ICU譫妄及ABCDE集束化預防方案

1、南華大學附屬第一醫(yī)院ICU 王橋生Delirium -譫妄內(nèi)容r譫妄的流行病學r譫妄概念、主要特征和分類r譫妄的目前關(guān)注情況r譫妄的危害r譫妄的風險因素r譫妄評估及診斷r譫妄的預防r譫妄預防的集束化方案-ABCDE方案r譫妄治療流行病學rDelirium occurs in up to 80% of patients admitted to intensive care units. Although under-diagnosed, delirium is associated with a significant increase in morbidity and mortality in

2、 critical patients.rICU患者譫妄發(fā)生率接近80%r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)流行病學rDelirium is common in the ICU, affecting 60% to 80% of mechanically ventilated patients and 20% to 50% of nonmechanically ventilated patientsr譫妄在ICU很常見r60-80%機械通氣患者發(fā)生譫妄r20-50%非機械通氣患者發(fā)生譫妄內(nèi)容r譫妄的流行病學r譫妄概念、主要特征和分類r譫妄的目前關(guān)注情況r譫妄的危害r譫妄的風

3、險因素r譫妄評估及診斷r譫妄的預防r譫妄預防的集束化方案-ABCDE方案r譫妄治療概念rDelirium in the intensive care unit (ICU) represents an acute form of organ dysfunction,which manifests as a rapidly developing disturbance of both consciousness and cognition that tends to fluctuate throughout the course of a dayr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

4、性的、迅速發(fā)展的意識和認知紊亂。譫妄的主要特征rThe American Psychiatric Association (APA)Diagnostic and Statistical Manual of Mental Disorders,fourth edition, text revision (DSM-IV) defines 4 key features of delirium:r(1) disturbance of consciousness with reduced awareness of the environment and impaired ability to focus,

5、 sustain, or shift attention;r (2) altered cognition (eg, impaired memory, language disturbance, or disorientation) or the development of a perceptual（知覺） disturbance (eg, hallucinations（幻覺）, delusions（妄想）, or illusions（錯覺）) that is not better accounted for by preexisting or evolving dementia（癡呆）; 譫

6、妄的主要特征r(3) disturbance that develops over a short period of time (hours to days) and tends to fluctuate during the course of the day;r(4) evidence of an etiologic factor (ie, delirium due to general medical condition, substance-induced delirium, delirium due to multiple causes, or delirium not other

7、wise specified) 譫妄分類-發(fā)病時間rThe classification of delirium can be subdivided by course over time and motor subtypes. r1.The terminology, according to the course over time, includesra) prevalent (if it is detected at the time of admission); rb) incident (if it emerges during the hospital length of stay

8、); rand c) persistent (if the symptoms persist over time)譫妄分類-運動亞型r2.The terminology according to motor subtypes includesr a) hyperactive delirium (in which there is an increase in the psychomotor activity and agitation, with attempts to remove invasive devices); rb) hypoactive delirium (characteriz

9、ed by psychomotor slowing, apathy(淡漠), lethargy（昏睡） and a decrease in response to external stimuli); rand c) mixed delirium (with unpredictable fluctuation of symptoms between the first two subtypes)譫妄分類r3.Additional definitions are described, which include rsubsyndromal delirium （亞臨床譫妄）and rdeliriu

10、m superimposed on dementia（譫妄疊加癡呆）譫妄分類-根據(jù)ICDSC評分工具r4.defined its presence, using the Intensive Care Delirium Screening Checklist(ICDSC), in a population from an ICU. The ICDSC assigns a score from 0 to 8 points, rdelirium : a score 4 rsubsyndromal delirium: a score between 1 and 3 內(nèi)容r譫妄的流行病學r譫妄概念、主要

11、特征和分類r譫妄的目前關(guān)注情況r譫妄的危害r譫妄的風險因素r譫妄評估及診斷r譫妄的預防r譫妄預防的集束化方案-ABCDE方案r譫妄治療目前ICU譫妄關(guān)注情況鎮(zhèn)靜和譫妄評估現(xiàn)狀使用現(xiàn)有譫妄評估方法的頻率ICU譫妄評估的障礙護理人員對譫妄評估的看法內(nèi)容r譫妄的流行病學r譫妄概念、主要特征和分類r譫妄的目前關(guān)注情況r譫妄的危害r譫妄的風險因素r譫妄評估及診斷r譫妄的預防r譫妄預防的集束化方案-ABCDE方案r譫妄治療譫妄的危害rincreased risk for prolonged mechanical ventilation, catheter removal,self-extubation,

12、and the need for physical restraints.rIn addition, 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.rEven after hospital discharge, the a

13、mount of time a patient has been delirious in the ICU predicts long-term cognitive impairment, physical disability, and death up to a year later.內(nèi)容r譫妄的流行病學r譫妄概念、主要特征和分類r譫妄的目前關(guān)注情況r譫妄的危害r譫妄的風險因素r譫妄評估及診斷r譫妄的預防r譫妄預防的集束化方案-ABCDE方案r譫妄治療ICU譫妄的風險因素rThe average medical ICU patient has 11 or more risk factors

14、 for developing delirium,r11which can be divided into baseline (predisposing) and hospital-related (precipitating) factors內(nèi)容r譫妄的流行病學r譫妄概念、主要特征和分類r譫妄的目前關(guān)注情況r譫妄的危害r譫妄的風險因素r譫妄評估及診斷r譫妄的預防r譫妄預防的集束化方案-ABCDE方案r譫妄治療譫妄評估rICU理想的譫妄評估工具r the scale used in this environment must ra) have the capacity to evaluate

15、the primary components of delirium (for example, awareness, inattention, disorganized thought and fluctuation course);r b) must have proven validity and reliability in ICU populations; rc) must involve a fast and easy evaluation; rand d) should not necessitate the presence of psychiatric professiona

