ICU譫妄（課堂PPT）

1、.1Delirium -譫妄診斷及譫妄診斷及ABCDE 譫妄譫妄預(yù)防策略預(yù)防策略南華大學(xué)附屬第一醫(yī)院ICU 黃麗萍.2內(nèi)容內(nèi)容譫妄的流行病學(xué)譫妄概念、主要特征和分類譫妄的危害譫妄的風(fēng)險(xiǎn)因素譫妄評(píng)估及診斷譫妄的預(yù)防譫妄預(yù)防的集束化方案-ABCDE方案譫妄治療.3流行病學(xué)流行病學(xué)Delirium occurs in up to 80% of patients admitted to intensive care unitsAlthough under-diagnosed, delirium is associated with a significant increase in morbidity

2、 and mortality in critical patients.ICU患者譫妄發(fā)生率接近80%盡管譫妄診斷不足，譫妄與明顯增加危重患者發(fā)病率和病死率相關(guān).4流行病學(xué)流行病學(xué)Delirium is common in the ICU, affecting 60% to 80% of mechanically ventilated patients and 20% to 50% of nonmechanically ventilated patients譫妄在ICU很常見60-80%機(jī)械通氣患者發(fā)生譫妄20-50%非機(jī)械通氣患者發(fā)生譫妄.5內(nèi)容內(nèi)容譫妄的流行病學(xué)譫妄概念、主要特征和分類譫妄

3、的危害譫妄的風(fēng)險(xiǎn)因素譫妄評(píng)估及診斷譫妄的預(yù)防譫妄預(yù)防的集束化方案-ABCDE方案譫妄治療.6概念概念DeliriumDelirium in the intensive care unit (ICU) represents an acute form of organ acute form of organ dysfunctiondysfunction,which manifests as a rapidly developing disturbance of both consciousness both consciousness and cognitionand cognition tha

4、t tends to fluctuatefluctuate throughout the course of a daya day譫妄以急性器官功能障礙為表現(xiàn)形式：傾向于1天內(nèi)波動(dòng)性的、迅速發(fā)展的意識(shí)和認(rèn)知紊亂。.7譫妄的主要特征譫妄的主要特征The American Psychiatric Association (APA)Diagnostic and Statistical Manual of Mental Disorders,fourth edition, text revision (DSM-IV) defines 4 key features of delirium:(1) dist

5、urbance of consciousness（意識(shí)）（意識(shí)） with reduced awareness of the environment and impaired ability to focus, sustain, or shift attention; (2) altered cognition（認(rèn)知）（認(rèn)知） (eg, impaired memory, language disturbance, or disorientation（定向障礙) or the development of a perceptual（知覺） disturbance (eg, hallucinati

6、ons（幻覺）, delusions（妄想）, or illusions（錯(cuò)覺） that is not better accounted for by preexisting or evolving dementia（癡呆）; .8譫妄的主要特征譫妄的主要特征(3) disturbance that develops over a short period of time (hours to days) and tends to fluctuate during the course of the day;以精神狀態(tài)急性變化及波動(dòng)為特點(diǎn)(4) evidence of an etiologic

7、 factorevidence of an etiologic factor（病因?qū)W）（病因?qū)W） (ie, delirium due to general medical condition （疾?。?，substance-induced delirium（藥物誘發(fā)）， delirium due to multiple causes, or delirium not otherwise specified) .9譫妄分類譫妄分類-發(fā)病時(shí)間發(fā)病時(shí)間The classification of delirium can be The classification of delirium can be

8、subdivided bysubdivided by course over time and motor course over time and motor subtypessubtypes. . 1.The terminology, according to the course The terminology, according to the course over time, includesover time, includesa) prevalenta) prevalent（普遍型）（普遍型） (if it is detected at the time of admissio

9、n); b) incidentb) incident（事件型）（事件型） (if it emerges during the hospital length of stay); c) persistentc) persistent（持久型）（持久型） (if the symptoms persist over time).10譫妄分類譫妄分類-運(yùn)動(dòng)亞型運(yùn)動(dòng)亞型2.The terminology according to motor subtypes includesThe terminology according to motor subtypes includes a) hyperacti

10、ve deliriuma) hyperactive delirium 活動(dòng)過多型(in which there is an increase in the psychomotor activity and agitation, with attempts to remove invasive devices);多語、運(yùn)動(dòng)增多、攻擊行為、刻板動(dòng)作、反應(yīng)敏捷為主b) hypoactive deliriumb) hypoactive delirium 活動(dòng)過少型(characterized by psychomotor slowing, apathy(淡漠), lethargy（昏睡） and a

