疼痛來(lái)源,1.preexisting diseases, invasive procedures, or trauma.2.Monitoring and therapeutic devices3. Routine nursing care and p

31、rolonged immobility,后果：inadequate sleep, exhaustion and disorientation.evokes a stress response characterized by tachycardia, increased myocardial oxygen consumption, hypercoagulability, immunosuppression,and persiste

32、nt catabolism.pulmonary dysfunction,Recommendation: All critically ill patients have the right to adequate analgesia and management of their pain.(Grade of recommendation C),Pain Assessment,The most reliable and valid

33、indicator of pain isthe patient’s self-report。,Analgesia Therapy,1.Nonpharmacologic：proper positioning of patients, stabilization of fractures, and elimination of irritating physical stimulation；Application of heat or c

34、old therapy,2.Pharmacologic therapies：include opioids,nonsteroidal anti-inflammatory drugs(NSAIDs), and acetaminophen.,理想：Desirable attributes of an opioid include rapid onset, ease of titration, lack of accumulation of

35、the parent drug or its metabolites, and low cost.Fentanyl has the most rapid onset and shortest duration, but repeated dosing may cause accumulation and prolonged effects.Morphine has a longer duration of action。hypot

36、ension may result from vasodilation and an active metabolite may cause prolonged sedation in the presence of renal insufficiency.,hydromorphone lacks a clinically significant active metabolite or histamine release.Meper

37、idine has an active metabolite that causes neuroexcitation (apprehension, tremors, delirium,and seizures) and may interact with antidepressants (contraindicated with monoamine oxidase inhibitors and best avoided with sel

38、ective serotonin reuptake inhibitors), so it is not recommended for repetitive use。,Remifentanil has not been widely studied in ICU patients and requires the use of a continuous infusion because of its very short duratio

39、n of action。 Be useful for requiring interruptions for neurologic examination,Adverse effects,patients. Of greatest concern are respiratory, hemodynamic, central nervous system, and gastrointestinal effects. hypotension

40、 :the combination of sympatholysis,vagally mediated bradycardia,and histamine release(when using codeine,morphine, or meperidine)central nervous system :hallucinations may increase agitation insome patients.gastrointes

41、tinal effects :Routine prophylactic use of a stimulant laxative may minimize constipation.Small-bowel intubation may be needed for enteral nutrition because of gastric hypomotility (45).,Opioid Administration Techniques

42、.,Bolus doses Intravenous administration intramuscular administration. a transdermal patch(on the permeability, temperature, perfusion, and thickness of the skin). Intramuscular administration is not recommended in hemo

43、dynamically unstable patients because of altered perfusion and variable absorption. Daily awakening,The use of a reversal agent,Naloxone , is not recommended because it can induce withdrawal and may cause nausea, cardiac

44、stress, and arrhythmias.,Recommendations:,1.A therapeutic plan and goal of analges(c)2.intravenous doses of an opioid analgesic are required, fentanyl, hydromorphone,and morphine are the recommended agents. (c)3. Sche

45、duled opioid doses or a continuous infusion is preferred over an “as needed” regimen to ensure consistent analgesia.A PCA device may be utilized to deliver opioids if the patient is able to understand and operate the dev

46、ice. (b),4.Fentanyl is preferred for a rapid onset of analgesia in acutely distressed patients. (C)5. Fentanyl or hydromorphone are preferred for patients with hemodynamic instability or renal insufficiency.(C)6. Morph

47、ine and hydromorphone are preferred for intermittent therapy because of their longer duration of effect.(C),NSAIDs,adverse effects, including gastrointestinal bleeding,bleeding secondary to platelet inhibition, and the d

48、evelopment of renal insufficiency.NSAIDs should not be administered to patients with asthma and aspirin sensitivity.ibuprofen Ketorolac and naproxen,COX-2 inhibitors,Acetaminophen should be maintained at less than 2 g

49、per day for patients with a significant historyof alcohol intake or poor nutritional status and less than 4 g per day for others,Recommendations:,NSAIDs or acetaminophenmay be used as adjuncts to opioids in selected pati