16、lsICU譫妄評估工具r1.the Confusion Assessment Method-ICU (CAM-ICU)n把RASS評分整合到CAM-ICU確定有效的兩個版本：葡萄糖牙版本和英國版本r2.the Intensive Care Delirium Screening Checklist(ICDSC)CAM-ICU臨床特征臨床特征評價指標評價指標精神狀態(tài)突然改變患者是否出現(xiàn)精神狀態(tài)的突然改變？過去24h是否有反常行為或起伏不定（如時有時無或者時而加重時而減輕）？過去24h鎮(zhèn)靜評分（SAS或MAAS）或昏迷評分（GCS）是否有波動？注意力散漫患者是否有注意力集中困難？患者是否有保持或轉(zhuǎn)移

17、注意力的能力下降？患者注意力篩查（ASE）得分多少（如：ASE的視覺測試是對10個畫面的回憶準確度；ASE的聽覺測試患者對一連串隨機字母讀音中出現(xiàn)“A”時點頭或捏手示意）？若患者已經(jīng)脫機拔管，需要判斷其是否存在思維無序或不連貫。常表現(xiàn)為對話散漫離題、思維邏輯不清或主題變化無常思維無序若患者在帶呼吸機狀態(tài)下，檢查其能否正確回答以下問題：（l）石頭會浮在水面上嗎？（2）海里有魚嗎？（3）一磅比兩磅重嗎？（4）你能用錘子砸爛一顆釘子嗎？在整個評估過程中，患者能否跟得上回答問題和執(zhí)行指令：（1）你是否有一些不太清楚的想法？（2）舉這幾個手指頭（檢查者在患者面前舉兩個手指頭）。（3）現(xiàn)在換只手做同樣的動

18、作（檢查者不用再重復動作）意識程度變經(jīng)(指清醒以外的任何意識狀態(tài)，如：警醒、嗜睡、木僵或昏迷)清醒：正常、自主的感知周圍環(huán)境，反應適度警醒：過于興奮嗜睡：磕睡但易于喚醒，對某些事物沒有意識，不能自主適當?shù)慕徽?，給予輕微刺激就能完全覺醒并應答適當。昏睡：難以喚醒，對外界部分或完全無感知，對交談無自主、適當?shù)膽稹．斀o予強烈刺激時，有不完全清醒和不適當?shù)膽?，強刺激一旦停止，又重新進人無反應狀態(tài)?；杳裕翰豢蓡拘眩瑢ν饨缤耆珶o意識，給予強烈刺激也無法進行交流ICU譫妄診斷rDSM-是目前譫妄最主要的診斷標準，較專業(yè)且繁瑣r意識意識模糊評定法（模糊評定法（CAMCAM法）法）：包括4個方面1.急性起病

19、，病程波動2.注意力障礙3.思維混亂4.意識清晰水平改變：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%。葡萄牙版本of CAM-ICUEnglish versions of CAM-ICURASS評分譫妄評分工具有效性譫妄鑒別診斷內(nèi)容r譫妄的流行病學r譫妄概念、主要特征和分類r譫妄的目前關(guān)注情況r譫妄的危害r譫妄的風險因素r譫妄評估及診斷r譫妄的預防r譫妄預防的集束化方案-ABCDE方案r譫妄治療非ICU患者譫妄預防ICU譫妄預防rOn the whole, the constellation（系列）

20、of risk factors for delirium affecting individual ICU patients varies from patient to patient and thus an individualized strategy for delirium prevention should be soughtr3 risk factors in particular, sedatives, immobility, and sleep disruption, are widespread in the ICU通過鎮(zhèn)靜管理預防譫妄ravoidance of benzo

21、diazepines is an important strategy when seeking to both prevent delirium and reduce its duration.通過疼痛管理預防譫妄rPain is a modifiable risk factor for delirium, and inadequate pain control is a frequent cause for agitation in the ICU. When pain is not assessed and treated, patients may be inappropriately

22、 given a sedative medication rather than an analgesic medication.rIn summary, these data suggest that opioids(阿片類) used to treat pain are protective against the development of delirium, whereas those used at doses high enough to cause sedation may increase the risk of delirium. rTherefore, patients

23、should undergo regular pain assessments, and when pain is detected effective doses of an analgesic（鎮(zhèn)痛） medication should be given, taking care to avoid inducing heavy sedation.ICU患者早期活動預防譫妄rdatas suggest a role for early mobility in the reduction of the duration of delirium among critically ill pati

24、ents.改善睡眠預防譫妄rSleep deprivation is nearly universal for ICU patients, with the average ICU patient sleeping between 2 and 8 hours in a 24-hour period.rNoise-reduction strategies (such as earplugs), normalizing day-night illumination(白天照明), minimizing care-related interventions during normal sleeping

25、 hours, and interventions promoting patient comfort and relaxation are low risk and often inexpensive, and should be implemented to prevent delirium.藥物干預預防譫妄rthere are currently no medications approved by the US Food and Drug Administration for the prevention or treatment of delirium.內(nèi)容r譫妄的流行病學r譫妄概念

26、、主要特征和分類r譫妄的目前關(guān)注情況r譫妄的危害r譫妄的風險因素r譫妄評估及診斷r譫妄的預防r譫妄預防的集束化方案-ABCDE方案r譫妄治療預防譫妄- ABCDE Approach rDelirium in the ICU is frequently multifactorial, so it is unlikely that a single intervention can prevent or reduce delirium with regularity(規(guī)則性)rTherefore, a bundled approach combining evidence-based practices in sedation management, ventilator weaning, delirium management, and early mobility and exercise, which is referred to as the ABCDE approach, has been proposed to improve multiple outcomes, including