11、decrease in response to external stimuli); 面無表情、說話緩慢、運(yùn)動(dòng)遲緩、反應(yīng)遲鈍和精神萎靡 c) mixed delirium c) mixed delirium 混合型(with unpredictable fluctuation of symptoms between the first two subtypes)癥狀在不斷變化, 患者精神狀態(tài)也隨時(shí)在改變，患者可能在一段時(shí)間情感淡漠, 短時(shí)間又變得不安寧、焦慮或易激惹.11譫妄分類譫妄分類3.Additional definitions are described, which include

12、subsyndromal deliriumsubsyndromal delirium （亞臨床譫妄）delirium superimposed on dementiadelirium superimposed on dementia（譫妄疊加癡呆）.12譫妄分類譫妄分類-根據(jù)根據(jù)ICDSC評(píng)分工具評(píng)分工具4.defined its presence, using the Intensive Care Delirium Screening Checklist(ICDSC), in a population from an ICU. The ICDSC assigns a score from 0

13、 to 8 pointsdelirium : a score 4 subsyndromal delirium: a score between 1 and 3 .13內(nèi)容內(nèi)容譫妄的流行病學(xué)譫妄概念、主要特征和分類譫妄的危害譫妄的風(fēng)險(xiǎn)因素譫妄評(píng)估及診斷譫妄的預(yù)防譫妄預(yù)防的集束化方案-ABCDE方案譫妄治療.14譫妄的危害譫妄的危害Increased risk for prolonged mechanical ventilation, catheter removal,self-extubation, and the need for physical restraints.In addition

14、, delirium predisposes patients（有譫妄傾向患者） to longer hospital stays, with greater health care costs, increased risk of death during the hospitalization, and increased odds of institutionalization following discharge.Even after hospital discharge, the amount of time a patient has been delirious in the

15、ICU predicts long-term cognitive impairment, physical disability, and death up to a year later.15.16.17.18內(nèi)容內(nèi)容譫妄的流行病學(xué)譫妄概念、主要特征和分類譫妄的目前關(guān)注情況譫妄的危害譫妄的風(fēng)險(xiǎn)因素譫妄評(píng)估及診斷譫妄的預(yù)防譫妄預(yù)防的集束化方案-ABCDE方案譫妄治療.19ICU譫妄的風(fēng)險(xiǎn)因素譫妄的風(fēng)險(xiǎn)因素老年、發(fā)病前已存在認(rèn)知障礙與癡呆、已有譫妄病史、危重癥患者、同時(shí)罹患多種疾病、應(yīng)用多種藥物及精神性藥物和營養(yǎng)不良。存在多種危險(xiǎn)因素的患者更易發(fā)生譫妄。ICU病房中過多的噪音及燈光，頻繁的護(hù)理操

16、作、疼痛使得患者睡眠剝奪或者晝夜節(jié)律紊亂是誘發(fā)譫妄的危險(xiǎn)因素之一。有研究表明，高血壓病和乙醇中毒與 ICU 譫妄有關(guān)。高齡和疾病嚴(yán)重程度是內(nèi)科 ICU 發(fā)生譫妄的獨(dú)立預(yù)測因子。.20.21內(nèi)容內(nèi)容譫妄的流行病學(xué)譫妄概念、主要特征和分類譫妄的危害譫妄的風(fēng)險(xiǎn)因素譫妄評(píng)估及診斷譫妄的預(yù)防譫妄預(yù)防的集束化方案-ABCDE方案譫妄治療.22譫妄評(píng)估譫妄評(píng)估ICU理想的譫妄評(píng)估工具 a)have the capacity to evaluate the primary components of delirium (for example, awareness, inattention, disorgan

17、ized thought and fluctuation course);b)must have proven validity and reliability in ICU populations; c)must involve a fast and easy evaluation; d)should not necessitate the presence of psychiatric professionals.23ICU譫妄評(píng)估工具譫妄評(píng)估工具1.the Confusion Assessment Method-ICU (CAM-ICU)把RASS評(píng)分整合到CAM-ICU確定有效的兩個(gè)版

18、本：葡萄糖牙版本和英國版本2.the Intensive Care Delirium Screening Checklist(ICDSC).24CAM-ICU.25ICU譫妄診斷譫妄診斷DSM-是目前譫妄最主要的診斷標(biāo)準(zhǔn)，較專業(yè)且繁瑣意識(shí)模糊評(píng)定法（意識(shí)模糊評(píng)定法（CAMCAM法）法）：包括4個(gè)方面1.急性起病，病程波動(dòng)2.注意力障礙3.思維混亂4.意識(shí)清晰水平改變：清晰（陰性)、警惕、嗜睡、昏睡、昏迷診斷：1和2存在，加上3或者4的任意一條即為CAM(+),表示譫妄存在。敏感性86%，特異性100%。.26葡萄牙版本葡萄牙版本of CAM-ICU.27English versions of