50、ents. (B) Ketorolac therapy should be limited to a maximum of five days, with close monitoring for the development of renal insufficiency or astrointestinal bleeding.Other NSAIDs may be used via the enteral route in app

51、ropriate patients.(B),SEDATION,anxiety and agitation原因：an inability to communicateamid continuous noise (alarms, personnel,and equipment), ontinuous ambient lighting,and excessive stimulation (inadequate analgesia, frequ

52、ent vital signs, repositioning,lack of mobility, and room temperature).Sleep deprivation and the circumstancesEfforts to reduce anxiety, including frequent reorientation, maintenance of patient comfort,provision of adeq

53、uate analgesia, and optimizationof the environment。,SEDATION,Agitation can be caused by multiple factors,such as extreme anxiety, delirium,adverse drug effects, and pain處理方法：the first priority is to identify and treat a

54、ny underlying physiological disturbances,such as hypoxemia, hypoglycemia hypotension, pain, and withdrawal from alcohol and other drugs.,deleterious effect,Ventilator dysynchrony, an increase in oxygen consumption, and i

55、nadvertent removal of devices and catheters。,Sedatives reduce the stress response and improve the tolerance of routine ICU proceduresmaintain patient safety and comfortof restraint and are not to be “used as a means of

56、 coercion, discipline,convenience, or retaliation by staff”。follow the intent of the Centers for Medicare and Medicaid Services regulation regarding restraints.Opioids may produce sedating effects, they do not diminish

57、awareness or provide amnesia for stressful events.,recall their ICU stay report unpleasant or frightening memories, which may contribute to posttraumatic stress disorder (PTSD) symptoms。Acute PTSD-related symptoms。Seda

58、tion of agitated critically ill patients should be started only after providing adequate analgesia and treating reversible physiological causes. ( C),(SAS) was the first scale reliable and validScale (MAAS) from the SAS

59、Ramsay scaleThe Vancouver Interaction and Calmness Scale (VICS)the Observer’s Assessment of Alertness/Sedation Scale in the operating roomThe COMFORT scale in children,Subjective Assessment of Sedation and Agitation.

60、,Objective Assessment of Sedation.,Include heart rate variability and lower-esophageal contractilitythe bispectral index (BIS)uses a digital scale from 100 (completely awake) to 0 (isoelectric EEG) BIS Limitations in t

61、he ICU environment Musclebasedelectrical activity may artificially elevate BIS scores if the patient has not received neuromuscular blockade,,Recommendations:,A sedation goal or endpoint should be established and regula

62、rly redefined for each patient. Regular assessment and response to therapy should be systematically documented.(C)The use of a validated sedation assessment scale (SAS, MAAS, or VICS) is recommended. (B)Objective measu

63、res of sedation, such asBIS, have not been completely evaluated and are not yet proven useful in the ICU.(C),Sedation Therapy,Benzodiazepines,(anterograde amnesia) but do not induce retrograde amnesia.have an opioid-sp

64、aring effect by moderating the anticipatory pain responseBenzodiazepines vary in their potency,onset and duration of action, uptake,distribution, metabolism, and presence or absence of active metabolitesPatient-specifi

65、c factors, such as age, concurrent pathology, prior alcohol abuse, and concurrent drug therapy, affect the intensity and duration of activity of benzodiazepines,Compromised hepatic or renal function may slow the clearanc

66、e of benzodiazepines or their active metabolites.tolerance to benzodiazepines may occur within hours to several days of therapyparadoxical agitation has also been observed during light sedation(drug-induced amnesia or

67、disorientation.)rapid onset and awakening after single doses Its long-acting metabolites, a prolonged duration of sedative effect may occur withrepeated doses,Lorazepam,Lorazepam has a slower onset but fewer potential d

68、rug interactions because of its metabolism via glucuronidation. less useful for the treatment of acute agitation.Lorazepam infusions should be prepared using the 2mg/mL injection and diluted to a concentration of 1 mg/m

69、L or less and mixed in a glass bottle. Despite these precautions, precipitation may develop. using a PCA device.The lorazepam solvents (PEG) and (PG) have been mplicated as the cause of reversible acute tubular necrosis