19、CAM-ICU.28RASS評(píng)分評(píng)分.29.30譫妄評(píng)分工具有效性譫妄評(píng)分工具有效性.31譫妄鑒別診斷譫妄鑒別診斷.32內(nèi)容內(nèi)容譫妄的流行病學(xué)譫妄概念、主要特征和分類譫妄的危害譫妄的風(fēng)險(xiǎn)因素譫妄評(píng)估及診斷譫妄的預(yù)防譫妄預(yù)防的集束化方案-ABCDE方案譫妄治療.33ICU譫妄預(yù)防譫妄預(yù)防On the whole, the constellation（系列） of risk factors for delirium affecting individual ICU patients varies from patient to patient and thus an individualized

20、individualized （個(gè)性化）（個(gè)性化）strategy for delirium strategy for delirium prevention should be soughtprevention should be sought3 risk factors in particular, sedatives,sedatives,（鎮(zhèn)靜藥物）（鎮(zhèn)靜藥物） immobility,immobility,（無法移動(dòng)）（無法移動(dòng)） and sleep disruption and sleep disruption, are widespread in the ICU.34苯二氮卓類藥物使

21、用是發(fā)生譫妄的危險(xiǎn)因素苯二氮卓類藥物使用是發(fā)生譫妄的危險(xiǎn)因素avoidance of benzodiazepinesavoidance of benzodiazepines（苯二氮卓類）（苯二氮卓類） is an is an important strategyimportant strategy when seeking to both prevent delirium and reduce its duration.35通過疼痛管理預(yù)防譫妄通過疼痛管理預(yù)防譫妄Pain is a modifiable（更改）risk factor for delirium, and inadequate p

22、ain control is a frequent cause for agitation in the ICU.When pain is not assessed and treated, patients may be inappropriately given a sedative medication rather than an analgesic（止痛） medication.36In summary, these data suggest that opioids(阿片類) used to treat pain are protective against protective

23、against the development of deliriumthe development of delirium, whereas those used at doses highdoses high enough to cause sedation（鎮(zhèn)靜） may increase the risk of deliriumincrease the risk of delirium. Therefore, patients should undergo regular pain assessments（疼痛評(píng)估）, and when pain is detected, effect

24、ive doses of an analgesic medication （鎮(zhèn)痛藥物）should be given, taking care to avoid inducing heavy sedation(誘導(dǎo)鎮(zhèn)靜）.37ICU患者早期活動(dòng)預(yù)防譫妄患者早期活動(dòng)預(yù)防譫妄datas suggest a role for early mobility（活動(dòng)） in the reduction of the duration of deliriumthe reduction of the duration of delirium among critically ill patients.38改善

25、睡眠預(yù)防譫妄改善睡眠預(yù)防譫妄Sleep deprivation（睡眠剝奪） is nearly universal for ICU patients, with the average ICU patientsleeping between 2 and 8 hours in a 24-hour period.39ICU病房中過多的噪音及燈光病房中過多的噪音及燈光Noise-reduction strategies (such as earplugs), normalizing day-night illumination(白天照明), minimizing care-related inter

26、ventions during normal sleeping hours, and interventions promoting patient comfort and relaxation are low risk and often inexpensive, and should be implemented to prevent delirium.40藥物干預(yù)預(yù)防譫妄藥物干預(yù)預(yù)防譫妄there are currently no medications approved by the US Food and Drug Administration for the prevention

27、or treatment of delirium. .41內(nèi)容內(nèi)容譫妄的流行病學(xué)譫妄概念、主要特征和分類譫妄的危害譫妄的風(fēng)險(xiǎn)因素譫妄評(píng)估及診斷譫妄的預(yù)防譫妄預(yù)防的集束化方案-ABCDE方案譫妄治療.42預(yù)防譫妄預(yù)防譫妄- ABCDE Approach Delirium in the ICU is frequently multifactorial（多因素）, so it is unlikely that a single intervention can prevent or reduce delirium with regularity(規(guī)則性).Therefore, a bundled approach combining evidence-based practices in sedation management（鎮(zhèn)靜藥物管理）, ventilator weaning(脫機(jī)）, delirium management, and early mobility and exercise, which is referred to as the ABCDE approach, has been proposed to improve multiple outcomes, including